Archer 3

A Choice A is correct. Guided imagery is a stress-reduction technique that can be done in any place at any time. In fact, this is one of the biggest advantages of this technique. Anytime the patient begins to feel anxious, they can practice guided imagery. Choice B is incorrect. Guided imagery can be done in any position that the patient is most comfortable in. They do not have to by lying down unless they choose to. Choice C is incorrect. It is not necessary for the client's mom or anyone else to be present for guided imagery unless they choose so. Any person, or no one at all, can be present depending on the client's preferences. Choice D is incorrect. Music can but does not have to be played during guided imagery, again it depends on the client's preferences.

A 12-year-old client with chronic asthma exacerbations has decided to try guided imagery as a way to manage the anxiety that is contributing to frequent asthma attacks. Which statement by the client indicates an understanding of this stress-reduction technique? A. "I can do this anytime and anywhere when I feel anxious." B. "I must be lying down to practice guided imagery." C. "My mom will have to be with me any time I try this." D. "I will play music every time I do my guided imagery to make sure it works."

C Choice C is correct. Following a thyroidectomy, one of the most serious complications is an ineffective airway due to tracheal compression, hematoma, and/or edema. Therefore, it is essential to have a tracheostomy set, oxygen, and suction available at the bedside for at least the initial 24-hour post-operative period. Choice A is incorrect. Dressing changes are performed as needed for bleeding. However, post-thyroidectomy bleeding may not be visible on the dressings. Discrete signs, such as cervical pressure and tightness, difficulty swallowing, and subjective shortness of breath are possible signs of bleeding, which may precede a blood-soaked dressing. The majority of post-operative clients are at risk for post-operative bleeding, with many experiencing signs and symptoms of post-operative bleeding prior to the late sign of blood presenting on the bandage. Choice B is incorrect. Pain control in the post-operative period is a concern following all surgical procedures, not simply thyroidectomies. Narcotics are typically administered on a PRN basis once the client has been transferred to the floor. Therefore, it is not appropriate to automatically administer a narcotic medication to the client upon the client's return to the room from the post-anesthesia care unit without first assessing the client and determining the time, dose, and response of the last narcotic medication given to the client. Choice D is incorrect. Although clients may have difficulty communicating due to laryngeal edema or nerve damage, difficulty communicating most commonly occurs due to endotracheal intubation. The client will still be able to speak, but may experience hoarseness of the voice. Post-endotracheal intubation hoarseness of the voice is an issue experienced by all clients who undergo procedures requiring intubation, not just thyroidectomy clients. Upon a 28-year-old post-thyroidectomy client's transfer from the post-anesthesia care unit to the medical-surgical floor, identify the preparation of the client's bedside with a tracheostomy set, oxygen, and suction as the action which demonstrates the nurse's understanding of the possible thyroidectomy complications. Before the client's arrival, the nurse should ensure the oxygen and the suction are working appropriately. Thyroidectomy carries a relatively high risk of post-operative respiratory obstruction, which may necessitate tracheostomy.

A 28-year-old post-thyroidectomy client is transferred from the post-anesthesia care unit to the medical-surgical floor. Which action demonstrates the medical-surgical nurse understands the possible complications of a thyroidectomy? A. Dressings are changed every two hours to best detect post-operative bleeding, so the nurse should place the dressings at the bedside. B. Pain is managed immediately upon the client's return to the room by promptly administering a narcotic medication. C. The bedside is prepared with a tracheostomy set, oxygen, and suction. D. The nurse teaches the client alternative means of communication upon arrival to the room.

B Choice B is correct. Assessments after knee surgery should include the 5 P's: pain, pallor, pulse, paralysis, and paresthesia. Capillary refill should be assessed during the pallor assessment. A normal capillary refill is less than two seconds. The capillary refill, in this case, is 5 seconds, which is indicative of a problem. Choice A is incorrect. This patient may not be able to move her leg due to pain after the surgery. Choice C is incorrect. This patient will have pain at the surgery incision site. If the patient continues to have severe and uncontrollable pain in the entire leg, the nurse should worry about compartment syndrome. Choice D is incorrect. This is a normal finding.

A 55-year old female has a complete knee replacement on her left knee. Which symptom would be the most likely to indicate a severe adverse reaction after surgery? A. Inability to move the leg B. Capillary refill 5+ for the left foot C. Severe pain at the left knee incision site D. Ability to move the toes

A Choice A is correct. Obtaining a 12-lead electrocardiogram is the priority as the client is exhibiting classic symptoms of acute coronary syndrome (ACS). Women over the age of 50 are at a higher risk of developing this potentially fatal syndrome. Women may exhibit manifestations other than substernal chest pain. The ECG will help determine if the client has a STEMI or an NSTEMI. Choices B, C, and D are incorrect. Supplemental oxygen, establishing intravenous access, and a respiratory assessment will need to occur. However, they do not prioritize establishing the severity of the ACS as the ECG will determine if the client has a STEMI. Additionally, the client reported difficulty with breathing, which does not necessarily indicate that she is hypoxic. The standard of care is to obtain a 12-lead electrocardiogram within ten minutes of symptom presentation. Unstable ACS (STEMI) may present with typical and atypical clinical features. Typical clinical features of ACS include: Substernal chest pain with a gradual onset. Pain that radiates to the arm or jaw. Chest pain that is not relieved with rest. Diaphoresis and pallor may be additional findings. Atypical clinical features of ACS include: Nausea and vomiting Dyspnea Significant fatigue Epigastric pain Atypical features are found in women and individuals with diabetes mellitus. Individuals with diabetes mellitus have attenuated chest pain because of neuropathy.

A 56-year-old female client presents to the emergency department (ED) who reports dyspnea, fatigue, and indigestion. The nurse should take which priority action? A. Obtain a 12-lead electrocardiogram B. Provide supplemental nasal cannula oxygen C. Established intravenous (IV) access D. Auscultate lung sounds

B Choice B is correct. Displacement is the ego defense mechanism that a client will most likely employ to cope with the stressors associated with lashing out at a target with socially unacceptable hostility. For example, a client under attack by another individual does not react and displaces their reaction (which is often intensified) on someone else. In this case, the spouse shouted at the client, which led to the client unloading their reaction to that conflict by being hostile to the nurse. Choices A, C, and D are incorrect. Identification is copying and mimicking the behaviors of others to overcome their feelings of inadequacy and lack of value. Undoing is the ego defense mechanism used when someone undoes something that has made them feel guilty, such as buying the wife a bouquet after being unfaithful. Compensation occurs when a person maximizes some strength to overcome feelings of weakness and inadequacy.

A client in the primary healthcare provider (PHCP) office is observed getting yelled at by their spouse. When the nurse interviews the client, the client is hostile and shouts at the nurse. This client is exhibiting which defense mechanism? A. Identification B. Displacement C. Undoing D. Compensation

D Choice D is correct. For a client with a pacemaker, it is recommended that they talk on their cellular phone opposite of the pulse generator to prevent electromagnetic interference. Choices A, B, and C are incorrect. Air travel is not prohibited for a client with a pacemaker. They should carry their medical alert card if they are stopped by airport security. Discarding radios and other home appliances is unnecessary as they do not cause any interference. CT scans are permitted for a client with a pacemaker. Diagnostics with an MRI are contraindicated. Following the placement of a pacemaker, the client will be provided with the following instructions: · Keep a pacemaker identification card in your wallet. · Following the procedure, avoid lifting your arm over your head for four weeks. · Do not lift heavy objects following the procedure until cleared by your primary healthcare provider (PHCP). · Taking a bath and shower is not restricted. · Do not apply pressure over the generator, and do not wear any tight clothing. · Operating household appliances would be considered safe.

A client is being discharged following the insertion of a permanent pacemaker. Which of the following should be included in the client's discharge instructions? A. Air travel will not be possible due to airport screening equipment. B. You will need to discard any radios at home that have antennas. C. Computed tomography (CT) scans are not permitted with this device. D. You should use your cellular phone on the opposite side of the generator.

C Choice C is correct. The nurse needs to establish the client's competence in signing the informed consent. An assessment of the client's level of consciousness and neurological assessment would determine if the client is mentally competent to give consent for surgery. Choice A is incorrect. The nurse should not yet bring the client to the operating room as his statement may indicate confusion. Consent for surgery must be made by a mentally competent individual. The nurse needs to assess the client first to check if he is competent to sign an operative consent. Choice B is incorrect. Administering pre-operative diazepam may worsen the client's level of consciousness as diazepam is a sedative-hypnotic. The nurse should assess the client first to determine his level of consciousness. Choice D is incorrect. If the client is deemed incompetent to sign the consent, the next-of-kin is the one that signs the consent for the client. The nurse however, should determine the client's level of consciousness first.

A client scheduled for abdominal surgery has just signed the informed consent form. Five minutes later, he tells the nurse "I can't wait to go to the Bahamas. Tell the captain to wait for me!" What is the most appropriate action of the nurse? A. Wheel the client to the OR B. Administer the pre-operative diazepam intramuscularly C. Assess the client's level of consciousness D. Ask the wife to co-sign the consent

D Choice D is correct. Clients undergoing brachytherapy have radium implants. They should have limited close contact with a family of up to only 30 minutes to 2 hours a day. The visitors should limit their exposure time to radium, have adequate distance between them, and use a lead shield against the radium. Choice A, B, and C are incorrect. These responses are apathetic and inappropriate. The client may get better sleep without the visitors ( Choice C), but this response does not address the radiation-related dangers to the visitor. Brachytherapy is an internal radiation therapy where a radiation source ( small radioactive implant) is placed close to cancer. This way, cancer receives a very high dose of radiation, but only low levels reach adjacent tissues thus, limiting side effects. Brachytherapy is commonly used to treat prostate, uterus, cervix, and vaginal cancers. It is essential to have safety measures in place during brachytherapy to protect the visitors and healthcare staff. Patients may be admitted to the hospital for a few days in a single room during brachytherapy. Once the level of radioactivity goes down to a safe level, the patients can go home. Following discharge, the clients should avoid contact with children and pregnant women for quite some time. The following are nursing specific instructions in caring for the clients receiving radioactive source implants: The patient should be in a single room with access to the bathroom. Post specific "stay times" on the room door and do not spend any more time in the room than needed to care for the patient. No pregnant visitors No visitors under the age of 18 years Visitors should remain at least 6 feet from the patient. The time can vary from 30 minutes to 2 hours per visitor per day. Housekeeping should not enter the room unless escorted by the nurse, and only essential cleaning must be performed.

