ARCHER - PRACTICE QUESTIONS #5

The nurse is caring for a client who is one day postoperative and had a water-seal chest tube placed for a hemothorax. The nurse observes that the drainage in the collection chamber has decreased in the previous three hours. The nurse should assess A. for tidaling in the water seal chamber. B. the tubing for any possible kinks. C. the system for an air leak. D. for bubbling in the suction control chamber.

Choice B is correct. The nurse should assess the tubing for any kinks for a client with hemothorax and who has had no drainage. The tubing directly empties into the drainage collection chamber, and considering that it is too early for the hemothorax to resolve, it is likely an obstruction in the tubing. Another intervention the nurse can take is moving the client to allow the fluid to drain into the system. Chest tube drainage should be free of any kinks. Choices A, C, and D are incorrect. Assessing for tidaling in the water seal would not be helpful because the issue is in the drainage collection chamber. Assessing for an air leak is irrelevant to problems in the water seal chamber. This client's issue is that the drainage in the suction control chamber is decreasing, so the problem would be the tubing and drainage collection chamber. An air leak would not cause drainage to decrease. This client's issue is the drainage decreasing, so assessing the suction control chamber for bubbling would not be relevant. The client's chest tube is to water seal, and the suction control chamber should not be bubbling.

The nurse is preparing to give alendronate to the client with osteoporosis. The nurse should explain to the client that the expected outcome of this medication is primarily to A. decrease bone inflammation. B. increase synovial fluid in the joint space. C. inhibit bone resorption. D. increase serum calcium levels.

Choice C is correct. Bisphosphonates such as risedronate, alendronate, ibandronate, zoledronic acid, and pamidronate are administered to inhibit bone resorption. Therefore, they decrease osteoclastic activity. The decrease in osteoclastic activity increases bone density, making the bone less prone to fracture. Choice A is incorrect. Bisphosphonates are not antiinflammatory. Osteoporosis is not an inflammatory type of condition as it results from increased osteoclastic activity, decreasing bone density. Choice B is incorrect. Bisphosphonates do not increase synovial fluid in the joint space. Osteoporosis is not a condition altering the synovial fluid in the joint space. Rheumatoid arthritis (RA) causes thickening of synovial joint fluid. Medications such as glucosamine chondroitin are used in conditions such as RA and osteoarthritis. Choice D is incorrect. Bisphosphonates do not increase serum calcium levels because they inhibit osteoclastic activity, preventing the bone's calcium from going into the blood. Bisphosphonates can also be used in hypercalcemia for this reason.

The nurse is evaluating a patient's response to peripheral pain. Which technique should the nurse use to perform this evaluation? A. Pressure on the patient's mid-back B. Sternal rub C. Squeezing the sternocleidomastoid muscle D. Pressing on the patient's nail bed

Choice D is correct. To test peripheral responses to pain, health care providers should apply pressure to outer body parts such as the toes or fingers. Pressing on the patient's nail bed is the most appropriate action. Choice A is incorrect. Applying pressuring on the patient's mid-back does not evaluate peripheral pain. Choice B is incorrect. Sternal rubs are most often used to test consciousness. Choice C is incorrect. Squeezing, the patient's sternocleidomastoid muscle does not evaluate peripheral pain. NCSBN client need Topic: Pharmacological Integrity, Reduction of Risk Potential

The nurse is caring for a client who was just intubated via an endotracheal tube (ETT). The nurse anticipates that the placement of the tube will be verified by Select all that apply. chest x-ray. cuff pressure. chest wall movement. end-tidal carbon dioxide (EtCO2). arterial blood gas (ABG).

Choices A and D are correct. When a client is intubated via ETT, the initial verification methods include a chest x-ray and end-tidal carbon dioxide (EtCO2). A chest x-ray will verify that the tube terminates 2-3 cm above the carina. End-tidal carbon dioxide (EtCO2) monitoring is a device that may be added and typically changes color when the tube is in the appropriate place. End-tidal carbon dioxide ranges between 20 and 40 mm Hg. Choices B, C, and E are incorrect. The cuff pressure is a parameter that is monitored to ensure that the ETT is appropriately anchored and allows for effective gas exchange through the tube and to deliver the tidal volume if the client were to receive mechanical ventilation. Normal pressure should range between 14-20 mmHg. Chest wall movement is not a definitive way to discern that the ETT is in the correct place. While this is a key assessment following intubation, it would not discern the definitive placement of the ETT. ABGs are frequently done during the course of a client being mechanically ventilated. However, they do not inform the nurse of the tube placement.

An elderly client has just finished a total knee replacement surgery. The nurse suspects fluid overload in the client. Which of the following signs and symptoms would confirm the nurse's suspicion? A. Blood pressure of 90/55 mmHg; weak, thready pulse; slightly elevated temperature. B. Cool, clammy skin; bounding pulse; cough. C. Headache, Lethargy, and abdominal pain. D. Fever; warmth, swelling, and redness at the operative site.

Explanation Choice B is correct. Cool and clammy skin, bounding pulses, productive cough, distended neck veins, edema, and polyuria are signs of fluid overload. Choice A is incorrect. Low blood pressure, weak and thready pulse, and a slightly elevated temperature would indicate dehydration. Choice C is incorrect. These are not symptoms of fluid overload and may indicate other co-morbidities. Choice D is incorrect. Fever, warmth, swelling, and redness at the operative site indicate infection.

Barrel chest

is a deformity in which the chest becomes expanded in size. Lung diseases that cause the chest to repeatedly over-expand or to remain in that position can lead to barrel chest, such as emphysema, cystic fibrosis, and asthma.

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 (2.775 to 4.165 mmol/L/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

Choice A is correct. DKA presents with hyperglycemia (serum glucose >250 mg/dL, >13.875 mmol/L), acidosis, hyperkalemia, and ketonuria. DKA treatment aims to lower blood glucose by 50 to 75 mg/dL per hour (2.775 to 4.165 mmol/L/hr ) This is accomplished by the prescribed regular insulin, which is given intravenously. If the blood glucose does not decrease by at least 50 - 75 mg/dL in the first hour, insulin infusion should be increased. Insulin infusion should be continued until acidosis resolves. Serum glucose should be maintained between 150 and 200 mg/dL (8.325 mmol/L and 11.10 mmol/L) until the DKA resolves. Once the blood glucose is lowered to 200 mg/dL(11.1 mmol/L), isotonic saline should be switched to D5 1/2 NS (dextrose 5% in 1/2 NS) to prevent hypoglycemia while the insulin infusion continues until the resolution of acidosis. Choice B is incorrect. Dextrose 50% should be available in the event of severe hypoglycemia. Dextrose 5% is not sufficient to treat hypoglycemia. Choice C is incorrect. The treatment goal for the hypovolemia caused by DKA is isotonic saline, not hypertonic saline. Choice D is incorrect. Urine output would decrease with the infusion of regular insulin as correcting the hyperglycemia would treat the polyuria, a hyperglycemia symptom.

The nurse is assessing a client who has sustained a blunt chest injury. Which of the following findings would support a diagnosis of pneumothorax? A. Diminished breath sounds B. Barrel chest C. Bradypnea D. Pulse deficit

Choice A is correct. Diminished or absent breath sounds in the affected area are an expected finding with pneumothorax. This is because air has entered the pleural space and collapsed that portion of the lung making it ineffective in gas exchange. Choice B is incorrect. A barrel chest occurs over time, indicating chronic obstructive pulmonary disease (COPD). In a barrel chest, the chest's anteroposterior (AP) diameter and its lateral diameter are 1:1 rather than the normal ratio of 1:1.5 due to lung overinflation and diaphragm flattening. Choice C is incorrect. When a client experiences a pneumothorax, the client's oxygenation status may decrease, causing the client to have tachypnea in an attempt to increase their oxygen saturation. The client would not experience bradypnea. Choice D is incorrect. Pulse deficit is when the client's peripheral pulse rate differs from the apical one. This occurs in arrhythmias such as atrial flutter and atrial fibrillation. This is not an expected finding in pneumothorax. Additional Info ✓ Pneumothorax may be caused by chest wall trauma, insertion of a central vascular access device (subclavian or intrajugular), severe pulmonary tuberculosis, and cystic fibrosis ✓ Pneumothorax causes a loss of negative pressure in the pleural space, leading to the collapsing of the lung that causes a reduction in vital capacity ✓ Manifestations of a pneumothorax include reduced or absent breath sounds on the affected side, tachypnea, tachycardia, and hyper resonance on chest percussion ✓ Nursing care includes applying supplemental oxygen and the preparation of the physician inserting a chest tube ✓ Pneumothorax is diagnosed by chest radiograph (x-ray)

The nurse caring for a client with iron deficiency anemia is preparing the client's plan of care. Which nursing diagnosis is the most appropriate for this client's care plan? A. Impaired gas exchange B. Ineffective airway clearance C. Deficient fluid volume D. Ineffective breathing pattern

Choice A is correct. Impaired gas exchange is the most appropriate nursing diagnosis for a client with iron deficiency anemia. Hemoglobin is the component in the blood responsible for transporting oxygen throughout the body. Iron is an essential substance for hemoglobin synthesis. In iron deficiency anemia, the hemoglobin is decreased, leading to impaired gas exchange. Choice B is incorrect. Iron deficiency anemia does not cause ineffective airway clearance. The nursing diagnosis of ineffective airway clearance is more likely to be caused by increased mucus secretions, an altered level of consciousness in the client, or an inadequate or absent cough reflex in the client. Choice C is incorrect. Iron deficiency anemia would not result in a fluid volume deficit nursing diagnosis. Choice D is incorrect. In relation to iron deficiency anemia, the nursing diagnosis of ineffective breathing pattern(s) is not the initial nor the most appropriate nursing diagnosis for this client's care plan.