A client with prostate cancer is undergoing brachytherapy. The client's wife is visiting him and asks if she can spend more time with her husband. The most appropriate response for the nurse should be: A. The hospital does not allow you to stay for more than the allotted visiting hours. B. You do not need to stay for longer than you should. C. Your husband will get better sleep if you go home. D. You can only stay up to half an hour to protect yourself from the radiation.

B Choice B is correct. Herbal supplements are not regulated in the same manner as traditional pharmacy-dispensed medications. Although the use of some herbal supplements may provide some beneficial effects, not all herbal supplements are safe for use. Clients on conventional pharmaceutical therapy (i.e., hypertensive medications) should be discouraged from using herbal supplements, especially those with similar pharmacological effects, as the combination may produce an excessive reaction of unknown interaction effects. The nurse should advise the client to discuss all herbal supplements (regardless of whether they address hypertension or not) with her attending HCP. Choice A is incorrect. Some herbal supplements may benefit some clients; therefore, it would be wrong for the nurse to make a blanket statement such as "herbal supplements are unsafe and should be avoided" to this client. Choice C is incorrect. Although the nurse should teach the client to take and monitor her blood pressure, doing this every 15 minutes is much too frequently. Choice D is incorrect. While the client should be informed that the use of an herbal supplement would prompt the need for the nurses to monitor her blood pressure closely, this would not be the priority response out of the choices provided. Here, the question asks for the most appropriate response from the nurse. Because herbs are regarded as food products, they are not subject to the same scrutiny and regulation as traditional medications. As a result, manufacturers are exempt from premarket safety and efficacy testing before the release of an herbal product and from any post-marketing surveillance. Although herbal remedies are perceived as being natural and therefore safe, many have adverse effects that can sometimes produce life-threatening consequences. Common herbal remedies that produce adverse effects on the cardiovascular system: include St. John's wort, motherwort, ginseng, gingko biloba, garlic, grapefruit juice, hawthorn, saw palmetto, danshen, echinacea, tetrandrine, aconite, yohimbine, gynura, licorice, and black cohosh.

A hypertensive client was prescribed antihypertensive medication. The client tells a clinic nurse that she prefers to take an herbal supplement to help lower her blood pressure. Which is the most appropriate response from the nurse? A. Tell the client that herbal supplements are unsafe and should be avoided B. Encourage the client to discuss the use of herbal supplements with her attending health care provider (HCP) C. Teach the client how to take her blood pressure and ask her to monitor it every fifteen minutes D. Tell the client that if she takes the herbal supplement, it will require the nurses to monitor her blood pressure closely

B Choice B is correct. A client with stage 3 and 4 pressure injuries present on the sacral region requires extensive wound care from an experienced nurse capable of properly assessing and caring for the client's pressure injuries. The nurse manager should assign this client to the experienced registered nurse for various reasons. First, accurate assessment and documentation of pressure injuries requires experience. Second, dressing stage 3 and 4 pressure injuries often requires complex, time-consuming methods. Third, this client will need to undergo a head-to-toe assessment for additional pressure injuries and areas at risk for pressure injuries, with all applicable areas documented and addressed. Fourth, the client (and any applicable caregivers) will require significant education on pressure points, the need to rotate every two hours, how moisture affects skin breakdown, etc. Therefore, this client is appropriate for the experienced registered nurse. Choice A is incorrect. Fatigue is an anticipated complaint in clients with Guillain-Barre syndrome (GBS). Studies have demonstrated that fatigue is one of the most disabling symptoms in GBS clients, often lingering for months or years following the onset of symptoms. Complaints of fatigue from a GBS client do not warrant using the most experienced nurse. Choice C is incorrect. A client who is two weeks postoperative following a laryngectomy would not warrant the expertise of the most experienced registered nurse at the home health nursing agency. At this point in the postoperative period, many of the risks the client faced in the immediate postoperative period are no longer a concern. Additionally, the client no longer requires extensive postoperative teaching or comprehensive nursing care. Therefore, this client does not require the most experienced registered nurse. Choice D is incorrect. From the time a client is admitted to a home health service, the goal of the home health service is to discharge the client. The primary method to accomplish this goal is client education. As such, the client education process begins upon the client's admission. Here, the client is due for discharge within the coming week, meaning the client possesses the requisite amount of applicable client education and has improved to the point of being eligible for discharge from home health services. Based on this information, this client does not require the services of the agency's most experienced registered nurse. Pressure injuries can develop secondary to immobilization or hospitalization, particularly in elderly, incontinent, or undernourished clients. Base the risk of pressure injury on standardized scaling systems as well as on the assessment of skilled clinicians. Pressure injuries are staged according to depth, but tissue damage may be deeper and more severe than is evident from the physical examination. Treat and help prevent pressure injuries by reducing skin pressure, repositioning frequently, and using protective padding and support surfaces.

A nurse manager of a home health nursing agency is completing client assignments for the nursing staff. Which client should be assigned to the most experienced registered nurse? A. A recovering Guillain-Barre syndrome client complaining of constant fatigue B. A client with stage 3 and 4 pressure injuries present on the sacral area C. A 2-week postoperative laryngectomy client due to laryngeal cancer D. A client due for discharge from home health services in the coming week

C Choice C is correct. Hyperthyroidism is related to hemodynamic variations, including increased heart rate and cardiac contractility, as well as decreased peripheral resistance due to serum thyroid hormone excess. Preoperative preparation of the patient is crucial to avoid intraoperative or postoperative complications and to minimize the vascularity of the gland. The incidence of complications is low in experienced hands; however, a small amount of intraoperative bleeding can reduce the visualization and preservation of the surrounding nerves, vasculature, and parathyroid glands. Lugol's solution (inorganic iodide) has been given preoperatively to patients to limit intraoperative bleeding and related complications resulting from thyroid gland vascularization. Choice A is incorrect. Doses of over 30 mg/day may increase the risk of agranulocytosis. The client may receive an iodine solution (Lugol's solution) for 10 to 14 days before surgery to decrease vascularity of the thyroid and thus prevent excess bleeding. Choice B is incorrect. Lugol's solution does not act to prevent tetany. Calcium is used to treat tetany.

A patient is scheduled to have a thyroidectomy. The nurse understands that the primary reason for giving Lugol's solution to a patient preoperatively is to: A. Decrease the risk of agranulocytosis postoperatively. B. Prevent tetany while the client is under general anesthesia. C. Reduce the size and vascularity of the thyroid and prevent hemorrhage. D. Potentiate the effect of the other preoperative medication so less medicine can be used while the client is under anesthesia.

B Choice B is correct. Confusion and disorientation in a dementia client are common findings. Dementia is a slow, progressive deterioration of mental functioning that impairs the client's cognition (i.e., memory, thinking, judgment, ability to learn, etc.). Symptoms of dementia often include memory loss, difficulty expressing language and performing activities, personality changes, general disorientation, confusion, and disruptive or inappropriate behavior. In the absence of any new or acute changes in the mental status of this specific client, the licensed practical nurse (LPN) is fully qualified to care for this client and is, therefore, the appropriate client for the registered nurse (RN) to designate to the LPN for care. Choice A is incorrect. Based on this client's symptoms, this client is not an appropriate client for the registered nurse (RN) to assign to the licensed practical nurse (LPN). Amitriptyline, a tricyclic antidepressant, has been associated with various movement disorders, including dystonia and dyskinesias. Based on the exhibited symptoms, the RN should be concerned that the client may be experiencing a dystonic reaction (potentially from the client's medication) which would require immediate intervention(s). Although this client likely requires transfer to a higher level of care to receive the appropriate medical care, at this time, this client should be cared for by a qualified registered nurse with psychiatric experience. Choice C is incorrect. Lithium, a mood stabilizer, is used primarily to treat bipolar disorder. A therapeutic lithium level ranges between 0.6 to 1.2 mEq/L, with levels of 1.5 mEq/L or greater considered toxic. This client's lithium level of 2.0 mEq/L indicates the client is experiencing severe lithium toxicity, therefore necessitating the client receive care over and beyond that which a licensed practical nurse (LPN) can provide. Based on this client's lab result, following an immediate discussion with the client's health care provider (HCP), the RN should initiate steps to transfer the client to a higher level of care to receive the appropriate medical care. Choice D is incorrect. Delirium tremens (DTs) is a form of severe alcohol withdrawal typically accompanied by profound confusion, autonomic hyperactivity, and/or cardiovascular collapse. When caring for a client with DTs, initial minor withdrawal symptoms are often characterized by anxiety, insomnia, palpitations, headache, and/or gastrointestinal symptoms, usually occurring as early as six hours after the client's last alcohol intake. As the hours and days progress, DTs are often associated with a number of complications, including hallucinations, respiratory depression, seizures, arrhythmias, and/or aspiration pneumonitis. Based on the unpredictable and unstable outcomes demonstrated by clients experiencing DTs, this client requires a level of care above which the licensed practical nurse (LPN) is capable of providing and is therefore inappropriate for the registered nurse (RN) to assign to the LPN. Additionally, the RN should immediately assess this client, speak with the client's health care provider (HCP) and arrange for the client to be transferred to a higher level of care to receive the appropriate medical care.

A registered nurse (RN) and a licensed practical nurse (LPN) work together in a psychiatric ward. Which of the following clients may the RN assign to the LPN? A. A client taking amitriptyline who is currently grinding their jaw and grimacing B. A client with dementia who is currently confused and disoriented C. A client with bipolar disorder with a lithium level of 2.0 mEq/L D. A client with a history of chronic alcoholism currently experiencing delirium tremens

C Choice C is correct. Recording intake and output is a skill within the scope of a UAP. This task may be appropriately delegated to a UAP to complete. Choices A, B, and D are incorrect. UAPs cannot perform any task that requires sterility. Collecting urine from an indwelling catheter requires clamping the tubing and collecting the urine using a sterile syringe and a sterile container. UAPs may assist with clean catch urine specimen collections, but not collection from an indwelling catheter. It would be inappropriate for a UAP to adjust oxygen as it is regarded as a medication. Removing a medication patch is not within the scope of a UAP. A UAP may provide a bed bath, but the nurse would need to remove any medication patches. Finally, a nitroglycerin patch does not need to be removed for showering or a bath. Unlicensed assistive personnel may assist with activities of daily living, the collection of vital signs, intake and output, client safety, and basic hygiene needs. UAPs should not be assigned tasks involving sterility, medication administration, or any initial tasks (such as the first ambulation).

The charge nurse is assigning tasks to a unlicensed assistive personnel (UAP). Which task would be appropriate to delegate? A. Collecting a urine specimen from an indwelling urinary catheter. B. Increase nasal cannula oxygen for a client by one liter a minute. C. Record how much drainage is in the suction cannister. D. Remove a nitroglycerin patch before giving a bath.

D Choice D is correct. When making client assignments, the RN should be assigned the client with the least predictable outcome who is unstable. The client with septic shock receiving intravenous vasopressors should be assigned to the RN because of the need to titrate the vasopressors. Further, this client being in shock, is not stable and requires frequent assessment. Choices A, B, and C are incorrect. An LPN should be assigned clients who are stable and with a predictable outcome. A client with a chronic illness such as anemia requiring epoetin injections can be delegated to the LPN (Epoetin, unlike RhoGAM, is not regarded as a blood product). Further, the client with a resolving pneumothorax may be assigned to the LPN because the condition is resolving. Finally, LPNs may do suction in an established tracheostomy. When making client assignments, the nurse should always assign the most unstable client to the RN. This also involves clients requiring initial assessments or discharge teaching. The LPN may reinforce teaching, data collection, and care for clients with low acuity illnesses

The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? A. A client with chronic anemia requiring epoetin injections. B. A client with a resolving pneumothorax with a chest tube. C. A client with a tracheostomy requiring intermittent suctioning. D. A client with septic shock requiring intravenous (IV) vasopressors.

A Choice A is correct. The first bodily area to be washed with a complete bed bath is the inner canthus of either eye, including the right or left eye. The washing is done from the inner to the outer canthus of the eye. The next steps for the bath are the rest of the face, the upper chest, the arms, and hands, after which you would proceed downward on the body from the head to the toes. Choice B is incorrect. Although the cheeks are washed near the beginning of a complete bed bath, washing either cheek is not the first bodily area to be washed. Choice C is incorrect. Although the forehead is washed near the beginning of a complete bed bath, washing the forehead is not the first bodily area to be washed. Choice D is incorrect. Although the chin is washed near the beginning of a complete bed bath, washing the chin is not the first bodily area to be washed.

The first bodily area to be washed with a complete bed bath is the: A. Inner canthus of the right eye B. Cheeks C. Forehead D. Chin

B Choice B is correct. A stoma that has retracted will appear concave and bowl-shaped. A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. Monitoring for signs of proper healing and educating the client/caregivers on signs of complicated healing is important. Complications that could arise from retracted stoma include difficulty maintaining appliance placement, which could lead to leakage and irritated skin. Choice A is incorrect. A narrow, flattened, or constricted stoma indicates stenosis. Choice C is incorrect. A dry, dusky, or reddish-purple stoma indicates ischemia. Choice D is incorrect. A healthy stoma will protrude about 2.5 cm with an open lumen at the top. It should appear pinkish-red and moist.

The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted? A. Narrowed and flattened B. Concave and bowl-shaped C. Dry and reddish-purple D. Pinkish-red and moist

A, B, E Choices A, B, and E are correct. Fentanyl can be delivered by a variety of routes, including transdermal patches. This patch is effective for around-the-clock pain control, but the client may still experience breakthrough pain requiring a more immediate release type of pain control. The client may reinforce the patch with tape if it starts to loosen. The fentanyl patch should be changed every 72 hours, with a new patch applied to a new site. Choices C and D are incorrect. Heat should not be applied to a fentanyl patch. This may result in the medication being rapidly discharged and could cause the client to experience opioid toxicity. The fentanyl patch is intended to provide around-the-clock pain control, and thus, it would be inappropriate for the client to remove it while they are sleeping. ✓ Fentanyl is an opioid that can be delivered in various preparations (intravenous, transdermal, buccal). ✓ The transdermal patch effectively provides a client with continuous pain control for 72 hours. ✓ This medication will take 24 hours to reach its peak effect, and the nurse should anticipate the client to experience breakthrough pain. ✓ Fentanyl patches should be applied to a clean area with minimal hair. Hair may be clipped but not shaven to ensure appropriate adhesion to the skin.

The nurse has provided medication instructions to a client who has been prescribed a fentanyl transdermal patch. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply. A. "I may still need pain medication while this patch is applied." B. "If the patch comes loose, I may reinforce it with a piece of tape." C. "I can apply heat to the patch site to increase the pain relief." D. "I should remove this patch while I am sleeping." E. "The patch will need to be changed every 72 hours."

B Choice B is correct. Multiple peri-pads being saturated overnight indicates heavy bleeding, which may signify a hemorrhage. The nurse should see and examine this patient first. Choice A is incorrect. The pain may be related to an episiotomy or a perineal tear during delivery, but this patient should not be prioritized over a client who may be hemorrhaging. Choice C is incorrect. The patient needs to be assessed for bonding problems; however, this is a psychosocial issue. Clients with physiological issues need to be evaluated first such as a possible hemorrhaging patient. Choice D is incorrect. The patient needs coaching and instructions from the nurse regarding breastfeeding and latching. However, this should not be prioritized over a possible hemorrhaging client.

The nurse in the gynecology ward has just finished receiving the report from the previous shift. Which patient should the nurse see first? A. A client who is complaining of perineal pain while voiding. B. A client who had multiple saturated perineal pads changed during the night. C. A client who is refusing her newborn to be roomed in with her. D. A client who is upset because her baby will not latch.

A Choice A is correct. The nurse must monitor potassium levels while the client is taking digoxin. Low levels of potassium may precipitate digoxin toxicity. Choices B, C, and D are incorrect. Calcium, sodium, and phosphorus do not have a relationship with digoxin. While the nurse should always monitor all electrolyte levels, potassium is what the nurse should watch most closely while the client takes digoxin because of its ability to precipitate toxicity. Digoxin is a cardiac glycoside utilized in the treatment of atrial fibrillation and heart failure. While this medication has fallen out of favor because of its numerous interactions, this medication is still available. The apical pulse must be obtained prior to administering this medication. The apical pulse must be at least 60/minute for adults; 70/minute for children; and 90/minute for infants. The therapeutic level for digoxin is 0.5-2 ng/mL

The nurse is caring for a client receiving digoxin. It would be a priority for the nurse to monitor the client's A. potassium. B. calcium. C. sodium. D. phosphorus.

A Choice A is correct. Nortriptyline is a tricyclic antidepressant (TCA) used to manage depressive and obsessive-compulsive disorders. Overdoses of tricyclics can be fatal because of their cardiotoxicity. Discerning how many pills were consumed would be very helpful. The priority for this client is to complete a 12-lead electrocardiogram followed by continuous cardiac monitoring. Choices B, C, and D are incorrect. The indication for the medication, previous suicide attempts, and circumstances leading up to the overdose are not priority questions to obtain. The immediate care of this client would not change based on these questions. However, knowing that a client took three pills versus thirty would be quite helpful in determining the severity of the overdose. Tricyclic antidepressants include nortriptyline, amitriptyline, and imipramine. These medications are utilized in the treatment of depressive and obsessive-compulsive disorders. This class of medications possesses significant anticholinergic effects and, therefore, would not be recommended for older adults. Overdose of a TCA is extremely serious because these medications are cardiotoxic.

The nurse is caring for a client who arrives with an intentional overdose of nortriptyline. Which information is essential to obtain? A. The number of pills that were consumed. B. The indication for the medication. C. Previous suicide attempts and methods. D. Circumstances leading up to the overdose

A Choice A is correct. Recent spinal surgery requires follow-up with the prescription of enoxaparin. This medication may cause a hematoma, which may consequently cause severe neurological impairment. Choices B, C, and D are incorrect. Diabetes mellitus and osteoarthritis are not contraindications for enoxaparin. Further, enoxaparin is utilized in the management of venous thromboembolism. Enoxaparin is a low molecular weight-based heparin that does not require monitoring the activated partial thromboplastin time (aPTT). The nurse still needs to monitor the client for bleeding as well as heparin-induced thrombocytopenia (HIT). HIT would manifest as a reduction of platelets and may seriously cause thrombosis elsewhere. Contraindications to administering enoxaparin include recent spinal surgery, epidural, peptic ulcer disease, thrombocytopenia, and uncontrolled hypertension.

The nurse is caring for a client who is prescribed enoxaparin. Which of the following findings in the medical history would require follow-up with the primary healthcare physician (PHCP)? A. Recent spinal surgery B. Diabetes mellitus C. Osteoarthritis D. Venous thromboembolism

A Choice A is correct. Thrombocytopenia is an adverse effect associated with this medication. This effect is linked to Heparin-Induced Thrombocytopenia (HIT). This may occur within five to fourteen days of exposure to the drug and may be hastened by exposure to higher-than-normal doses. Choices B, C, and D are incorrect. Leukocytosis (an increase in the overall white blood cell count), polycythemia (an increase in red blood cells), and neutropenia (a decrease in neutrophils) are not adversely associated with enoxaparin. Enoxaparin comes in prefilled syringes to prevent dosing errors. The bubble should not be expelled before administration. If the drop is expelled, part of the dose would be wasted. ➢ Enoxaparin is administered subcutaneously. It should be injected at either a 90 or 45-degree angle. This medication should only be administered in the abdomen and not rubbed afterward. ➢ Enoxaparin is a low molecular weight-based heparin that does not require monitoring the activated partial thromboplastin time (aPTT). ➢ The nurse still needs to monitor the client for bleeding as well as heparin-induced thrombocytopenia (HIT). HIT would manifest as a reduction of platelets and may seriously cause thrombosis elsewhere. ➢ Contraindications to administering enoxaparin include recent spinal surgery, epidural, peptic ulcer disease, thrombocytopenia, and uncontrolled hypertension. ➢ The antidote for enoxaparin is protamine sulfate.

The nurse is caring for a client who is receiving prescribed enoxaparin. Which of the following findings would indicate the client is having an adverse effect? A. Thrombocytopenia B. Leukocytosis C. Polycythemia D. Neutropenia

A Choice A is correct. Isotretinoin is indicated in the treatment of moderate to severe acne vulgaris. This medication may raise triglyceride levels, and thus a baseline lipid panel is necessary along with periodic monitoring. Choices B, C, and D are incorrect. A C-Reactive Protein, Hemoglobin A1C, and International normalized ratio (INR) are all laboratory data not relevant to isotretinoin. This medication is highly hepatotoxic, and the liver function tests are laboratory data that should be monitored before and during treatment. Isotretinoin may also be utilized in the treatment of moderate to severe acne vulgaris as it has demonstrated its ability to shrink the sebaceous glands. This medication is highly teratogenic, and the client should be counseled on reliable contraception. A negative pregnancy test is required prior to the start of treatment. Laboratory monitoring of the client's liver function tests and triglycerides is essential. This medication may cause a liver injury and raise triglyceride levels.