The nurse is caring for a client with severe sepsis admitted to the critical care unit. Which of the following interventions should the nurse prioritize during the initial management of sepsis? A. Administer prescribed broad-spectrum antibiotics B. Initiate invasive hemodynamic monitoring C. Administer pain medication to keep the client comfortable D. Administer prescribed corticosteroids

Choice A is correct. Sepsis is a life-threatening condition caused by a systemic reaction to an infection. Prompt administration of appropriate antibiotics is crucial in the management of sepsis to target the underlying infectious source and prevent further progression. Early initiation of broad-spectrum antibiotics is the priority before specific culture and sensitivity results are available. Broad-spectrum antibiotics would be given after appropriate cultures have been obtained. Choice B is incorrect. In some cases, invasive hemodynamic monitoring may be necessary to guide fluid and vasopressor therapy but is not the highest priority during the initial management of sepsis. There is not enough information in the question to support this answer. Sepsis is life-threatening organ dysfunction brought on by a dysregulated response to infection ✓ Common antibiotics used in sepsis include vancomycin, azithromycin, doxycycline, and ceftriaxone ✓ If untreated, the client could progress to septic shock. Septic shock is a subset of sepsis in which circulatory, cellular, and metabolic alterations are associated with a higher mortality rate than sepsis alone. ✓ Septic shock is associated with both systemic inflammatory response syndrome (SIRS) and sepsis with multiple organ dysfunction syndrome (MODS)

During shift change, a nurse receives report regarding a client with ulcerative colitis, learning the client has experienced severe diarrhea over the past 24 hours. When assessing the client, the nurse should watch for signs of: A. Metabolic acidosis B. Metabolic alkalosis C. Malnutrition D. Malabsorption

Choice A is correct. The nurse should watch for signs of metabolic acidosis, as diarrhea is one of the conditions most commonly associated with this acid-base imbalance due to bicarbonate loss occurring with diarrhea. Symptoms and signs of metabolic acidosis are primarily those of the underlying cause (i.e., here, the client's diarrhea). More severe acidemia (i.e., pH < 7.10) may cause nausea, vomiting, and malaise. Choice B is incorrect. Clients with vomiting, diuretic use, or excessive over-the-counter antacid use are at risk for metabolic alkalosis. Metabolic alkalosis occurs due to an elevation of sodium bicarbonate which leads to an increase in a client's HCO3- level. Choice C is incorrect. Malnutrition is a possible long-term complication of ulcerative colitis. This complication typically requires more than 24 hours of active symptoms before occurring. Choice D is incorrect. Malabsorption is a possible long-term complication of ulcerative colitis. This complication typically requires more than 24 hours of active symptoms before occurring.

The nurse has just attended a conference on caring for the client receiving positive pressure ventilation (PPV). Which statement by the nurse would indicate a correct understanding of the conference? A. "Positive pressure mechanical ventilation helps improve oxygenation and supports breathing by delivering air into the lungs at an increased pressure during inspiration." B. "Clients receiving positive pressure mechanical ventilation can breathe spontaneously without any assistance from the ventilator machine." C. "Positive pressure mechanical ventilation is used primarily for clients with a normal respiratory drive to enhance their natural breathing pattern." D. "The rate and depth of positive pressure mechanical ventilation are solely determined by the client's effort and respiratory rate."

Choice A is correct. This statement accurately reflects the purpose and mechanism of positive pressure mechanical ventilation. This elevated pressure helps inflate the alveoli, enhancing oxygenation and supporting breathing for clients who are unable to breathe adequately on their own due to compromised lung function. Choice B is incorrect. Positive pressure ventilation is used when clients are unable to breathe sufficiently on their own due to various conditions. Including but not limited to Acute Respiratory Distress Syndrome (ARDS), Status Asthmaticus, and Central Nervous System Depression (e.g., Stroke, Brain Injury). Choice C is incorrect. Clients who require positive pressure ventilation often have impaired respiratory drive. Positive pressure ventilation takes over the work of breathing to support the client's respiratory efforts and ensure sufficient oxygenation and carbon dioxide removal. Choice D is incorrect. With positive pressure mechanical ventilation, the rate and depth of breaths are determined by the ventilator settings, not the client's effort or respiratory rate.

You are caring for an 8-month-old infant with a tracheostomy. Upon assessment, you visualize secretions within the tracheostomy that require suctioning. In preparation to suction the infant's tracheostomy, which of the following settings would be the most appropriate suction setting? A. 120 mmHg B. 90 mmHg C. 60 mmHg D. 40 mmHg

Choice B is correct. 90 mmHg would be the most appropriate suction setting for an 8-month-old infant based on the choices provided. For infants and children up to 24 months, tracheostomies should be suctioned using 80-100 mmHg. Choice A is incorrect. A suction setting of 120 mmHg is the upper limit for children aged 24 months and older. Therefore, this suction setting would be too powerful to utilize on an 8-month-old infant. Choice C is incorrect. 60-80 mmHg is the recommendation for suctioning newborns and neonates (i.e., up to 28 days). Therefore, 60 mmHg will likely not provide adequate suctioning power for this client. Choice D is incorrect. Attempting to suction a tracheostomy using 40 mmHg would not produce enough suctioning power to render a viable result. This pressure is not indicated for any age range. Pressure setting for newborns and neonates: 60-80 mmHg Pressure setting for infants and children up to 24 months: 80-100 mmHg Pressure setting for children over 24 months and teens: 100-120 mmHg Tracheostomy suctioning removes thick mucus and secretions from the trachea and lower airway that the client cannot clear by coughing. Suctioning should be performed in the morning, before bed, and when needed.

The nurse is speaking with a client who is being evaluated for possible acute leukemia. Which of the following questions from the nurse is most relevant? A. "How would you describe your sleeping patterns recently?" B. "Have you experienced respiratory or other infections recently?" C. "Over the past few months, have you experienced weight fluctuations?" D. "Have you noted any recent bowel changes?"

Choice B is correct. A client with leukemia is at risk for bleeding tendencies and recurrent infections. The nurse should ask the client about the frequency and severity of infections, including common colds, influenza, pneumonia, bronchitis, and/or any unexplained fevers occurring over the preceding six-month period. Additionally, the nurse should inquire about any abnormal bleeding tendencies, which is another primary clinical manifestation of leukemia. Choice A is incorrect. Although leukemia may be associated with insomnia, this is not one of the primary clinical manifestations of the disease. Choice C is incorrect. Whether a client experiences weight loss (and the degree of any weight loss experienced) often correlates significantly with the type of leukemia the client is ultimately diagnosed. Some leukemias tend to cause higher rates of unexplained weight loss and/or loss of appetite in clients than other types of leukemias. If unexpected weight loss transpires, the client does not traditionally "experience weight fluctuations," as implied in the nurse's question above, as the client would be more likely to experience an unexplained weight loss. Learning Objective Recognize the most relevant question by the nurse to the client who is currently undergoing evaluation for acute leukemia as the question which pertains to whether the client has experienced any recent respiratory or other infections.

The nurse is planning a staff education program about septic shock. Which of the following serum lactic acid levels are concerning for sepsis? A. 0.5 mmol/L B. 2.2 mmol/L C. 1.9 mmol/L D. 1.5 mmol/L

Choice B is correct. A serum lactate level above 2 mmol/L is one of the criteria for diagnosing septic shock. Septic shock is a critical and life-threatening medical condition triggered by a severe infection. It occurs when the body's response to the infection becomes overwhelming, leading to a cascade of widespread inflammation, decreased blood pressure, compromised blood flow to vital organs, and cellular dysfunction. Choice A is incorrect. A serum lactate level of 0.5 mmol/L is not the threshold used in the new definition of septic shock. Choice C is incorrect. A serum lactate level of 1.9 mmol/L is lower than the threshold used in the new definition of septic shock. Choice D is incorrect. The threshold for serum lactate level in sepsis is 2 mmol/L. 1.5 mmol/L does not meet this criteria. Additional Info ✓ If a client's serum lactate level exceeds 2 mmol/L, nurses should promptly notify the healthcare team for further evaluation and intervention. Elevated lactate levels may indicate tissue hypoperfusion and the need for immediate treatment. ✓ Administering intravenous fluids is a critical nursing intervention in septic shock management. Close monitoring of the client's response to fluid resuscitation is necessary to ensure adequate tissue perfusion and optimize serum lactate levels. ✓ Elevated lactate levels suggest tissue hypoperfusion and potential organ dysfunction. Nurses should advocate for the timely initiation of appropriate treatments, such as vasopressors or other interventions, to address the underlying cause and improve tissue perfusion.

The nurse is caring for a client with epistaxis. The nurse should perform which appropriate action? A. Position the client upright and leaning forward while gently pinching their nose intermittently B. Position the client upright and leaning forward while gently pinching their nose continuously C. Ask the client to blow their nose and then put lateral pressure on the nose D. Instruct the client to hold their nose while bending forward at the waist

Choice B is correct. During epistaxis, the nurse should position the client upright while leaning slightly forward and pinching the nasal alae together. This position prevents blood from entering the larynx, thereby decreasing the likelihood of possible aspiration. Choices A, C, and D are incorrect. Continuous pressure for at least ten minutes is recommended to treat epistaxis. Intermittent pressure would not achieve the same results because of the alleviation of the pressure. Blowing the nose would increase the risk of dislodging any clotting that has occurred, thereby increasing the client's bleeding. Having the client blow their nose would increase the risk of dislodging any clotting that has formed. Instructing the client to bend at the waist would increase the vascular pressure within the client's nose, potentially dislodging any previously formed clots. Both of these interventions would lead to increased bleeding in any client experiencing epistaxis.

The nurse is teaching a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching? A. "If I experience double-vision, I should put an eye patch on both eyes for a few hours." B. "Planning my activities should help manage the fatigue." C. "I should plan to take a hot bath for my muscle spasms." D. "This disease may cause me to have an increased sensitivity to pain."

Choice B is correct. Fatigue is a significant clinical feature associated with MS. Strategies to mitigate fatigue and maximize functioning include spacing activities out, planning them in a planner or whiteboard, and taking frequent breaks. Fatigue is often worsened during elevations in temperature. Thus, activities may be best performed early morning or late evening when temperatures are not as high. Choices A, C, and D are incorrect. Visual alterations are a common clinical feature of MS, specifically double-vision (diplopia). The nurse should recommend an eye patch on one eye that is alternated every few hours. Heat aggravates MS symptoms, and hot baths should be discouraged. MS may cause a client to experience a decreased sensitivity to pain because of the insult to the nervous system.