The nurse is caring for a client who is receiving prescribed isotretinoin. Which laboratory data is essential prior to the initiation of this therapy? A. Lipid panel B. C-Reactive Protein C. Hemoglobin A1C D. International normalized ratio (INR)

A, B, D, E Choices A, B, D, and E are correct. These products are gastric irritants, and overexposure to these substances may cause PUD. Prolonged NSAID use (such as ibuprofen) is commonly implicated in the causation of PUD because of their ability to inhibit COX-1 in the gastrointestinal tract. H. pylori is a gram-negative bacteria that may be acquired by an individual consuming contaminated food or water. Alcohol and tobacco usage causes more gastric acid to be discharged. When used together, the risk for PUD is substantially increased. Choice C is incorrect. IBS is a functional GI disorder that causes spasms of the large bowel. This disorder is not implicated in causing PUD. Three ulcers make up PUD and include duodenal ulcers, gastric ulcers, and stress ulcers. Many ulcers are caused by H. pylori infection. Gastric ulcers usually develop in the antrum of the stomach near acid-secreting mucosa. Duodenal ulcers occur more often than other types. Most duodenal ulcers are present in the upper portion of the duodenum. Stress ulcers are acute gastric mucosal lesions occurring after an acute medical crisis or trauma. Treatment for PUD includes PPIs, H2 blockers, and antibiotics if the cause is H. pylori.

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as risk factors for peptic ulcer disease (PUD)? Select all that apply. A. Prolonged ibuprofen use B. Tobacco use C. Irritable bowel syndrome D. H. pylori E. Alcohol consumption

A Choice A is correct. Oxybutynin chloride is an anti-cholinergic medication often used for overactive bladder. This medication is not used to prevent organ rejection. Choice B is incorrect. Prednisone, a glucocorticoid medication, is frequently used in conjunction with other medicines to prevent organ rejection. Choice C is incorrect. Tacrolimus is an immunosuppressive medication used to prevent organ rejection. Choice D is incorrect. Cyclosporine is an immunosuppressive medication used to prevent organ rejection.

The nurse is discussing the use of medications to prevent organ rejection with the health care provider. Which of the following medicines is not used to avoid organ rejection? A. Oxybutynin chloride B. Prednisone C. Tacrolimus D. Cyclosporine

A Choice A is correct. DKA treatment aims to lower the blood glucose by 50 to 75 mg/dL/hr. This is accomplished by the prescribed regular insulin, which is given intravenously. Choices B, C, and D are incorrect. Dextrose 50% should be available in the event of severe hypoglycemia. Dextrose 5% is not sufficient to treat hypoglycemia. The treatment goal for the hypovolemia caused by DKA is isotonic saline, not hypertonic saline. Urine output would decrease with the infusion of regular insulin as correcting the hyperglycemia would treat the polyuria, which is a symptom of hyperglycemia.

The nurse is planning a staff development conference about diabetic ketoacidosis (DKA). Which of the following information should the nurse include? A. The goal is to lower blood glucose by 50 to 75 mg/dL/hr. B. Dextrose 5% should be available for hypoglycemia symptoms. C. Hypovolemia caused by DKA may be treated with 3% saline. D. The urine output would increase once regular insulin is initiated.

C Choice C is correct. A large leg abscess will need significant time for incision and drainage (I&D). Children who are not yet adolescents are not mature enough to cooperate adequately during such surgical procedures. Children undergoing most surgeries require general anesthesia because this minimizes their fears of intrusive or mutilating procedures. General anesthesia provides necessary sedation so the surgery can be safely performed. Choice A is incorrect. A peripheral nerve block will not be able to provide adequate anesthesia to proceed with the I&D procedure of a large leg abscess. For the child to cooperate with such surgery, sedation is necessary. General anesthesia provides necessary analgesia and sedation to the child. Choice B is incorrect. Although spinal anesthesia may achieve an analgesic effect, the child still may not cooperate with the surgical procedure because spinal anesthesia does not provide sedation. Choice D is incorrect. Local anesthesia is helpful while addressing small abscesses. A large abscess requires more time and requires the child to cooperate. Children undergoing such procedures require general anesthesia to provide necessary sedation as well because this minimizes their fears of intrusive or mutilating procedures.

The nurse is preparing a 3-year-old child for an incision and drainage of a large left leg abscess. The nurse understands which of the following types of anesthesia will be administered to the child? A. Peripheral nerve block B. Spinal anesthesia C. General Anesthesia D. Local Anesthesia

B Choice B is correct. A total laryngectomy is the removal of the larynx and surrounding lymph nodes. This is a significant procedure that requires the placement of a tracheostomy. The client will need an interdisciplinary approach to their care. A central figure for a client with a tracheostomy is a respiratory therapist collaborating with the nurse regarding tracheostomy management. Choices A, C, and D are incorrect. Healthcare professionals essential in managing client care following a total laryngectomy include respiratory and speech therapy. Psychiatry may be useful later in the rehabilitation process because the client may develop a disturbed body image. Endocrinology, dermatology, and infectious disease are not relevant to the care of a client who underwent a total laryngectomy.

The nurse is preparing a client for a total laryngectomy. When developing a plan of care for this client, the nurse recommends a consultation from which healthcare provider (HCP)? A. Endocrinology B. Respiratory therapy C. Dermatology D. Infectious disease

A Choice A is correct. Patients who are anxious prior to anesthesia are at higher risk of experiencing postoperative emergence excitement or delirium. The nurse should focus on actions that aim to reduce the patient's anxiety to reduce this patient's risk of emergence excitement. The nurse should provide reassurance, explain the purpose of procedure, and allow the patient to express concerns/ask questions. Choice B is incorrect. This action would be appropriate in the post-operative phase as the patient comes out of general anesthesia, but would not be a preventative action in the pre-operative phase to reduce the risk of emergence excitement. Choice C is incorrect. This action is dismissive and does not offer the patient a chance to voice concerns. The TKA procedure would likely require general anesthesia and it would be false for the nurse to reassure the patient that it is simple or minor. Choice D is incorrect. Patients with a history of recent drug or alcohol use may be at increased risk of post-operative emergence excitement, but this action would only identify the risk factor, not actively reduce the patient's risk of experiencing this problem.

The nurse is preparing a patient for scheduled total knee arthroplasty (TKA). Which action by the nurse would be most important to reduce this patient's risk for experiencing emergence excitement after this procedure? A. Ask the patient about any concerns regarding the procedure. B. Monitor for changes in the patient's respiratory status. C. Reassure the patient that this is a simple, minor procedure. D. Ask the patient about any recent alcohol and drug use.

C Choice C is correct. Prochlorperazine should not be mixed with other medications as it is not compatible. Choice A is incorrect. The nurse does not need to check the respiration and temperature of the patient. Instead, the nurse should monitor the blood pressure and heart rate of the patient. Choice B is incorrect. These medications do not need to be diluted with normal saline. Choice D is incorrect. Prochlorperazine should not be mixed with other medications as it is not compatible.

The nurse is preparing to administer prochlorperazine maleate 10 mg IM and butorphanol 2 mg IM to a patient. Which is the most appropriate nursing action? A. Check the client's respirations and temperature B. Dilute the medications in 5 mL of normal saline C. Draw the medications in separate syringes D. Draw both medications in the same syringe

B Choice B is correct. When infusing fresh frozen plasma (FFP), the nurse should ensure that the FFP is ABO compatible with the recipient. Choices A, C, and D are incorrect. A baseline platelet count is not needed because FFP is utilized to correct coagulopathy - not thrombocytopenia. Baseline coagulation studies may be obtained, such as the internationalized normalized ratio (INR) or activated partial thromboplastin time (aPTT). FFP is infused over fifteen to thirty minutes, whereas packed red blood cells are administered over two to four hours. An electrocardiogram is not indicated prior to any blood product transfusion. ✓ FFP is indicated for deficiency of certain clotting factors. ✓ This blood product may also be used for warfarin toxicity and Vitamin K. ✓ FFP may also provide some volume resuscitation; however, its primary purpose is to assist with clotting. ✓ FFP is administered to a client over 15-30 minutes.

The nurse is preparing to transfuse fresh frozen plasma (FFP) to a client. Which of the following actions would be appropriate for the nurse to take? A. Obtain baseline platelet count B. Verify ABO compatibility C. Infuse over two to four hours D. Obtain a 12-lead electrocardiogram

C Choice C is correct. Preeclampsia occurs when a woman develops high blood pressure after 20 weeks of gestation. Choice A is incorrect. High blood pressure that presents before 20 weeks, usually is preexisting hypertension unrelated to pregnancy. Choice B is incorrect. Kidney function can be affected by high blood pressure but is not the defining factor of preeclampsia. Choice D is incorrect. Frequent nausea and vomiting, which sometimes limit weight gain during pregnancy, are known as hyperemesis gravidarum, not preeclampsia.

The nurse is providing education to a student nurse assigned to care for a pregnant mother with preeclampsia. The nursing student would not need to be corrected if they said which of the following about this condition? A. "If a woman develops high blood pressure at her first prenatal appointment she likely has preeclampsia." B. "The kidneys cause fluid overload leading to preeclampsia." C. "High blood pressure is one of the findings in preeclampsia and occurs after 20 weeks gestation." D. During preeclampsia episodes, the mother experiences frequent nausea and vomiting, sometimes preventing weight gain.

B, C Choices B and C are correct. Respiratory acidosis is caused by the inability to expel carbon dioxide either through obstruction in the airway or decreased ventilation. A pneumothorax causes shallow breathing, which causes the retention of CO2 (an acid). Opioids are central nervous system depressants. When the client is exposed to toxic levels, the effect causes hypoventilation and the retention of CO2. Choices A, D, and E are incorrect. An aspirin overdose stimulates causes metabolic acidosis because excessive ingestion leads to an increase in the hydrogen ion concentration. Renal disease also causes metabolic acidosis because of the kidneys inability to recycle bicarbonate in the body.

The nurse is teaching a class on acid-base imbalances. It would be correct for the nurse to identify which of the following would cause respiratory acidosis? Select all that apply. A. Aspirin overdose B. Pneumothorax C. Opioid overdose D. Anxiety E. Renal disease

B Choice B is correct. A colonoscopy is a test used to study the lining of the large intestine. Four to six hours before the procedure. the nurse is correct to instruct the client to not intake anything by mouth (NPO). Choice A is incorrect. The day before the process, the nurse should tell the client to have a clear liquid diet. Choice C is incorrect. Chalky white stools after the procedure are expected with a barium enema - not a colonoscopy. Choice D is incorrect. Abdominal pain and distention are unlikely as this would be worrisome for a perforation.

The nurse is teaching a patient who is scheduled for a colonoscopy. Which of the following information should the nurse include? A. "The day before the procedure you may have a regular diet." B. "You will not have anything to eat or drink by mouth for 4 to 6 hours prior to the test." C. "You may notice chalky white stools immediately after the procedure." D. "Your abdomen will be painful and distended after the test."

C Choice C is correct. A neonate is expected to be pinkish in appearance. Saliva should be minimal and the normal temperature for a newborn is from 36.5 °C to 37 °C. These signs need to be evaluated by the nurse to determine whether the baby needs further assessment. Choice A is incorrect. Molding and overriding sutures in a neonate are normal and may persist for a few days. Choice B is incorrect. Acrocyanosis in the newborn may be present for 2 to 6 hours. Meconium is expected to be passed within 24 hours after delivery. Choice D is incorrect. Tremors in the neonate are common. There is no need to worry about this sign.

The nurse is working in the NICU for the morning shift. While assessing four neonates less than 6-hours old, which neonate warrants additional attention from the nurse? A. A neonate with a molded head and overriding sutures. B. A neonate with cyanotic hands and feet that has not passed meconium. C. A neonate that is spitting up excessive mucus, with a temperature of 36.1 °C (97°F), and is dusky in appearance. D. A neonate with abdominal respirations and intermittent tremors of the extremities.

B Choice B is correct. A patient with increased intracranial pressure should have the head of the bed elevated at 30 or 40 degrees. Nurses should also be sure to avoid Trendelenburg and prevent the patient's neck from flexing. A standard ICP is about 5 to 15 mmHg. Choice A is incorrect. 25 degrees is too low and could increase intracranial pressure. Choice C is incorrect. 10 to 20 degrees is too low and could increase intracranial pressure. Choice D is incorrect. 5 to 10 degrees is too low and could increase intracranial pressure.

The nurse notes that her patient arriving from the emergency department has increased intracranial pressure and is planning to adjust the bed to accommodate them. At what angle should the nurse elevate the head of the bed? A. 25 degrees B. 30-40 degrees C. 10-20 degrees D. 5-10 degrees

D Choice D is correct. Sertraline is an antidepressant medication used to treat generalized anxiety disorder and major depressive disorder. This medication is a selective serotonin reuptake inhibitor (SSRI). Choices A, B, and C are incorrect. Schizophrenia is treated with antipsychotics such as haloperidol, aripiprazole, and ziprasidone. Bipolar disorder is treated with mood stabilizers such as lamotrigine, lithium, and valproic acid. Bulimia only has one medication approved for its treatment, and it is fluoxetine.

The nurse receives a prescription for sertraline. The nurse understands that this medication is used to treat which condition? A. Schizophrenia B. Bipolar disorder C. Bulimia D. Major depressive disorder

D Choice D is correct. When a client misses three or more oral contraceptive pills in a row, she should throw out the rest of the pack and start a new pack of pills the following Sunday. The nurse needs to inform her to use additional methods of contraception ( barrier methods, condoms) until seven days after starting a new pack of pills. Choice A is incorrect. Taking a contraceptive pill right away and continuing with the usual schedule is an instruction given to the clients who missed only one day of taking their pill. Choice B is incorrect. Taking two pills right away and two pills for the rest of the cycle is not indicated. Such a practice increases estrogen levels, placing the client at high risk of venous thromboembolism and arterial thrombotic events ( myocardial infarction, stroke). Choice C is incorrect. Taking two pills as soon as they remember, two capsules the following day, and continuing with one pill for the rest of the cycle is an instruction indicated for women who missed two consecutive contraceptive pills.

The nurse working in the gynecology clinic talks to the client who is concerned because she missed taking her contraceptive pill for four days. The most appropriate instruction of the nurse is: A. "Take one pill now and continue taking the pills on your regular schedule tomorrow." B. "Take two pills now and continue taking two pills for the rest of your regular schedule." C. "Take two pills now and two pills tomorrow. Continue with your usual schedule the following day." D. "Here's a new set of pills. Start taking the new pills this Sunday and throw away your old one, and use the second form of contraception for the next 7 days after starting your new pack."

A Choice A is correct. The patient has a history of chronic venous insufficiency, atrial fibrillation, and varicose veins, which are all risk factors for developing blood clots. The patient is also presenting with hallmark signs of deep vein thrombosis (unilateral lower leg pain, swelling, and redness). DVT is an emergency because a clot may dislodge and travel, causing a stroke or myocardial infarction. Of the choices, DVT is the most emergent situation. Choice B is incorrect. Cellulitis is an infection in the soft tissue. Although it is typically unilateral, it would not be as urgent as a blood clot. The patient's history of venous problems would not be a relevant risk factor for developing cellulitis. Choice C is incorrect. Osteomyelitis is an infection of the bone, caused by an external pathogen that usually enters the blood or tissue via an open wound. The patient's history of venous problems would not be a relevant risk factor for developing osteomyelitis. Choice D is incorrect. Lymphedema would cause bilateral swelling that is not warm to the touch.

The patient has a history of chronic venous insufficiency, atrial fibrillation, and varicose veins. Upon assessment, the RN finds the patient to be afebrile with left calf edema, pain, and erythema that is warm to the touch. What is the RN's most urgent concern? A. Deep vein thrombosis (DVT) B. Cellulitis C. Osteomyelitis D. Lymphedema

A Choice A is correct. The client's dietary modifications include low fat, low sodium, high fiber, high calcium, and high potassium. The nurse should reeducate the client that eating beef and pork is rich in saturated fats and should only be eaten sparingly. Choice B is incorrect. The client's dietary modifications include low fat, low sodium, high fiber, high calcium, and high potassium. Fruits and vegetables have a high fiber, vitamin, and mineral content; therefore, must be consumed regularly to help lower blood pressure. Choice C is incorrect. The client's dietary modifications include low fat, low sodium, high fiber, high calcium, and high potassium. Canned foods have a high sodium content due to preservatives; therefore, the patient should avoid these. Choice D is incorrect. The client's dietary modifications include low fat, low sodium, high fiber, high calcium, and high potassium. Yogurt is rich in calcium and low in fat.

The patient is being discharged from the hospital after being admitted because of hypertension. The nurse is talking to the patient about dietary modifications for hypertension. The nurse should reinforce her teaching when the client states which of the following: A. "I'm glad I can still eat beef and pork every day." B. "I will need to get used to eating fruits and vegetables." C. "I should stop eating canned foods." D. "I have already told my son to buy me some yogurt when I get home."

A, C, D Choices A, C, and D are correct. Respiratory infections are common in acute pancreatitis due to retroperitoneal fluid pushing the diaphragm upwards and causing the patient to take shallow abdominal breaths. Assisting the patient to change positions frequently, encouraging deep breathing as well as coughing exercises, and positioning patients for maximum chest expansion would all be preventative interventions to reduce the risk of respiratory infection. Choice B is incorrect. The question is looking for preventative actions to reduce the patient's risk of respiratory infection. While documentation would be indicated to recognize any changes or complications, it would not prevent disease.

The patient is diagnosed with acute pancreatitis. Which preventative intervention should the nurse implement to reduce the patient's risk of developing a respiratory infection? Select all that apply. A. Assist the patient to turn and reposition frequently. B. Document the respiratory rate and oxygen saturation. C. Place the patient in a semi-fowlers position. D. Encourage deep breathing and coughing.

3 tablets

The primary healthcare provider (PHCP) prescribes 30 mg of phenobarbital by mouth, once daily. The medication label reads phenobarbital 10 mg tablets. The nurse prepares to administer how many tablet(s) per dose? Fill in the blank.

1.4 mL

The primary healthcare provider (PHCP) prescribes amoxicillin 80 mg/kg/day to be given in two divided doses. The infant weighs 19.2 lbs. The label of the medication reads 250 mg/mL of amoxicillin. How many mL of amoxicillin should the nurse administer for one dose? Fill in the blank. Round your answer to the nearest tenth.

C Choice C is correct. HIV is a blood-borne pathogen, therefore sharing needles with IV drug abusers exponentially increases the risk of contracting the disease. Choices A, B, and D are incorrect. Although all of these answer choices are true, the most appropriate statement for the nurse to discuss is reflected in choice C.

When providing care for a patient with known IV drug use, which statement would be appropriate for the nurse to discuss to highlight the risk factors of this behavior? A. The use of these drugs can increase the risk of contracting diseases due to immunosuppression. B. IV drug use can lead to skin infections at the injection sites and poor health. C. The risk of contracting and spreading bloodborne pathogens such as HIV, which can progress to AIDS, is a considerable risk factor for this activity. D. Drug use can lead to unsafe sex practices, increasing the risk of transmission of sexually transmitted diseases/infections.

C Choice C is correct. Carbon monoxide is a hazardous gas that can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm. This odorless and colorless gas can be deadly, so it is recommended that all homes have a carbon monoxide alarm. Choice A is incorrect. Although ozone can be present and harmful in buildings, there is not a simple and relatively inexpensive monitor and alarm for ozone that is similar to a smoke alarm. Choice B is incorrect. Although nitrous oxide is a medical gas, there is not a simple and relatively inexpensive monitor and alarm for nitrous oxide that is similar to a smoke alarm. Choice D is incorrect. Although carbon dioxide is a gas, there is not a simple and relatively inexpensive monitor and alarm for carbon dioxide that is similar to a smoke alarm.

Which hazardous gas can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm? A. Ozone B. Nitrous oxide C. Carbon monoxide D. Carbon dioxide

C Choice C is correct. 3% saline is a hypertonic solution, so the nurse should monitor for signs/symptoms of fluid volume overload and pulmonary edema (increased blood pressure, crackles in lungs, shortness of breath). This type of fluid increases extracellular osmolality and volume. High osmotic pressure causes water to shift from inside cells into the extracellular fluid. Hypertonic solutions are used to treat hypovolemia and hyponatremia. Choice A is incorrect. The nurse should expect to monitor serum sodium levels, not serum bicarbonate (HCO3), to assess the effectiveness of treatment. Choice B is incorrect. The nurse should assess serum sodium levels, not urine sodium levels. Choice D is incorrect. A 24-hour urine collection would not be the most effective way to monitor for fluid overload.