The nurse teaches a group of students about phenytoin. Which of the following statements would indicate understanding? A. "Phenytoin is a selective serotonin reuptake inhibitor (SSRI) commonly used for epilepsy." B. "The therapeutic range of phenytoin is 10-20 mcg/mL, and levels above this range can lead to toxicity." C. "Phenytoin is contraindicated in clients with Parkinson's disease due to potential exacerbation of symptoms." D. "Phenytoin is primarily metabolized by the liver and has no significant drug interactions."

Choice B is correct. Phenytoin has a narrow therapeutic range, and maintaining drug levels within the 10-20 mcg/mL range is essential for effective seizure control. Levels above the therapeutic range can result in phenytoin toxicity, characterized by symptoms such as nystagmus, ataxia, and confusion. Choice A is incorrect. Phenytoin belongs to the class of antiepileptic drugs known as hydantoins and works by stabilizing neuronal membranes and decreasing seizure activity. Choice C is incorrect. Phenytoin is not contraindicated in clients with Parkinson's disease. However, it may have some extrapyramidal side effects and can potentially worsen Parkinson's symptoms in some individuals. Choice D is incorrect. Phenytoin is extensively metabolized by the liver, primarily through the CYP450 enzyme system. It is known to have numerous drug interactions, Phenytoin has been used as a first-line drug for many years, it is indicated for the management of tonic-clonic and partial seizures. ✓ Phenytoin has many advantages for long-term therapy. It is usually well tolerated, highly effective, and relatively inexpensive. It can also be given intravenously if needed. Most often, however, phenytoin is taken orally. ✓ Teach the client and family that serum drug levels are checked every 6 to 12 hours after the loading dose and then 2 weeks after oral phenytoin has started. The desired serum therapeutic range is 10 to 20 mcg/mL

ather has sickle cell anemia, and the mother is a carrier. You tell them that their baby has what chance of having sickle cell anemia? A. 25% B. 50% C. 75% D. 100%

Choice B is correct. Sickle cell anemia is an autosomal recessive disease. The normal chromosome is represented as S, and the sickle cell gene-containing chromosome is expressed as s. Therefore, sscharacterizes sickle cell anemia, Ss defines the carrier, and SS is the normal phenotype. The baby has a 50% chance of having sickle cell anemia (ss). From the information presented in the question, the father is ss because he has the disease, and the mother is Ss since she is a carrier. The disease is referred to as sickle cell anemia or sickle cell disease, whereas the carrier state is referred to as sickle cell trait. Sickle cell anemia is inherited in an autosomal recessive pattern, which means that both copies of the gene in each cell should have the mutations necessary to have that disease (ss). The parents of an individual with an autosomal recessive condition such as sickle cell disease must each carry one copy of the mutated gene. The odds or chances of the offspring having the disease or carrier state are determined by the Punnett square. Based on the combinations, the baby has a 50% chance of having sickle cell disease (ss).

The nurse is preparing to insert a nasogastric tube (NGT). Which action should the nurse take? A. Rinse the tube with warm, soapy water B. Perform hand hygiene C. Don sterile gloves D. Obtain a computed tomography (CT) scan to verify placement

Choice B is correct. To minimize the risk of infection, the nurse should wash their hands before inserting a nasogastric tube (NGT). Choice A is incorrect. The nurse should not wash the tube with warm, soapy water. While the insertion of an NGT is not a sterile procedure, the risk of contaminating the tube is significant if this should occur. Choice C is incorrect. The nurse does not need to wear sterile gloves while inserting an NGT. This is not a sterile procedure, and wearing sterile gloves would waste facility resources. Standard/clean gloves are worn during this procedure. Choice D is incorrect. After the initial insertion, the nurse should verify placement via a radiograph (abdominal or kidneys, ureters, bladder [KUB]). Subsequent verification should occur by aspirating gastric content and assessing its desired pH (less than four). A CT scan is unnecessary and substantially more expensive than a radiograph. Tips when inserting a nasogastric tube ✓ When inserting an NGT for an adult, measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum. ✓ Confirmation of placement via x-ray immediately after completed insertion is required. ✓ Do not advance the tube during inspiration or coughing because it is likely to enter the respiratory tract. ✓ The tip of the NG tube must reach the stomach to avoid the risk of pulmonary aspiration.

The nurse is conducting a physical examination, what percussion sound does the nurse expect to hear over the abdomen? A. Hyperresonance B. Tympany C. Resonance D. Dullness

Choice B is correct. Tympany is the percussion sound heard over hollow organs. The small intestine and colon are hollow organs; they predominate over most of the abdominal cavity. Choice A is incorrect. Hyperresonance is the sound heard by tapping on the surface of the chest. It is an exaggerated chest resonance heard in various abnormal pulmonary conditions. Choice C is incorrect. Resonance is a low-pitched, hollow sound usually heard over healthy lung tissue. Choice D is incorrect. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors. Additional Info ✓ When applicable the nurse should ensure that the client is in a comfortable and relaxed position for an accurate assessment of abdominal percussion sounds. ✓ The nurse should perform percussion in all four abdominal quadrants to assess for variations in percussion sounds that might indicate different underlying structures or potential abnormalities. ✓ The nurse should be adept at differentiating between various percussion sounds, not only identifying tympany but also recognizing dullness or flatness that might indicate underlying solid organs or fluid accumulation.

The nurse is completing an assessment of a 6-year-old client with an asthma exacerbation. Which of the following assessment findings is of most concern to the nurse? A. Expiratory wheezing B. Sudden absence of wheezing C. Persistent cough D. Head bobbing

Choice B is correct. Wheezing is expected during an exacerbation. If a client should experience a sudden absence of wheezing, this may indicate respiratory arrest. If the asthma attack improves, a gradual decrease in wheezing is expected (not a sudden cessation). Choice A is incorrect. Expiratory wheezing is an expected finding when a client is having an asthma exacerbation. This occurs when there is inflammation in the airways and air trapping, making it hard for the client to exhale all the air in their lungs fully. The wheezing is audible as they attempt to exhale. Although it is a significant finding, it is not the finding of most concern in this question because the client still has a patent airway. Choice C is incorrect. A persistent cough is an expected finding when a clhasaving an asthma exacerbation. This finding is not of most concern. Choice D is incorrect. Head bobbing is an indication of increased work of breathing in the pediatric client experiencing an asthma exacerbation. It occurs when the child's head moves forward each time they take a breath. This finding is significant and an indication that further support is needed, but it is not the priority.

The nurse is caring for a client reporting phantom limb pain after a below-the-knee amputation. The client is experiencing what type of pain? A. Perceived pain B. Somatic pain C. Neuropathic pain D. Nociceptive pain

Choice C is correct. A client who is reporting of phantom limb pain after a below-the-knee amputation (BKA) is most likely experiencing neuropathic pain. Peripheral neuropathic pain, such that occurs with neuralgia, phantom limb pain, and carpal tunnel syndrome, is described as a burning, sharp and shooting pain, and it is often chronic. Choice A is incorrect. Although a client who is reporting of phantom limb pain after a below-the-knee amputation is feeling and perceiving pain, this pain after a below-the-knee amputation is not referred to as perceived pain. Choice B is incorrect. A client who is reporting of phantom limb pain after a below-the-knee amputation is not likely to be experiencing somatic pain. Somatic pain is a type of nociceptive pain that results from damage to the bones, skin, and muscles. Choice D is incorrect. A client who is reporting of phantom limb pain after a below-the-knee amputation is not experiencing peripheral nociceptive pain. Nociceptive pain is classified as bodily nociceptive pain and visceral nociceptive pain, not peripheral nociceptive pain.

The nurse is caring for a client receiving assist-control (AC) via mechanical ventilation. The nurse understands that this setting is used to do which of the following? A. Allow spontaneous breaths at the client's tidal volume. B. Deliver additional pressure at the end of exhalation. C. Deliver a preset tidal volume during spontaneous breaths. D. Provide inspiratory pressure during ventilations.

Choice C is correct. Assist-control (AC) is a volume mode on a mechanical ventilator that senses a client's ability for a spontaneous breath. When the client takes a spontaneous breath, it will deliver the tidal volume preset on the ventilator. This is in addition to the client receiving the ventilated breaths preset in the rate. For example, if the client is at a preset rate of 12 and taking 4 spontaneous breaths, each breath of the 16 will receive 515 mL of gas (the tidal volume preset).

The nurse is caring for a client experiencing an exacerbation of rheumatoid arthritis (RA). The nurse should obtain a prescription for A. allopurinol. B. verapamil. C. prednisone. D. methotrexate.

Choice C is correct. Rheumatoid arthritis is a chronic autoimmune disease that can lead to joint damage and disability. The steroid prednisone is a fast-acting and effective treatment for rheumatoid arthritis and is often prescribed alongside disease-modifying antirheumatic drugs. More specifically, prednisone is a corticosteroid with anti-inflammatory and immunosuppressive properties used to treat rheumatoid arthritis. In general, most clients will experience benefits from prednisone within one to four days if the prescribed dose is adequate to reduce the client's level of inflammation. Choice A is incorrect. Allopurinol, a xanthine oxidase inhibitor, is an FDA-approved urate-lowering medication most commonly used for managing gout. This medication lowers the client's uric acid levels by reducing the production of uric acid in the body. Allopurinol is not utilized in the treatment of rheumatoid arthritis. Choice B is incorrect. Verapamil is a calcium channel blocker that may be used in hypertension, Raynaud's phenomena, or migraine headache prophylaxis. This medication does not have utility in rheumatoid arthritis. Choice D is incorrect. Methotrexate is an immunomodulating medication used to prevent exacerbations of rheumatoid arthritis. This is a maintenance medication. Other maintenance medications used in RA include etanercept and hydroxychloroquine. Learning Objective Following a client's admission to the ward for exacerbation of rheumatoid arthritis, the nurse should anticipate the health care provider (HCP) prescribing prednisone to combat the client's inflammation and produce immunosuppression.

A newly licensed registered nurse is tasked by a nurse educator to perform a wet-to-dry dressing change on a client with a stage 3 pressure ulcer. Which action would indicate to the nurse educator that the registered nurse is following proper technique? A. The registered nurse cleans the ulcer from the outside, rotating into the inside of the ulcer. B. The registered nurse packs the incision with sterile gauze, then pours sterile normal saline over the dressing. C. The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin. D. The registered nurse saturates the old dressing with sterile saline before removing it.

Choice C is correct. The wet dressing should not touch the intact skin as this may cause skin breakdown and potentially introduce additional pathogens into the wound. Choice A is incorrect. The registered nurse should clean in a circular motion, beginning from the inside and rotating outward. Once the nurse reaches the edge of the wound, the nurse should change gloves and equipment. Choice B is incorrect. When a wet-to-dry dressing is ordered, dressings are to be soaked before application to the client's tissue. The dressing is then allowed to dry while on the client, therefore allowing the removal of that dressing to essentially debride a small portion (i.e., existing debris and necrotic tissue if applicable) of the wound before the replacement dressing is applied. Choice D is incorrect. Saturating the existing dressing prior to removal would defeat the purpose of having the dressing removed dry. Dry removal allows debris and necrotic tissue to be removed with the dressing.

An infant is admitted to the pediatric floor to rule out cystic fibrosis. The nurse assesses the infant's stool, concluding the stool is consistent with a diagnosis of cystic fibrosis. Which of the following would describe this infant's stool? A. Small, hard, pellet-like stool B. Green, malodorous stool C. Oily, odorous, bulky stool D. Loose, yellow stool

Choice C is correct. This disease process frequently affects the pancreas, intestines, and hepatobiliary systems, resulting in the malabsorption of fats, fat-soluble vitamins, and protein in 85 to 95% of cystic fibrosis clients. As a result, gastrointestinal manifestations include the frequent passage of bulky, foul-smelling, oily stools. Additional Info ✓ Cystic fibrosis is an inherited disease affecting primarily the gastrointestinal and respiratory systems. ✓ While universal newborn screening for cystic fibrosis is now standard in the United States, it is important to note that this screening tool cannot diagnose cystic fibrosis alone. When a newborn screening returns a positive result, it is followed by a sweat test to confirm the diagnosis. ✓ Despite advances in genetic testing, the sweat chloride test remains the standard for confirming a cystic fibrosis diagnosis in most cases because of the test's sensitivity, specificity, simplicity, and availability. ✓ Although most cases of cystic fibrosis are first identified by newborn screening, up to 10% of those with cystic fibrosis are not diagnosed until adolescence or early adulthood.

The nurse is caring for a client who has had an exacerbation of Bell's palsy. The client is experiencing paralysis of their eye, the nurse should plan to A. tape an eye patch to the affected eyelid at all times. B. instruct the client to keep both eyes closed. C. assess the pupil's size and reactivity to light. D. apply the prescribed ocular lubricant to the affected eye.

Choice D is correct. Bell's palsy is a lower motor neuron facial nerve palsy that can result in the weakness of facial muscles and the muscles responsible for eye closure (orbicularis oculi). A client with Bell's palsy who cannot blink would be unable to close the affected eye. As a result, the cornea becomes overly dry, leading to an increased risk of corneal ulceration and scarring. Eye lubricant (i.e., typically artificial tears) must be applied as often as every hour during the day to keep the eye moist and prevent corneal drying. A moisturizing eye ointment may be used at night. Choices A, B, and C are incorrect. Applying an eye patch with tape on the eyelid may cause the patch to slip into the open eye and cause a corneal abrasion. During the day, the client should protect the open eye with glasses or goggles. At night, the client may use a soft eye patch to cover the open eye, but it should not be taped to the eyelid. Instead, the soft eye pad should be secured with one end of the tape on the client's forehead and the other end on the cheek diagonally. It is not necessary for the client to keep the unaffected eye closed. Bell's palsy does not affect the pupil's reaction to light and accommodation.

An 8-year-old pediatric client arrives complaining of swelling and pain in the bilateral knees. The child's parent informs the nurse, "The swelling came out of nowhere, and it just keeps getting worse." The initial impression is Lyme disease. Which additional question should be included during the assessment and history? A. "Have you noted any flank pain and a decrease in the urine volume?" B. "Has there been a fever of over 103 degrees over the last two to three weeks?" C. "Have you noticed any rashes on the palms or soles?" D. "Do you have headaches, malaise, or sore throat?"

Choice D is correct. Clients with Lyme disease often develop a musculoskeletal, flu-like syndrome consisting of malaise, fatigue, chills, fever, headache, stiff neck, myalgias, and arthralgias that may last for weeks. Symptoms are often nonspecific, resulting in the diagnosis being frequently missed if erythema migrans is absent. Choice A is incorrect. Urinary tract infections and/or a decrease in urine production are not symptoms commonly associated with Lyme disease. Choice B is incorrect. Any fever associated with Lyme disease is typically a low-grade fever. Choice C is incorrect. Erythema migrans, the hallmark and best clinical indicator of Lyme disease, is the first sign of the disease. It occurs in at least 75% of clients, beginning as a red macule or papule at the site of the tick bite, usually on the proximal portion of an extremity or the trunk (especially the thigh, buttock, or axilla), between 3 days and 32 days after a tick bite. The area expands, often with a clearing between the center and periphery resembling a bull's eye. Erythema migrans does not present as rashes on the client's palms and soles.

The nurse is caring for a client who has overdosed on clonazepam. Which of the following abnormalities in the arterial blood gas (ABG) would be expected? A. metabolic acidosis B. metabolic alkalosis, fully compensated C. respiratory alkalosis D. respiratory acidosis

Choice D is correct. Clonazepam is a benzodiazepine which depresses the central nervous system (CNS). The depression of the CNS can subsequently lower the respiratory rate and cause respiratory depression. When the client's respiratory rate decreases too much, the body retains CO2 (which, as an acid, lowers the pH, causing acidosis). The elevated CO2 level and, subsequently, low pH are what the nurse would anticipate following a clonazepam overdose. Choice A is incorrect. Benzodiazepines would cause bradypnea, and the bradypnea would cause the client to retain the CO2. This would result in respiratory acidosis, not metabolic acidosis. Choice B is incorrect. Metabolic alkalosis is not an ABG result the nurse would anticipate for a client who has experienced a clonazepam overdose. An example of a client who would present with this ABG result would be an individual who has consumed a large number of over-the-counter antacids, such as Alka-Seltzer. The client's significant sodium bicarbonate ingestion (hence the elevated HCO3 level) resulted in an elevation of their pH level. The body compensates by retaining CO2 (hence the high CO2 level), returning the pH to the normal range.

The intensive care nurse (ICU) cares for a group of assigned clients. The nurse should initially follow-up with the client who is A. mechanically ventilated and not taking spontaneous breaths while in the assist-control (AC) mode. B. being treated for a flail chest, reporting chest pain with inhalation. C. noted to have gentle bubbling in the water seal chamber of their chest tube when coughing. D. receiving intravenous (IV) dopamine via a peripheral vascular access device and reports pain at the IV site.

Choice D is correct. Dopamine is a vasopressor and is indicated in the treatment of shock. Dopamine is a vesicant, and a significant adverse effect of dopamine is that it can extravasate and cause severe tissue damage. This emphasizes why this medication should be infused through a central line to prevent this adverse complication. The nurse should immediately attend to this client and stop the infusion. If extravasation is suspected, the nurse should stop the infusion and aspirate any remaining IV fluid from the catheter. Choice A is incorrect. The mechanically ventilated client has a protected airway, and the lack of spontaneous respirations explains why the client is receiving ventilation via assist control. Assist control provides full airway protection and delivers a preset number of breaths at a preset amount of tidal volume. The nurse does not need to follow up with the client as the ventilator provides appropriate treatment. Choice B is incorrect. A flail chest occurs from blunt force trauma and causes the client to have pain with inspiration. Another classic manifestation of a flail chest is paradoxical chest wall movement (inward thorax movement during inspiration, with outward movement during expiration). This is an expected finding. Choice C is incorrect. Gentle bubbling in the water seal chamber of their chest tube when coughing is normal and does not require follow-up. Continuous bubbling in the water seal chamber would require follow-up that suggests an air leak.

The nurse is caring for a client following a knee arthroscopy procedure. Which of the following assessments should be the priority? A. Wound and skin integrity B. Mobility assessment C. Skin and vascular assessment D. Circulation and sensation

Choice D is correct. Following the client's knee arthroscopy, the nurse should prioritize performing circulatory and sensation assessments. As with all orthopedic procedures, compartment syndrome is one of the most severe post-procedure complications. Following an arthroscopy, swelling may occur in the affected limb due to fluid extravasation into the leg. This fluid accumulation increases the compartment pressure, leading to decreased or impaired vascular flow to the tissues. Compartment syndrome is a medical emergency, as it may cause irreversible neurological and circulatory impairments of the limb. Typically, the earliest symptom of compartment syndrome is a client reporting pain that is out of proportion to the severity of the injury. Early signs of compartment syndrome include swelling, pallor, paresthesia, coolness, numbness, and weak pulses. Late symptoms include pulselessness and paralysis. Therefore, the nurse's priority is to perform circulatory and neurological assessments on the affected extremity. Once circulatory and neurological integrity is established, the nurse may perform additional checks or interventions.

The nurse is helping develop a care plan for a client with a low serum albumin level. The nurse should take which action? A. Obtain a capillary blood glucose B. Implement seizure precautions C. Implement strict bed rest D. Collaborate with a registered dietician

Choice D is correct. Normal albumin levels are 3.5-5.0 g/dL, 34-50 g/L. Collaboration with a registered dietitian (RD) is recommended for numerous reasons. First, the registered dietician can perform a nutritional assessment. Second, following the nutritional assessment, the registered dietician can focus on increasing the protein intake necessary for healing. Third, the registered dietician can make recommendations regarding appropriate foods that may be integrated into the client's diet based on the client's personal preferences. Fourth, the registered dietician can perform client education and educate the client regarding the nutritional needs of the client and food sources of protein. Therefore, collaborating with a registered dietician will significantly benefit this client experiencing hypoalbuminemia and should be included in the client's care plan. Choice A is incorrect. Capillary blood glucose monitoring is not required for a client with hypoalbuminemia. Choice B is incorrect. Seizure precautions are not necessary for clients with hypoalbuminemia. This would be required if the client had severe hyponatremia (< 125 mEq/l, mmol/L). Choice C is incorrect. Strict bed rest is not indicated for hypoalbuminemia clients.