Which nursing intervention would be a priority for a patient receiving 3% saline maintenance fluids? A. Monitor serum HCO3- B. Monitor urine sodium C. Assess blood pressure D. Collect 24-hour urine output

A, B Choices A and B are correct. Poor feeding is often one of the first signs of decreased cardiac output in an infant. It becomes harder for the infant to breathe while feeding; they often become sweaty and pale during feedings. This is a classic sign of decreased cardiac output (Choice A). Irritability, restlessness, or lethargy are vital signs of decreased cardiac output in the infant (Choice B). Choice C is incorrect. Tachycardia, not bradycardia, would be a sign of decreased cardiac output. The body senses decreased perfusion and provides feedback to the heart to beat faster to make up for it. In doing so, the infant compensates for the decreased cardiac output for some time. Only after their body can no longer keep up will it progress to bradycardia. Choice D is incorrect. Decreased urine output would be a sign of decreased cardiac output. As the perfusion to the body lessens, blood is reserved for essential organs and the kidneys do not get as much blood flow; eventually leading to decreased urine output.

Which of the following are signs of decreased cardiac output in an infant with congenital heart disease? Select all that apply. A. Poor feeding B. Irritability C. Bradycardia D. Increased urine output

B, D Choices B and D are correct. The nurse must perform a thorough assessment of the perfusion status of the extremity distal to where the puncture was. In a cardiac cath, a sheath is inserted through an artery and snaked up into the heart. This sheath occluded blood flow during the procedure. So, we must monitor the extremity through which they placed the sheath to ensure perfusion returns properly. This includes assessing the pulse, capillary refill, the color of the extremity if there is any pain or numbness, and movement of the extremity. Usually, a femoral artery is used, so we must monitor the perfusion of the foot on the leg that was accessed (Choice B). Monitoring for hematoma formation over the access site is a critical nursing intervention. The most common complication after a cardiac catheterization is bleeding, and the creation of a hematoma shows bleeding under the skin. The nurse should notify the health care provider if she notes a hematoma forming so that they may evaluate the patient. Be sure to monitor for other signs of bleeding as well, especially around the access site (Choice D). Choice A is incorrect. If the patient who is postoperative from a cardiac catheterization has metformin scheduled, the dose should be held for 48 hours post-op. Iodinated contrast used for cardiac catheterization may cause kidney failure. Should such acute kidney failure occur, metformin metabolites can accumulate and cause lactic acidosis. Therefore, metformin should always be held for 48 hours after any procedure that involves iodinated contrast. Choice C is incorrect. Positioning is critical after a cardiac catheterization. For 4 to 6 hours post-op, the head of the bed should be flat or slightly elevated but no more than 30 degrees. Such positioning prevents bleeding and helps the access site from the cardiac catheterization ultimately heal. It is also essential to educate the patient about this so that they will be still and not try to stand up on their own before they are allowed to.

Which of the following are substantial nursing interventions for a patient who is one-hour post-op from a cardiac catheterization? Select all that apply. A. Administer their regularly scheduled metformin on time. B. Assess the pulse of the extremity distal to the puncture site. C. Position them supine with the head of bed at 45 degrees. D. Monitor for hematoma formation at the puncture site.

A Choice A is correct. A young child may place small or loose parts of toys in his mouth. A toy that is safe for a 10-year-old child could be deadly for a toddler. Choice B is incorrect. 5-year-old eating yogurt is not a safety concern. Choice C is incorrect. An infant sleeping in an empty crib is not a safety concern. According to the American Academy of Pediatrics, blankets and pillows increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Several infants die each year while sleeping, and the cause is attributed to SIDS, suffocation, entrapment, or strangulation. Blankets increase the risk of all these four reasons. Choice D is incorrect. A 3-year-old drinking a glass of juice is not a safety concern.

Which of the following children would the nurse identify as a priority for having the greatest risk for choking and suffocating? Correct A. A toddler playing with his 9-year-old brother's construction set. B. A 5-year-old eating yogurt for a snack. C. An infant asleep in her crib without a blanket. D. A 3-year-old drinking a glass of juice.

A, B Choices A and B are correct. It is essential to refrain from talking much about the delusions that your manic patient is having. Delusions of grandeur, such as the patient thinking they are god, come from a need for them to feel necessary and proper about themself. You need to support the patient's confidence in a realistic way. By refraining from talking excessively about the delusion, you are not supporting its reality, which is therapeutic for the patient (Choice A). Setting boundaries and limits are incredibly crucial for the manic patient. These patients can be incredibly manipulative and by setting limits, you will be helping them come back down to reality. Consistency is also key to these boundaries. For example, if you make a rule that lights must be off at 10:00 pm each night, this rule should be followed every single night without exception (Choice B). Choice C is incorrect. Enforcing three meals a day will not work for the manic patient. They are too busy to sit down for a large meal and will end up just forgetting to eat. This can lead to severe malnutrition and dehydration. It is essential to provide the patient with finger foods and stay with them while they walk and eat. Keep them calm and try to maximize the calories that they are getting instead of trying to enforce sitting through three meals a day. Choice D is incorrect. It is not therapeutic to argue with a manic patient. These patients are very manipulative and argumentative. They will fight back and their behavior will escalate. It is essential to help guide them towards reality by setting boundaries and letting them know their delusion is not your reality, but you should never argue.

Which of the following nursing interventions are appropriate for a manic patient experiencing delusions of grandeur? Select all that apply. A. Refrain from talking excessively about their delusion B. Set boundaries C. Enforce three meals a day D. Argue that their delusions are not your reality

A Choice A is correct. Idiosyncratic side effects of medications are relatively unpredictable and they occur on a highly individual basis. Distinctive side effects of medications are peculiar, rare, and unusual side effects of the drug. Choice B is incorrect. Pharmacokinetics addresses the four phases of medications, which are the absorption, distribution, biotransformation or metabolism, and excretion of drugs; not the three phases of medications. Choice C is incorrect. Isoniazid may more slowly, but not more rapidly, absorb among Scandinavians when compared to Japanese clients. Ethnic differences in terms of medications are referred to as ethnopharmacology. Choice D is incorrect. Medications can lead to decreased, rather than increased absorption when they have similar metabolic pathways. Related metabolic pathways can lead to the accumulation of drugs and toxicity when one or more medications share the same metabolic pathway.

Which of the following pharmacological statements is accurate? A. Idiosyncratic side effects to medications are relatively unpredictable and they occur on a highly individual basis. B. Pharmacokinetics addresses the three phases of medications which are the absorption, distribution, and excretion of medications. C. It is possible that isoniazid will more rapidly absorb among Scandinavians when compared to Japanese clients. D. Medications can lead to increased absorption when they have similar metabolic pathways.

A, B, C, D Choices A, B, C, and D are all correct. All rhythm changes will affect cardiac output. This is especially important to remember when you are administering antiarrhythmics to your patient, as these medications and their effect will also change the cardiac output. There are two reasons that rhythm changes affect cardiac output. 1 - they break your heart rate. 2 - they change your stroke volume. Remember, CO = HR x SV, so any change to either heart rate or stroke volume subsequently affects your cardiac output. A - Supraventricular tachycardia (SVT) - There is an increase in heart rate, but a decrease in stroke volume. This is because the heart is beating so fast that there is not enough time for diastole and, therefore, not enough time for the atriums to fill with blood. This decreases preload, which decreases contractility due to starling's law, which reduces stroke volume. Patients in SVT have decreased cardiac output. B - Sinus bradycardia - The heart rate is lower, due to bradycardia, so the cardiac output is lowered. Remember, CO = HR x SV. Decreased HR = decreased CO. C - Ventricular tachycardia - There is an increase in heart rate and a decrease in stroke volume. This is because the heart is beating fast and irregularly. There is not enough time for diastole and therefore not enough time for the atriums to fill with blood. This decreases preload, which decreases contractility due to Starling's law, which reduces stroke volume. Patients in VT have decreased cardiac output. This is a lethal rhythm. D - Mobitz type II heart block - This type of heart block causes a decreased heart rate, which once again decreases cardiac output. CO = HR x SV. Decreased HR = decreased CO. Patients in Mobitz type II heart block have decreased cardiac output.

Which of the following rhythm changes will have an impact on cardiac output? Select all that apply. A. Supraventricular tachycardia B. Sinus bradycardia C. Ventricular tachycardia D. Mobitz type II heart block

B,C Choices B and C are correct. A respiratory rate of 88 is tachypneic, which is what we would expect for an infant experiencing neonatal abstinence syndrome (NAS). Tachypnea is a common sign of NAS, as is respiratory distress. It is not uncommon to appreciate an increased work of breathing, including things such as nasal flaring, head bobbing, and retractions in these infants (Choice B). Diaphoresis or excessive sweating is a common symptom of infants in neonatal abstinence syndrome. Most of these infants are incredibly irritable, hot, and sweaty. It is similar to the withdrawal you would expect in an adult that goes cold turkey on a drug (Choice C). Choice A is incorrect. A temperature of 36.5 degrees Celsius is an average temperature, whereas an infant withdrawing from heroin would likely present with a fever. For NAS scoring, an illness is higher than 37.8 degrees Celsius. Most of these infants are incredibly irritable, hot, and sweaty. It is similar to the withdrawal you would expect in an adult that goes cold turkey on a drug. Choice D is incorrect. In an infant experiencing neonatal abstinence syndrome, you would expect to see very loose frequent stools, not constipation. These loose stools are so prevalent that many of these infants end up with horrible skin breakdown due to sitting in diapers filled with loose stool. It is essential to know that diarrhea is a common sign of NAS, so that you may monitor for these complications.

Which of the following signs and symptoms would you expect to see in an infant withdrawing from heroin? Select all that apply. A. Temperature 36.5 degrees Celsius B. Respiratory rate 88 C. Diaphoretic D. Constipation

A, D Choices A and D are correct. Any increase in volume will cause an increase in cardiac output. When you increase the amount of mass in circulation, you increase the patient's stroke volume. Since the formula for cardiac output is CO = HR x SV, there are two ways to increase CO - by increasing the HR or increasing the SV. One sure way to increase the stroke volume, or amount of blood that the heart is pumping out with each beat, is to increase the amount circulating. Fluid boluses are commonly used to increase cardiac output (Choice A). Dopamine will increase cardiac output. Dopamine is an inotrope that improves the contractility of the heart. This means that the center will contract harder and pump out more blood with each contraction. This is an increase in stroke volume and because CO = HR x SV, an increase in SV causes an increase in CO. Any inotrope that improves the contractility of the heart will cause an increase in CO. This includes dopamine, dobutamine, and milrinone, to name a few (Choice D). Choice B is incorrect. Furosemide administration would decrease cardiac output. Furosemide is a potent loop diuretic, which induces diuresis and therefore reduces the amount of fluid in the vasculature. With reduced volume, preload in the heart is decreased. With decreased preload, there is diminished contractility due to Starling's law ("The greater the stretch on the myocardium before systole (preload), the stronger the ventricular contraction"). With decreased contraction, there is reduced stroke volume, and therefore decreased cardiac output. Choice C is incorrect. The administration of propranolol will decrease cardiac output. This is due to propranolol decreasing the heart rate. Propranolol is a beta-blocker used to control the pulse of the heart and therefore reduces the heart rate. Since CO = HR x SV, any decrease in the heart rate will decrease cardiac output; this is why the administration of any beta-blocker will lower cardiac output.