The nurse is caring for an older adult client with delirium for the third time in the past four months. While reviewing the client's medical record to determine the cause, the nurse should prioritize reviewing the client's A. vital signs. B. height and weight. C. family medical history. D. current medications.

Choice D is correct. Polypharmacy is a significant cause of delirium. Older adults are at risk for polypharmacy, which raises the risk of falls, delirium, hospitalization, and financial hardship. The nurse should review the client's current medications, including over-the-counter medications. Choice A is incorrect. Vital signs are key to assessing a client's overall physical health. However, they provide a limited diagnostic tool in determining if the client has delirium. While hypoxia most certainly can cause delirium, the fact that the client has had multiple episodes of delirium suggests an offending medication, such as a benzodiazepine or anticholinergic. Choice B is incorrect. Height and weight are key to determining if the older adult client is attaining optimal nutrition. Malnutrition is a risk factor for delirium; however, considering the multiple bouts of the client's delirium in such a short period suggests an issue with a medication (or medications). Older adults have frequent medication changes, making polypharmacy much more plausible. Choice C is incorrect. Family medical history would not have a substantial cause of delirium. Delirium is acute and is often caused by polypharmacy, sensory deprivation, and certain infections. Family medical history would be much more valuable in determining the risk for conditions such as heart disease and certain cancers.

The nurse is teaching a client about their newly established colostomy. Which of the following statements by the client would require follow-up? A. "I will call my primary healthcare provider (PHCP) immediately if my stoma becomes bluish." B. "I should slowly introduce high-fiber foods in my diet." C. "I must always wear a pouch over my stoma." D. "I should clean the skin around my stoma with rubbing alcohol."

Choice D is correct. Skincare is an essential part of teaching a client with a colostomy. The client should not use abrasive products such as rubbing alcohol on the peristomal skin because it may cause damage and lead to poor adherence of the appliance (specifically, the wafer) to the skin. Mild (not moisturizing soap) should be used on the peristomal skin. Choice A is incorrect. Bluish discoloration of the stoma indicates necrosis and requires immediate action. The client needs to call the PHCP when this happens. The color of a normal, healthy stoma should be reddish to pink. Choice B is incorrect. The client can return to a regular diet once discharged and introduce high-fiber foods slowly because gas and cramping are a concern if too much fiber is consumed at once. Choice C is incorrect. A colostomy pouch should be worn over the stoma to collect the feces that is coming out of the stoma.

The nurse is paired with an LPN in the pediatric unit. A four-month-old infant with a temporary colostomy is being discharged today. What is the most appropriate action of the nurse and the LPN? A. The LPN completes the discharge instructions to the mother. B. The LPN demonstrates to the mother how to irrigate the child's colostomy. C. The LPN gives the mother the child's medications, instructions on how to administer them, and explains the purpose of the medications. D. The LPN is tasked by the nurse to remove the child's IV catheter.

Choice D is correct. The LPN can remove the child's IV catheter and perform other routine tasks. Choice A is incorrect. The LPN cannot provide discharge instructions. It is not within their scope of practice. Choice B is incorrect. Demonstrating how to irrigate a colostomy to the mother constitutes discharge teaching. The LPN cannot provide discharge instructions and education. It is not within their scope of practice. Choice C is incorrect. Providing medication education and instruction to the mother constitutes discharge teaching. The LPN cannot provide discharge instructions and teaching. It is not within their scope of practice.

The intensive care unit (ICU) nurse is caring for a client with septic shock. The assessment shows bleeding from the peripheral intravenous site, gum bleeding, and hematuria. Based on the assessment, the nurse should take which action? A. Assess if the client is receiving heparin products B. Review the client's most recent lactic acid level C. Assess the client's oxygen saturation D. Notify the primary healthcare provider (PHCP)

Choice D is correct. The client is manifesting signs of disseminated intravascular coagulation (DIC). This critical complication often happens in the intensive care unit and is usually secondary to other serious etiologies such as sepsis. In this condition, the clotting system is activated significantly, leading to platelet consumption and clotting factors. DIC can manifest with either bleeding or clotting complications. Thrombocytopenia (low platelet count), coagulopathy (increased prothrombin time, increased partial thromboplastin time, decreased fibrinogen), and hemolysis are hallmarks of DIC. The nurse needs to notify the physician of this critical condition change. Choice A is incorrect. The client having septic shock makes them highly likely to develop this complication. Heparin could cause heparin-induced thrombocytopenia. However, heparin does not cause disseminated intravascular coagulation (DIC). The client's admitting diagnosis and bleeding from the IV site coincide with the causation of this disorder. Choice B is incorrect. Reviewing the client's lactic acid level would be irrelevant to the client developing DIC. This level helps determine if the client is responding to antibiotics, intravenous fluids, and supplemental oxygen. A serum lactic acid level greater than 2 mmol/L or greater may indicate sepsis. Choice C is incorrect. Assessing the client's oxygen saturation may also be performed later. The client is not in apparent respiratory distress based on the information presented. Hypoxia is not the cause of his bleeding complications. DIC should be suspected in this bleeding, septic client, and the nurse must notify the physician immediately since urgent intervention is needed

The nurse is caring for a client whose hemoglobin is 10 g/dL (100 g/L) [Male: 14-18 g/dL, Female: 12-16 g/dL, Male 125-170 g/L, Female 115-155 g/L]. What is the highest priority nursing goal for this client? A. Encourage mobility B. Promote skin integrity C. Prevent constipation D. Conserve the client's energy

Choice D is correct. These test results indicate anemia. The impaired oxygen-carrying capacity of red blood cells causes cellular hypoxia and results in fatigue. Conserving energy limits oxygen expenditure and minimizes fatigue. Hemoglobin, abbreviated Hb or Hgb, is the iron-containing oxygen-transport metalloprotein in the red blood cells of almost all vertebrates as well as the tissues of some invertebrates. Hemoglobin in the blood carries oxygen from the lungs or gills to the rest of the body. Normal hemoglobin is 14-18 g/dL for males and 12-16 g/dL for females. The hematocrit, abbreviated Hct, is a blood test that measures the volume percentage of red blood cells in the blood. The measurement depends on the number and size of red blood cells. Normal hematocrit is 42-52% for males and 37-47% for females. Choice A is incorrect. Increased mobility increases the demand for oxygen and contributes to fatigue. Choice B is incorrect. Although hypoxic tissues are more vulnerable to breakdown, protecting the integumentary system is not as high of a priority as the promotion of the body's overall oxygenation. Choice C is incorrect. Constipation is not a problem in anemia.

A client is upset because they just found out that they have syphilis. The client tells the nurse, "This is so upsetting! Does everyone need to know?" Which of the following responses, if made by the nurse, is the most therapeutic? A. "We need to report this diagnosis to the local public health department, and they will contact your past partners." B. "According to the Health Insurance Portability and Accountability Act (HIPAA), I can't tell anyone without your permission." C. "You really should contact your sexual partners so they can be treated too." D. "I understand you're upset. I'll stay here with you so that you can talk about it.

Choice D is correct. This response by the nurse encourages verbalization of the client's feelings and is an example of therapeutic communication. This communication technique prioritizes the client's physical, mental, and emotional well-being. Therefore, this is the most therapeutic and appropriate response the nurse should make to this client. Choice A is incorrect. While it is true that the public health department will attempt to notify any sexual partners the client reports, this is not the most therapeutic response the nurse should make to the client. Immediately after learning of the syphilis diagnosis, the client needs the nurse to be supportive and allow them to express their emotions. While the public health department does indeed contact those exposed to infectious diseases in order to combat the spread of such diseases, this is not the time to inform the client of this, as this would not be therapeutic to the client at this particular moment. Choice B is incorrect. This statement is erroneous. When state law requires a specific disease to be reported to a public health agency (such as a public health department), HIPAA allows the minimum necessary information to be reported to the applicable health department regardless of the client's consent. Once the client has composed themself, the client should be informed that the disease will be reported to the local health authority and that all information will be held in strict confidence. This is not a violation of HIPAA or the Privacy Rule.

The new graduate nurse knows that malignant hyperthermia is a serious adverse reaction that can occur after the administration of which of the following medications? Select all that apply. halothane vancomycin succinylcholine omeprazole penicillin hydrocodone

Choices A and C are correct. Malignant hyperthermia is a severe adverse medication reaction. The nurse should know to monitor for this adverse reaction when administering induction agents such as halothane and succinylcholine. These medications can cause excess calcium to build up in the cells, resulting in the client experiencing sustained skeletal muscle contractions. These contractions cause a hypermetabolic state and fever and can lead to death. Choices B, D, E, and F are incorrect. Vancomycin does not carry the risk of malignant hyperthermia. It is an antibiotic that has many other adverse reactions. Omeprazole is a proton-pump inhibitor (PPI) used to treat reflux. It does not cause malignant hyperthermia. Penicillin is an antibiotic that does not cause malignant hyperthermia. Hydrocodone is a pain medication with other adverse reactions but not malignant hyperthermia.