Which of the following would cause an increase in cardiac output? Select all that apply. A. 2 L normal saline fluid bolus B. Furosemide C. Propranolol D. Dopamine

D Choice D is correct. The Patient-Generated Subjective Global Assessment is a screening tool you would use to screen clients for their current nutritional status. The Patient-Generated Subjective Global Assessment, referred to as the PG-SGA nutritional assessment, is an assessment tool that can be used to assess nutritional status, among others, such as the Nutritional Screening Initiative screening and assessment tool. Choice A is incorrect. The Klein-Bell Scale is used to perform a neurological and musculoskeletal assessment, not a nutritional screening or evaluation. Choice B is incorrect. The Barthel Index is used to perform a neurological and musculoskeletal assessment, not a nutritional screening or evaluation. Choice C is incorrect. The Wong-Baker assessment tool is a pain assessment tool, not a nutritional screening or assessment tool.

Which screening tool would you use to screen clients for their current nutritional status? A. The Klein-Bell Scale B. The Barthel Index C. The Wong-Baker Assessment tool D. The Patient Generated Subjective Global Assessment

B Choice B is correct. Equianalgesia is the term that is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine. The equianalgesic of an opioid, when compared to parenteral morphine, is mathematically calculated. Choice A is incorrect. Morphine equivalency relates to the equivalency of an opioid analgesic when compared to parenteral morphine. Choice C is incorrect. Morphine equivalent relates to the equivalency of an opioid analgesic when compared to parenteral morphine. Choice D is incorrect. The morphine factor is the term that elements in the power of parenteral morphine.

Which term is used to describe the comparative potency and strength of an opioid analgesic when compared to parenteral morphine? A. Morphine equivalency B. Equianalgesia C. Morphine equivalent D. The morphine factor

A Choice A is correct. A milieu environment is the type of care environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. A milieu environment is planned and maintained in a manner that eliminates all possible stressors so that the clients with emotional and behavioral problems can concentrate their energies and thoughts on the things impacting them rather than external stressors that have been eliminated from the environment of care. Choice B is incorrect. A locked environment is not the type of care environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. Clients are placed in a locked environment only when all alternative measures are not possible or practical, and the client is in grave danger to themselves and others, as consistent with the regulations of the Centers for Medicare and Medicaid Services and the Joint Commission on the Accreditation of Healthcare Organizations. Choice C is incorrect. Although mindfulness therapy is used for a large number of clients with different psychiatric mental health disorders in a wide variety of care environments, mindfulness is not the environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. Choice D is incorrect. An environment that employs universal seclusion for all clients is not the type of care environment that is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues. Seclusion and restraint are a last resort and, as such, they are not employed unless all other measures to protect the client and others from imminent harm have not been effective, as consistent with the regulations of the Centers for Medicare and Medicaid Services and the Joint Commission on the Accreditation of Healthcare Organizations.

Which type of care environment is the most therapeutic and the most conducive for the treatment of clients with emotional and behavioral issues? A. A milieu environment B. A locked environment C. One employing mindfulness therapy D. One employing universal seclusion

B Choice B is correct. 25 to 35 pounds. The amount of optimal weight gain during pregnancy is determined based on the woman's body mass index (BMI) before pregnancy. BMI is a measure of body fat calculated from weight and height. Please use the following table to determine the recommended weight gain during pregnancy. A baseline BMI of 22 indicates that this woman's baseline is in the healthy range (Normal BMI = 18.5 to 24.9). The recommended weight gain for this client is 25 to 35 pounds. Weight gain during pregnancy is crucial to the health and well-being of the baby and the mother. Gaining too little weight can lead to premature birth and low infant birth weight. Gaining too much weight can also result in premature birth and obesity of the child in later life. Excessive weight gain can result in strenuous labor, the increased possibility of needing a caesarian section, and increased bleeding. Choice A is incorrect. This is the recommended weight gain during singleton pregnancy for an underweight woman. Choice C is incorrect. This is the recommended weight gain during singleton pregnancy for an overweight woman. Choice D is incorrect. This is the recommended weight gain during singleton pregnancy for an obese woman.

You are caring for a pregnant woman with a baseline BMI of 22. You educate this client on the desirable weight gain during pregnancy with one baby for her is: A. 28 to 40 pounds B. 25 to 35 pounds C. 15 to 25 pounds D. 11 to 20 pounds

A Choice A is correct. As individuals age, they are at increased risk for senile cataracts. During the early stages of this condition, diminishing distance vision is the highest risk for older adults. The nurse must caution the patient that the ability to see signs when driving will present a significant risk. Choice B is incorrect. Usually, near vision is not affected by these cataracts. Choice C is incorrect. In the early stages, color vision is not usually affected, although there may be changes as the condition progresses. Choice D is incorrect. Extraocular movements are not affected by senile cataracts. The cranial nerves that control eye movements are not affected by cataracts.

You are working in a community clinic. You are giving instructions to a 72-year-old man who was diagnosed today with early bilateral senile cataracts. You know that the man understood your instructions when he says: A. "I may have to quit driving until I get the cataracts treated." B. "I am going to miss being able to read the morning newspaper." C. "My wife will have to pick out my clothes since I won't be able to see the colors." D. "I will have to be careful since my eyes won't move together.

A, B Choices A and B are correct. An acute illness (fever, sepsis, infection) typically causes delirium, so delirium often has an abrupt onset (Choice A) with rapid progression. There are significant changes in activity resulting in hyperactivity or hypoactivity (Choice B). Delirium is typically reversible when the underlying illness is resolved. Delirium typically lasts for hours to days, whereas dementia lasts for months to years and is usually irreversible. Choices C and D are incorrect. These two characterize dementia. Dementia has a variety of causes with gradual changes in mentation. In dementia, psychomotor changes occur later in the disease; speech is sparse and may progress to mutism as the disease advances.

You are working with older adults in the clinic. The 80-year-old woman is brought to the clinic by her family with fever and changes in her mental status. When attempting to differentiate between delirium and dementia, you know that delirium is characterized by which of the following? Select all that apply. A. Abrupt onset B. Change in psychomotor activity C. Irreversible D. Lasts for months to years

A, F Choices A and F are correct. When making client assignments, the LPN should be assigned to a stable client with a predictable outcome. A client receiving antibiotics for lower extremity cellulitis is a low acuity illness and may be cared for by the LPN. Scheduled tube feedings and colostomy irrigations are within the scope of an LPN, and this can be delegated. Choices B, C, D, and E are incorrect. The RN should assume care for clients who are unstable and may have unpredictable outcomes. The client having an exacerbation of myasthenia gravis may be unstable and require frequent assessment. A client receiving mechanical ventilation with a chest tube has an unpredictable outcome and should be assigned to the RN. An RN can only initiate referrals; thus, this client is appropriate for the RN. RhoGAM is a blood product and can only be given by an RN

The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the LPN? Select all that apply. A client A. receiving antibiotics for lower extremity cellulitis. B. newly admitted with an exacerbation of myasthenia gravis. C. with a chest tube and receiving mechanical ventilation. D. requiring a referral to an outpatient support group. E. needing to receive intramuscular RhoGAM. F. needing scheduled tube feedings and colostomy irrigations.

D Choice D is correct. The nurse should use all the data gathered to analyze the situation. The client had abdominal surgery and has hypoactive bowel sounds. The nurse needs to do a further assessment to determine if there are any impending GI problems for the client and if any treatments need to be initiated. Choice A is incorrect. The client's wound dressing is dry and intact. The client is not hysterical. There is no sign of infection. Choice B is incorrect. The client states that he is not in pain; there is no need for pain relief. Choice C is incorrect. The client is four days post-op; the client is already expected to have normoactive bowel sounds. However, the client is exhibiting hypoactive bowel sounds, which signifies a problem.

The nurse is caring for a 4-day post-abdominal surgery client. The nurse notes a temperature of 37 °C, no complaints of pain at the incision site, dry wound dressing, and hypoactive bowel sounds on all quadrants. Which conclusion can the nurse make based on all the assessment data? A. The client's wound is getting infected. B. The nurse should implement pain relief measures. C. There are no present problems for the client. D. The nurse should perform an additional GI assessment.

C Choice C is correct. The nurse needs to assess the situation further when conflicting information is noted. Although the client states that his pain level is 1/10, his grimace at every movement tells otherwise. The nurse should validate her observations and make further assessments. Choice A is incorrect. The nurse needs to validate her observations first alongside what the client tells her to perform a more appropriate intervention. Choice B is incorrect. The nurse should not dismiss her observations about the client. Choice D is incorrect. Before performing interventions such as distraction, the nurse should validate her observations first.

The nurse is caring for a client in pain. The nurse asks the client which level of pain he is in, and the client says it's 1 out of 10. The nurse notices that the client grimaces every time he moves. What is the nurse's most appropriate action? A. Administer analgesics to the client. B. Move on to other patients. C. Ask the client about his grimacing with every movement. D. Encourage the client to watch his favorite TV show

D, E Choices D and E are correct. Site ecchymosis ( Choice D) can be treated with the elevation of the extremity and applying cold compresses to the site. Catheter embolus ( Choice E) refers to the migration of catheter fragments following a fracture/ rupture of the catheter. Catheter rupture may occur due to excessive pressure when flushing the line. Excessive force should not be applied if the catheter does not flush easily. Catheter embolism can be managed by placing a tourniquet above the site to limit blood flow and catheter particle migration. The other common intravenous therapy complications and recommended interventions are as follows: Mechanical phlebitis (Choice A is incorrect): Phlebitis refers to the inflammation of the vein. Phlebitis due to catheter-related injury/ irritation is called "mechanical" phlebitis. Signs and symptoms include tenderness, erythema, and edema. If phlebitis is accompanied by thrombosis of the superficial veins, it is called "superficial thrombophlebitis" or superficial venous thrombosis. If it becomes infected, it is referred to as "suppurative thrombophlebitis." Treatment of phlebitis is aimed at reducing inflammation. Mechanical phlebitis is treated with the application of warm, moist compresses along with the administration of non-steroidal anti-inflammatory agents. Superficial Thrombophlebitis (Choice B is incorrect): Treatment should be aimed at reducing the swelling and symptoms. Elevation of the limb minimizes the swelling. The affected extremity should be elevated, not kept below the heart level. Ambulation should be encouraged. The physician may order a venous doppler to exclude concomitant deep vein thrombosis. Extravasation (Choice C is incorrect): Manual pressure should not be applied to the extravasated site. Management is focused on the elevation of the affected limb to help reabsorb the extravasated infiltrate. Septic (suppurative) Thrombophlebitis (Choice F is incorrect): Septic thrombophlebitis is characterized by the presence of a thrombus with inflammation and pus formation (suppuration). Clinical features include fever, redness, tenderness, a palpable cord, and purulent drainage at the affected venous site. If pus drainage is present, culture is necessary. Treatment includes catheter removal and broad-spectrum antibiotics as prescribed.

Select the complications of intravenous therapy that are accurately paired with its possible treatment after the intravenous line is discontinued. A. Mechanical phlebitis: the application of ice B. Superficial thrombophlebitis: lowering the extremity below the level of the heart C. Extravasation: the application of manual pressure to the site D. Site ecchymosis: elevation of the extremity and applying cold compresses E. Catheter embolus: placing a tourniquet above the site to limit blood flow and catheter particles migration F. Suppurative thrombophlebitis: the injection of a thrombolytic directly into the IV

C Choice C is correct. The best and most effective way to evaluate your adult client's response to non-pharmacological comfort interventions is to compare pre- and post-intervention data using a numerical pain rating scale that is typically a scale from 0 to 10 with 0 being the absence of pain, 1 is the presence of minimal pain, and 10 is the greatest pain imaginable. Choice A is incorrect. The PQRST pain assessment method is used to assess pain and not to measure comfort levels. PQRST stands for precipitating events, quality of the pain, region or area of the pain, severity of the pain, and triggers that cause the pain. Choice B is incorrect. Asking the client if they feel better after the comfort intervention is not the best and most effective way to evaluate your adult client's response to non-pharmacological comfort interventions because this open-ended question elicits only a yes or no response and no other objective data about the level of intensity of the pain. Choice D is incorrect. Comparing pre and post-intervention data using the NIPS (Neonatal Infant Pain Scale) pain rating scale to evaluate your adult client's response to non-pharmacological comfort interventions is not a way to evaluate your adult client's response to non-pharmacological comfort interventions because the NIPS scale is used to assess pain among the neonate and not the adult population of clients.

The best and most effective way to evaluate your adult client's response to non-pharmacological comfort interventions is to: A. Use the PQRST pain assessment method to measure comfort. B. Ask the client if they feel better after the comfort intervention. C. Compare pre- and post-intervention data using a numerical pain rating scale. D. Compare pre- and post-intervention data using the NIPS pain rating scale

B Choice B is correct. Tenofovir-emtricitabine is a medication used as pre-exposure prophylaxis (PrEP) for clients at high risk for HIV infection. This medication is taken daily and may provide up to 96% efficacy against HIV infections. Choices A, C, and D are incorrect. The other options are not utilized in PrEP. Voriconazole is an antifungal agent. Raloxifene is an estrogen modulator utilized in the management of breast cancer. Lurasidone is an atypical antipsychotic indicated for psychotic and mood disorders. ✓ Pre-exposure prophylaxis (PrEP) is an effective medication in reducing HIV infections for those at risk. ✓ PrEP can be administered via a daily pill or an injection every two months. ✓ The efficacy of PrEP is up to 99% when taken as prescribed. ✓ Indications for a client to start PrEP include unprotected intercourse, multiple sexual partners, and intravenous drug use.

The nurse is caring for a client interested in pre-exposure prophylaxis for human immunodeficiency virus (HIV). Which prescription would the nurse anticipate? A. Voriconazole B. Tenofovir-emtricitabine C. Raloxifene D. Lurasidone

D Choice D is correct. Compartment syndrome occurs when pressure increases in one area of the fascia groups around the muscle, causing a decrease in blood flow to the other parts of the affected limb. Compartment syndrome is identified by increasing pain in the affected limb, passive pain when moved, and pale swollen tissue distal to the site. Quick diagnosis is essential in compartment syndrome because permanent damage can occur to the tissue within 4 to 6 hours. Choice A is incorrect. A fat embolism is a complication of a fracture that occurs when a fat globule from the bone marrow is released into the blood system. This complication generally occurs within 48 to 72 hours after the injury. Choice B is incorrect. A disease related to a breach can occur at any time during the healing process. While infection, usually osteomyelitis, is a complication of a fracture, it results in red and swollen skin, an elevated temperature, and some pain. Choice C is incorrect. A pulmonary embolism can occur because of a fracture but presents with chest pain and shortness of breath rather than problems at the fracture site.

The nurse performs a focused assessment on a casted patient experiencing increased pain in the affected limb. The nurse notes pallor and swelling distal to the cast area. The patient reports increased pain upon passively moving the extremity. Which of the following fracture-related complications should the nurse be concerned about? A. Fat embolism B. Infection C. Pulmonary embolism D. Compartment syndrome

A, B, C Choices A, B, and C are correct. Assessing that the client has bruising over the sacral area is achieved by visually inspecting the skin. Noting the presence of a foul odor is an example of inspection that uses the sense of smell. The nurse would inspect the client's neck to note visible jugular vein distension. Choices D and E are incorrect. Assessment of tympany in the abdomen is obtained through percussion and is typically observed over areas of air-filled organs such as the intestines. Assessment of the bowel sounds is obtained through auscultation with a stethoscope. Inspection is the first step in a physical assessment and describes the process of obtaining purposeful observations about a client using the senses of vision, hearing, and smell. Auscultation involves listening to areas of the client's body (such as lungs, heart, and bowel sounds) with a stethoscope. Palpation and percussion are methods that use the sensation of touch and are performed by using the hands or fingers to tap or feel areas of the client's body. Palpation gives information about aspects such as the skin temperature, turgor, moisture level, tenderness, and the presence of any edema. Percussion provides information about whether an area is filled with air, an organ, bone, or other solid masses.

The nurse performs a physical assessment on a client. Which of the following would the nurse recognize as a technique of inspection? Select all that apply. A. Ecchymosis to sacral area. B. Foul odor noted to urine. C. Jugular veins distended. D. Abdomen is tympanic. E. Bowel sounds hyperactive

D Choice D is correct. Swimming is the best exercise at this point in the mother's pregnancy. Swimming is low impact and requires no balance, which can be troublesome with the weight a woman carries in her third trimester. Choices A, B, and C are incorrect. These activities are too high of an intensity for a woman who is just starting an exercise regimen and require careful steadiness.

The prenatal client is 7 months pregnant and wants to start an exercise program. The nurse should suggest which of the following exercises to the patient? A. Bike riding B. Circuit training C. Aerial yoga D. Swimming

D Choice D is correct. Weight bearing means a person is working against the weight of another object. Weight bearing helps with osteoporosis because it strengthens muscles and builds bone. Studies have shown that weight bearing exercise increases bone density and reduces the risk of fractures. An estimated 10 million Americans have osteoporosis. The risk increases with age and is much higher in women, mainly in relationship with hormonal changes at menopause and inadequate calcium intake. Cigarette smoking, moderate to heavy alcohol consumption, and lack of weight-bearing exercise, also increase the risk of osteoporosis. Choice A is incorrect. This is not the most appropriate choice. All people should avoid potentially dangerous activities. Choice B is incorrect. Exercise to strengthen muscles is important, but for the client with osteoporosis the emphasis should be placed on building bone density, which will reduce the risk of fractures. Weight bearing exercises are the best option for this. Choice C is incorrect. While weight loss can help reduce the stress on joints and alleviate symptoms related to arthritis or back pain, obesity is not a high-risk factor for osteoporosis.

What is the most appropriate instruction to give a client with osteoporosis regarding exercise? A. Avoid exercise activities that increase the risk of fractures. B. Exercise to strengthen muscles and thereby protect bones. C. Exercise to reduce weight. D. Exercise doing weight-bearing activities.

A Choice A is correct. Impaired mobility in older adults creates a risk for airway collapse, reduced air exchange, hypoxia, hypercapnia, and acidosis. Reduced gag and cough reflexes can place older people at risk for aspiration of secretions and, potentially, aspiration pneumonia. There is a possibility of postoperative respiratory complications because of impaired cough reflex, weaker muscles, and decreased inspiratory capacity. Older adults are at increased risk of respiratory complications due to stress. The nurse should pay attention to maintaining adequate ventilation, keeping lung volumes high, clearing secretions, and positioning to prevent aspiration. Choices B, C, and D are incorrect. The airway always assumes priority in an assessment.

What is the priority nursing assessment for a 76-year-old patient with pneumonia? A. Airway patency B. Percussion sounds C. Breath sounds D. Respiratory rate

A Choice A is correct. To assess turgor in an adult, the most reliable method is to pinch a fold of skin on the anterior chest, release it, and observe for the skin to promptly recoil to its original state. Choice B is incorrect. Turgor is assessed in infants and toddlers on the abdomen. Choice C is incorrect. Turgor can not be checked on the calf in any population. Choice D is incorrect. A fold of skin on the forehead can be used to check skin turgor in the elderly, not children.

When assessing hydration in an adult patient, the nurse will: A. Pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal. B. Pinch a fold of skin on the abdomen and observe for recoil to normal. C. Pinch a fold of skin on the calf and observe for recoil normal. D. Pinch a fold of skin on the forehead and allow for the skin to recoil in children.

A Choice A is correct. The discoloration of the abdomen and periumbilical area is known as Cullen's sign and indicates pancreatitis when it occurs in conjunction with other symptoms. Other findings include elevated white blood cell count, bilirubin, and urinary amylase levels. Choice B is incorrect. In pancreatitis, bowel sounds are generally diminished or absent. Choice C is incorrect. Bilirubin levels are generally elevated in instances of pancreatitis. Choice D is incorrect. Bluish discoloration of the feet is not associated with pancreatitis. However, bluish discoloration of the flanks is known as Turner's sign and is used as an indicator of pancreatitis.

patient is being evaluated in the clinic for pancreatitis. Besides an elevated white blood cell count and serum lipase levels, which assessment finding indicates a positive finding for pancreatitis? A. The discoloration of the abdomen and periumbilical area B. Overactive bowel sounds C. Low bilirubin levels D. Bluish discoloration of the soles of the feet