The nurse is developing a plan of care for a client who has epilepsy and is undergoing an electroencephalogram. Which of the following should the nurse include in the client's plan of care? Select all that apply. Provide padding to the side rails Verify suction is at bedside and working properly. Keep bite block at bedside in case of seizure. Ensure nasal cannula is available and working at the bedside. Establish peripheral vascular access

Choices A, B, and E are correct. Ensuring the side rails are raised and padded will provide a safe environment for the client in case of a seizure. It is imperative to have suction ready at the bedside should the client vomit during a seizure. Timely clearing of the airway will prevent aspiration, maintain a patent airway, and keep your client safe. Suctioning the client should only occur once the seizure has terminated, as it is contraindicated to putting objects in the client's mouth. Ensuring that peripheral vascular access is essential because if the client has a seizure, parenteral benzodiazepines (diazepam/lorazepam) are necessary. Choices C and D are incorrect. It is not appropriate to put a bite block or any other object into a client's mouth that is seizing. This could result in injury to yourself or the client. Nursing priorities during a seizure are ensuring the client is safe and has a patent airway. While it is essential to have oxygen available in the room, a nasal cannula is inappropriate for this client. There should be a face mask or Ambu bag readily available that is an appropriate size and connected to 10 L of 100% oxygen.

The nurse is caring for a client who has developed Malignant Hyperthermia. Which of the following actions should the nurse take? Select all that apply. Apply a cooling blanket Insert indwelling urinary catheter Monitor hourly blood glucose Obtain blood cultures Administer prescribed Dantrolene

Choices A, B, and E are correct. Malignant hyperthermia is a medical emergency and requires the nurse to intervene by applying a cooling blanket and ice to the axilla and groin. The nurse should also monitor the client's urinary output by inserting an indwelling catheter. Hydrating the client is essential because the client risks developing rhabdomyolysis and preventing kidney damage; aggressive hydration is implemented, and its efficacy can be monitored using an indwelling catheter. The nurse should be prepared to administer Dantrolene as this skeletal muscle relaxant is an effective treatment. Choices C and D are incorrect. Monitoring a client's hourly glucose is an appropriate intervention for diabetic ketoacidosis (DKA). This intervention is not applicable for malignant hyperthermia. Obtaining blood cultures is not indicated because this autonomic reaction is not pathogenic. Obtaining blood cultures will be indicated if the client has bacteremia. Additional Info Malignant hyperthermia is a rare but potentially fatal adverse reaction to inhaled anesthesia or intravenous succinylcholine. This condition may be genetic. The client will manifest tachycardia, muscle rigidity, fever, and rhabdomyolysis. Thus, the nurse must monitor the client for acute kidney injury and metabolic acidosis. Dantrolene is a muscle relaxant that should be used to treat this emergency.

The nurse is assessing a client with suspected Cushing's triad. Which of the following findings would support a diagnosis of Cushing's triad? A. hypotension, jugular venous distention, and muffled heart tones B. irregular respirations, bradycardia, and widening pulse pressure C. fixed pupils, hypotension, and bradycardia D. bradycardia, hypotension, and bradypnea

Explanation Choice B is correct. Irregular respiration, bradycardia, and widened pulse pressure are the three symptoms that makeup Cushing's triad. Cushing's triad occurs when the intracranial pressure in the skull has increased, thus causing these symptoms to happen. These manifestations are a late sign of increased intracranial pressure, where headache and altered level of consciousness are early signs. Choices A, C, and D are incorrect. Hypotension, jugular venous distention, and muffled heart tones are classic manifestations of Beck's triad, which is found with cardiac tamponade. Fixed pupils are an extremely late sign of increased intracranial pressure and are not found in Cushing's triad. The rest of the options are not reflective of this triad.

The nurse is planning a staff developmental conference about confidentiality. Which of the following scenarios should the nurse include as a violation of client confidentiality? A. Informing a visitor of the room number of a client admitted with pneumonia B. Telling a police officer who brought a client into the emergency department (ED) the urine drug screen results C. Notifying the pharmacist that a client is HIV positive and may have a potential drug interaction D. Informing local authorities that a client is suspected of being a victim of domestic violence

Explanation Choice B is correct. The results of a Urine Drug Screen (UDS) are confidential, and that confidentiality should not be pierced because an individual is a police officer. If the police officer requests the results, they should obtain a legal court order and present it to risk management to obtain the necessary records. Choice A is incorrect. Directory information (if a client is admitted, generalized condition description, and location) is directory information and can be disclosed (please click herefor additional information on directory information). Choice C is incorrect. The nurse notifying the pharmacist and revealing the client's HIV status is okay because the pharmacist verifies and dispenses the client's medications, establishing a professional relationship with this client. Choice D is incorrect. Most healthcare workers are mandatory reporters and should notify the appropriate authorities of suspected domestic violence.

Tympany is a percussion sound commonly located in the: A. Upper arm B. Abdomen C. Lower leg

Explanation Choice B is correct. Tympany is the percussion sound heard over the abdomen. Percussion is part of the physical assessment, which is done to produce sound or elicit tenderness. The person who is assessing will tap fingers on the patient, similar to the tapping of a drumstick on a drum. The vibrations that the fingers produce create percussion tones conducted into the patient's body. If the waves travel through dense tissue, the percussion tones are quiet or flat. If they go through air or fluid, the tones are louder. The loudest tones are over the lungs and hollow stomach. The most peaceful percussion sounds are heard over bones. Percussion sounds are described as hyperresonant (diseased lungs), full (healthy lungs), tympanic (abdomen), dull (organs), and flat (over bones).

The nurse is teaching a parent of a 12-year-old diagnosed with iron deficiency anemia prescribed ferrous sulfate elixir. It would be appropriate for the nurse to instruct the parent to A. have your child remain upright for 30 minutes after taking this medication. B. dilute the medication in water or juice. C. administer this prescribed medication with food. D. have your child take this medication with foods rich in calcium.

Explanation Choice B is correct. When ferrous sulfate elixir is prescribed, it is okay for the client to mix it with water or juice and then drink the medication with a straw. Once the medication has been consumed, the client should rinse their mouth out to prevent any staining to the teeth. Choice A is incorrect. A client doesn't need to sit upright 30 minutes after taking ferrous sulfate. This is appropriate instruction for clients taking bisphosphonate, such as alendronate, to prevent esophagitis. Choice C is incorrect. Ferrous sulfate should not be administered with food. The client should take this medication on an empty stomach. If extreme gastric upset occurs, the client may take it with food. However, food may decrease the drug plasma levels, decreasing the medication's efficacy. It should be stressed that this medication is best taken on an empty stomach. Choice D is incorrect. For a client taking ferrous sulfate, calcium decreases the absorption. Ferrous sulfate should not be administered with milk or milk products.

The nurse is caring for a client with severe sepsis who is receiving vasopressor therapy. Despite adequate fluid resuscitation, the client's blood pressure remains low. Which intervention should the nurse anticipate as the next step in managing the hypotension? A. Administering a bolus of crystalloid solution B. Initiating continuous renal replacement therapy C. Titrating the vasopressor infusion D. Administering a blood transfusion

Explanation Choice C is correct. If the client's blood pressure remains low despite fluid resuscitation and the initiation of vasopressors, the next step in managing hypotension in sepsis is to titrate the vasopressor up or possibly add a second infusion. Choice A is incorrect. While fluid resuscitation is essential, this client is not responding adequately to fluids, necessitating the consideration of vasopressors. Choice B is incorrect. Renal replacement therapy is not the primary intervention for managing refractory hypotension. Vasopressor therapy takes precedence. Choice D is incorrect. While blood transfusion may be indicated for specific conditions, it is not the primary intervention for managing refractory hypotension in severe sepsis.

The nurse is planning a staff development conference about mechanical ventilator modes. Which of the following information should the nurse include? A. Assist-control allows spontaneous breathing at the client's rate and tidal volume between the ventilator breaths B. Synchronized intermittent mandatory ventilation applies positive airway pressure throughout the respiratory cycle to prevent alveolar collapse C. Pressure support ventilation delivers a set airway pressure and is used for spontaneously breathing clients D. Continuous positive airway pressure is used to provide full ventilator support for clients not taking spontaneous breaths

Explanation Choice C is correct. Pressure support ventilation is used during weaning, providing pressure and positive end-expiratory pressure (PEEP) to spontaneously breathing individuals. This mode does not provide a tidal volume, so the client must be able to spontaneously breathe and take in an adequate tidal volume for this mode. Choices A, B, and D are incorrect. Assist-control (AC) provides full ventilation support. A set tidal volume, rate, and FiO2 are added. This differs from synchronized intermittent mandatory ventilation (SIMV), where SIMV will allow clients to take spontaneous breaths in between each breath given by the ventilator at their own tidal volume. SIMV does not apply positive airway pressure throughout the respiratory cycle to prevent collapse; this description belongs to continuous positive airway pressure (CPAP), a weaning mode. CPAP does not provide ventilator support as it is used primarily as a weaning mode to get the client extubated.

The nurse is caring for a client scheduled for a lumbar puncture (LP). Which of the following clinical manifestations would require follow-up by the nurse? A. nuchal rigidity B. temperature 101° F (38.3° C) C. petechial rash D. restlessness

Explanation Choice D is correct. Restlessness is a central manifestation associated with increased intracranial pressure. This manifestation requires follow-up because increased ICP is a contraindication to a lumbar puncture. Choice A is incorrect. Nuchal rigidity is a clinical manifestation of bacterial meningitis. Nuchal rigidity is not a manifestation that is a contraindication to an LP. Bacterial meningitis requires an LP to confirm this diagnosis. Choice B is incorrect. Fever is not a contraindication to an LP. Strong contraindications to an LP include increased intracranial pressure. Choice C is incorrect. A petechial rash is not a contraindication to an LP. Fever, petechial rash, and nuchal rigidity are manifestations of bacterial meningitis. If bacterial meningitis is suspected, an immediate LP is performed before administering broad-spectrum antimicrobials. Additional Info ✓ Lumbar puncture is a procedure that is done to extract CSF, measure CSF pressure, or instill medication(s) ✓ Informed consent is required ✓ Strict surgical asepsis is necessary during this procedure ✓ A significant contraindication for this procedure is if the client has increased ICP or significant risk for bleeding

Hyperlipidemia

A condition in which there are high levels of fat particles (lipids) in the blood. Examples of lipids include cholesterol and triglycerides. These substances can deposit in blood vessel walls and restrict blood flow. This creates a risk of heart attack and stroke. Hyperlipidemia doesn't cause any symptoms. The condition is diagnosed by routine blood tests, recommended every five years for adults. Treatments include medication, a healthy diet, and exercise.

nuchal rigidity

A sensation of soreness or discomfort in the neck when trying to move it or turn the head from side to side. bacterial meningitis

The nurse is caring for a client with acute pulmonary edema. The nurse plans to take which actions? Select all that apply. Administer prescribed furosemide Elevate the head-of-the-bed to 60 degrees Obtain a STAT chest computed tomography (CT) scan Notify the Rapid Response Team (RRT) Provide oxygen via nasal cannula Administer prescribed morphine

Additional Info Pulmonary edema is a medical emergencyoccurring because of fluid volume excess or left-sided heart failure. Pulmonary edema manifests as restlessness, tachypnea, hypoxia, and a feeling of impending doom. The nurse should execute actions such as elevation of the head of the bed, oxygen via a mask, prescribed diuretics and morphine, and notification to the rapid response team. Other treatments include continuous positive airway pressure therapy and/or nitrates.

Which part of the laryngeal cartilage is a full circular ring and is the narrowest part of the airway in young children? A. Hyoid B. Arytenoid C. Cricoid D. Thyroid

Choice C is correct. The cricoid appears as a full circular ring and is the most narrow part of the airway. While intubating, it can be useful to place pressure on the cricoid to make the airway more comfortable to access. Choice A is incorrect. The hyoid is a semi-circle ring, not a circular ring. It helps support the tongue. Choice B is incorrect. The arytenoid muscle is at the back of the larynx and allows the vocal cords to work correctly. Choice D is incorrect. The thyroid is an organ that sits below the "Adam's apple" and is not a part of the airway.

clonus

Clonus is involuntary and rhythmic muscle contractions caused by a permanent lesion in descending motor neurons. Clonus may be found at the ankle, patella, triceps surae, wrist, jaw, biceps brachii. Additional Info ✓ Clonus (also called myoclonus) is the sudden, brief, jerking contraction of a muscle or muscle group often seen in seizures ✓ Clonus can be found in the ankle or wrist ✓ For a video reviewing this assessment, please click here

diplopia

Double vision, which is also called diplopia, causes people to see two of the same image—whether horizontal, vertical or diagonal—instead of one

Lithium

The findings requiring follow-up include the decreased sodium level, which is concerning because hyponatremia facilitates lithium toxicity. The elevated BUN requires follow-up because this is further evidence of dehydration. The lithium level is elevated, which is quite concerning for toxicity. The white blood cell (WBC) count is elevated, but this is not a concern. Lithium causes leukocytosis, which is a benign side effect. While this could mask acute infection and inflammation, this is an expected finding.

The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following? A. Atonic seizure B. Tonic-clonic seizure C. Absence seizure D. Complex partial seizure

Choice A is correct. Atonic seizures are drop attacks or drop seizures that cause a sudden loss of muscle tone and result in the client collapsing. This is quite serious as this may cause a client to sustain an injury. Choices B, C, and D are incorrect. Tonic-clonic seizures are characterized by stiffening the muscles (tonic), then the client has muscle jerking (clonic). Absence seizures feature a brief staring gaze with an impaired level of consciousness. These are common in children and may occur multiple times throughout the day. Complex partial seizures cause an impairment in consciousness, so the client may exhibit automatisms such as lip-smacking or repeating certain words/phrases.

The nurse is caring for a client who has sickle cell disease (SCD). Which prescription from the primary healthcare provider (PHCP) should the nurse anticipate? A. hydroxyurea B. methotrexate C. nortriptyline D. verapamil

Choice A is correct. Hydroxyurea is an effective treatment for SCD. This medication increases fetal hemoglobin and decreases hemoglobin S. By increasing fetal hemoglobin, the sickling effect can be reduced, and oxygen carrying capacity can be improved. Choices B, C, and D are incorrect. Methotrexate is a medication indicated to treat autoimmune conditions such as rheumatoid arthritis. Nortriptyline is a tricyclic antidepressant (TCA) with significant anticholinergic properties and would be detrimental to the management of SCD. Verapamil is a calcium channel blocker and is utilized in the management of hypertension and other vascular disorders.

The nurse is performing a physical assessment on a client. Which of the following findings would indicate a positive result for clonus? A. Rubor of the feet and ankles when the leg is in the dependent positon B. Rapid, rhythmic muscle contractions C. Popping or clicking of the knee joint with movement D. Audible cracking and palpable grating with movement of the joints

Choice B is correct. Clonus is an abnormal response to deep tendon reflex stimulation characterized by rapid, rhythmic muscle contractions. Choice A is incorrect. Rubor of the feet and ankle, when positioned dependently, is a consistent finding of peripheral arterial disease. Choice C is incorrect. Popping or clicking of the knee would indicate damage to fibrocartilage in the knee or meniscal injury. Choice D is incorrect. Audible cracking and palpable grating with the movement of joints describe crepitation (crepitus). This finding would indicate fracture, dislocation, or osteoarthritis.

Following the application of a fiberglass cast to treat the client's severe ankle sprain (i.e., Grade 3), a nurse performs client education. During this discussion, the client asks, "How long will my cast take to dry?" Based on this type of cast, the nurse should respond: A. Eight hours B. 30 minutes C. At least 24 hours D. At least 48 hours

Choice B is correct. Fiberglass, a waterproof synthetic casting material, can dry and become rigid within minutes. Typically, the cast will be fully dried within 30 minutes of application. Although the client would be allowed to bear weight on the cast 30 minutes after application if allowed by the health care provider (HCP), crutches or another assistive device may be indicated. Choice A is incorrect. Typically, a fiberglass cast will be fully dried within 30 minutes of application. Depending on the size and location of the cast, a plaster cast takes at least 24 hours to dry. Choice C is incorrect. Plaster was the traditional material used for casts but is used less often today. Depending on the size and location of a plaster cast, this type of cast would take at least 24 hours to dry. Here, since the client received a fiberglass cast, this would not be the correct response. Choice D is incorrect. As mentioned above, plaster was the traditional material used for casts but is used less often today. Depending on the size and location of a plaster cast, this type of cast would take at least 24 hours to dry. Clients who receive large plaster casts may require 48 hours or more to dry completely. Additional Info Grade 3 sprains may require a short leg cast or cast-brace for 10 to 14 days. During the initial phase of ankle sprain, early weight-bearing as tolerated is typically recommended during this phase. Crutches may be needed due to pain during ambulation.

The nurse is caring for a client newly prescribed ropinirole. The nurse understands that this medication is prescribed to treat which condition? A. Multiple Sclerosis B. Parkinson disease C. Schizophrenia D. Guillain-barré syndrome

Choice B is correct. Ropinirole is a dopaminergic drug used in conjunction with other medications to treat Parkinson's disease. Additionally, this medication is indicated to treat restless leg syndrome. Choices A, C, and D are incorrect. Multiple sclerosis is treated by interferons, muscle relaxers, and steroids. This medication would be detrimental for an individual with schizophrenia because it increases dopamine levels which can trigger psychosis. Guillain-barré syndrome is treated with plasmapheresis or immune globin.

The nurse is caring for a client with myasthenia gravis who is six hours postoperative following a thymectomy. Which item should the nurse have at the client's bedside? A. Calcium gluconate B. Bag-valve mask C. Tracheostomy kit D. Atropine sulfate

Choice B is correct. This client should have a bag-valve-mask setup (Ambu) and suction equipment at the bedside. A recent total thymectomy procedure puts this client at risk for myasthenic crisis (an exacerbation of myasthenia gravis symptoms due to insufficient cholinergic medications) and risk for impaired gas exchange (due to potential hemothorax/pneumothorax). A myasthenic crisis results in muscle weakness and increases the risk of respiratory issues. Noninvasive mechanical ventilation should be used to support respiratory status and improve gas exchange in the event of respiratory distress until other interventions are available. Choice A is incorrect. Calcium gluconate should be readily available after a client has a subtotal thyroidectomy because of the risk of severe hypocalcemia. This is not required after a client has a thymectomy. Choice C is incorrect. A tracheostomy kit is not necessary after this procedure. This would be a supply item to have available after the client has had a subtotal thyroidectomy because of the risk of airway edema. Choice D is incorrect. The Tensilon test is used to differentiate cholinergic crisis from myasthenic crisis and may cause cardiac dysrhythmias or cardiac arrest. Atropine, the antidote for Tensilon, should be available if the client is undergoing this test, but it would not be important following a thymectomy.

The nurse is assessing a client with Guillain Barré syndrome. Which of the following would be an expected finding? A. Hyperreflexia B. Perseveration C. Dystonia D. Paresthesia

Choice D is correct. Guillain Barré is a polyneuropathy manifested by paralysis, paresthesia, autonomic disturbances, and depressed or absent reflexes. The paresthesia is typically found in the peripheral extremities and may persist for quite some time, even after the return of motor function. Choices A, B, and C are incorrect. Depressed or absent reflexes are a hallmark of this disease process. Perseveration is when the individual repeats something, such as a phrase. This is commonly seen in Alzheimer's disease. This is not a feature in Guillain-Barré. Dystonia is an adverse effect associated with dopaminergic drugs such as haloperidol. This muscle repetitive muscle contraction is not related to Guillain Barré.

The nurse is caring for a client receiving a continuous infusion of heparin for a pulmonary embolism. The nurse reviews the client's laboratory data and should take which action? See the image below. Select all that apply. Discontinue the heparin infusion Obtain an immediate activated partial thromboplastin time (aPTT) Assess the client's intravenous site for bleeding Prepare to administer a unit of packed red blood cells Notify the primary healthcare provider (PHCP)

Choices A and E are correct. Discontinuing the heparin infusion is essential because this is a life-threatening complication. Heparin-induced thrombocytopenia (HIT) is a hypercoagulable condition and promotes clotting. Continuing heparin in a client with HIT and acute pulmonary embolism may cause an extension of thrombus and even death. The physician must be notified; however, the heparin infusion must be held while awaiting the physician's orders. Choices B, C, and D are incorrect. Obtaining an immediate aPTT would be unhelpful because the issue is an autoantibody reaction with the heparin. This reaction would show in the client's platelets. Assessing the client for bleeding would be highly unlikely as thrombosis is likely to occur with this complication. Preparing a unit of packed red blood cells would not be an effective treatment as the client is not bleeding, and the immediate treatment is to cease the client's exposure to heparin.

The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect? Select all that apply. unilateral frontotemporal pain nausea photophobia fever nuchal rigidity Vomiting

Migraine headaches have complex pathophysiology that is not entirely understood. The current thought process regarding this syndrome is that it is caused by a combination of neuronal hyperexcitability and vascular, genetic, hormonal, and environmental factors. During an acute migraine headache, often the client may feel as though they are experiencing a stroke because of transient facial paralysis and/or numbness that may be experienced.

lactic acid level

When the oxygen level is low, carbohydrate breaks down for energy and makes lactic acid. Lactic acid levels get higher when strenuous exercise or other conditions—such as heart failure, a severe infection (sepsis), or shock—lower the flow of blood and oxygen throughout the body. Normal lactate levels are less than two mmol/L, with hyperlactatemia defined as lactate levels between 2 mmol/L and 4 mmol/L. Severe levels of lactate are 4 mmol/L or higher.

Epistaxis

nosebleed

The nurse is caring for a post-operative client two days following abdominal surgery. Upon assessment, the client reports a dull ache in their right calf with a "funny feeling" in the toes. What should the nurse do next? A. Elevate the client's legs by placing a pillow underneath the ankles and tell them to drink more water. B. Tell the client to stay in bed and contact the primary health care provider (PHCP) to report the assessment findings. C. Instruct the client to rub or massage their legs to stimulate blood flow. D. Encourage the client to ambulate and educate them on the dangers of prolonged bed rest.

hoice B is correct. The subjective symptoms reported by the client may indicate impaired circulation, deep vein thrombosis (DVT), thrombophlebitis, or another surgical or post-surgical complication. The client's verbalized complaint and post-surgical status align with the symptoms and risk factors for a DVT. Although there is no evidence that early activity increases the risk of clot dislodgement and pulmonary embolism and may help to reduce the risk of postphlebitic (post-thrombotic) syndrome, ambulation should not be encouraged in this client until the cause of the client's symptoms has been confirmed by the PHCP, as no diagnostic testing or imaging has been performed at this time. The next action for the nurse is to instruct the client to remain in bed (to ensure the client is safely situated) before contacting the PHCP to alert them of the assessment findings. Choice A is incorrect. While elevating the client's legs by placing a pillow underneath the ankles may be beneficial to reduce swelling and discomfort by increasing venous return, fluids should be withheld until the PHCP is notified of the nurse's assessment findings. In this post-surgical client, if any injury or post-surgical complication is suspected, procedures may be required, and it may be necessary that the client refrains from oral intake before those interventions. Therefore, the client should remain NPO until the nurse has spoken with the HCP at the earliest. Choice C is incorrect. Until a DVT has been ruled out as a cause of the client's symptoms, the client should not be instructed to massage their leg(s), as doing such is connected to the risk of loosening a clot and causing a life-threatening pulmonary embolus. Therefore, the client should be instructed to avoid massaging their leg(s) until further notice.

The nurse understands that which of the following are potential causes of metabolic alkalosis? Select all that apply. Vomiting Diarrhea Antacids Starvation Hypokalemia

Additional Info ✓ Metabolic alkalosis is a medical condition characterized by an elevation in blood pH above the normal range of 7.35-7.45, resulting from an accumulation of bicarbonate ions (HCO3-) in the body. ✓ Causes: The most common causes of metabolic alkalosis include excessive vomiting or gastric suction, diuretic use, hyperaldosteronism, and excess bicarbonate administration. ✓ Symptoms: The symptoms of metabolic alkalosis include confusion, twitching, muscle cramps, and tingling in the fingers and toes. Severe cases can lead to seizures, respiratory depression, and cardiac arrest. Diagnosis: Diagnosis of metabolic alkalosis involves measuring arterial blood gases, serum electrolytes, and urine pH. ✓ Treatment: Treatment depends on the underlying cause of metabolic alkalosis. It may involve fluid and electrolyte replacement, correction of acid-base imbalance, and addressing the underlying condition.

SEPTIC SHOCK

Additional Info ✓ Nurses must promptly assess clients with suspected septic shock and initiate appropriate interventions. Early recognition and intervention are vital to prevent further deterioration and improve outcomes. Earlier on in the presentation of sepsis, clients present with the following vital sign changes: Fever, temperature higher than 38 C, or hypothermia, temperature lower than 36 C Tachycardia with a heart rate higher than 90 beats per minute in adult patients or less than two standard deviations for age in pediatric patients Tachypnea with respiratory rate greater than 20 breaths per minute in adult patients or more than two standard deviations for age in pediatric patients ✓ If hypotension persists despite adequate fluid resuscitation, vasopressor medications may be required to support blood pressure and maintain adequate perfusion to vital organs. Nurses should carefully monitor the client's hemodynamic response and titrate vasopressor dosages as needed. ✓ Continuous monitoring of vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is crucial in septic shock. Early signs of deterioration should be promptly identified to guide interventions and prevent complications.

low serum albumin level

you may have malnutrition. It can also mean that you have liver disease, kidney disease, or an inflammatory disease. Higher albumin levels may be caused by acute infections, burns, and stress from surgery or a heart attack. Additional Info ✓ Albumin is a major serum protein that is below normal, often found in clients who have had inadequate nutrition for extended durations of time. ✓ Albumin synthesis takes place in the liver, after which it is excreted into the bloodstream. ✓ Low albumin values are associated with longer hospital stays. ✓ Hypoalbuminemia is the most common nutrition-related abnormality in clients with infection. ✓ Albumin plays a key role in fluid and electrolyte balance. ✓ For some clients, severe undernutrition results in decreased serum albumin and prealbumin, resulting in delayed healing and third spacing. One must treat the underlying cause of hypoalbuminemia. ✓ High albumin may indicate dehydration. Look for increased hemoglobin and/or hematocrit in such clients. ✓ Some causes of low albumin may include the use of intravenous fluids, rapid hydration, and overhydration; cirrhosis or other liver diseases (including chronic alcoholism); burns, nutritional deficiencies, or protein-losing enteropathies (including Crohn's disease and ulcerative colitis).

The nurse is preparing to suction a client's tracheostomy. Place the steps in the appropriate order that the nurse should perform. Place the steps below in the appropriate order.

Identify the client, perform hand hygiene, and gather supplies Perform hand hygiene and apply personal protective equipment (PPE) Apply a continuous pulse oximeter to the client Apply sterile gloves Using an aseptic technique, open the suction kit or catheter package and prepare supplies Suction the client as the catheter is removed for a maximum of 15 seconds. Place the tip of catheter into a sterile basin and suction a small amount of normal saline solution from the basin by occluding the suction vent

The nurse works on a medical-surgical unit and is responsible for assessing the client's vital signs. Which of the following clients should have their temperature measured orally? Select all that apply. A 61-year-old woman who had oral surgery A 44-year old man with chest pain on oxygen via nasal canula An 83-year-old woman with diarrhea A 29-year-old client with an earache A 6-year-old client with a sore throat and difficulty swallowing

Choices B, C, and D are correct. There is no contraindication for oral temperature measurement in any of these clients. The oral temperature is measured with the probe placed under the tongue and the lips closed around the instrument. Oxygen delivered by nasal cannula does not affect the accuracy of the measurement. An adult client with chest pain (Choice B), diarrhea (Choice C), or an earache (Choice D) can receive oral temperatures. Choices A and E are incorrect. A is incorrect. Oral surgery may falsely increase the local temperature by causing surgery-related inflammation. Oral temperature measurement is contraindicated in clients with altered mental status and may not cooperate fully. Choice E is incorrect. E is incorrect. This client may have symptoms interfering with accurate oral temperature measurements, such as pain or discomfort while swallowing. In this case, an alternative temperature measurement method, such as axillary (armpit) or tympanic (ear), would be more suitable.

Packed Red Blood Cells Fresh Frozen Plasma Platelets

Explanation Packed Red Blood Cells are indicated for hemoglobin of 7 g/dL or less. Additionally, the transfusion time for PRBCs is 2-4 hours. The blood product should be type-specific, but if not possible, O negative may be administered as it is the universal donor. When infusing PRBC's, 0.9% saline should be spiked with the blood product using y-type tubing. Fresh Frozen Plasma is indicated for clotting factor replacement and volume expansion. FFP must be type specific and is administered over 15-30 minutes. To determine efficacy, the nurse should reassess the PT/INR after the transfusion. Platelets are used to treat platelet dysfunction and thrombocytopenia. Platelet transfusions are indicated once the platelet count reaches 20,000-25,000 mm3. Platelets do not have to be type specific as they are pooled from as many as ten donors. The infusion time is 15-30 minutes.

endotracheal tube (ETT)

Additional Info ✓ When a client is being mechanically ventilated, airway patency is the priority. ✓ A bag-valve mask should be readily available during a power failure or emergency resuscitation. ✓ Review ventilator settings frequently and collaborate with respiratory therapy to assist in ventilator management. ✓ The client's head of the bed should be more than 30 degrees when supine to decrease the risk for aspiration and ventilator-associated pneumonia (VAP). ✓ VAP can be prevented by Oral care using an antiseptic Minimizing exposure to proton pump inhibitors Meticulous hand hygiene by nursing staff/visitors Pulmonary hygiene measures such as chest physiotherapy When caring for a client on a ventilator, you should be familiar with the following settings: Mode (Volume [SIMV, A/C] or Pressure [PSV]) Rate (Number of breaths per minute) Tidal volume (the amount of gas delivered to the client) Fraction of inspired oxygen (FiO2 - the percentage of oxygen given per breath) PEEP (pressure added at exhalation to keep the small airways open and mitigate atelectasis) Pressure support (PS - provides added pressure when the client takes a spontaneous breath)

A client is seeking guidance on secondary prevention strategies to prevent cancer. Which strategies would be most appropriate for the nurse to include in the client's educational plan? Select all that apply. Eliminate alcohol intake Pap smears Rehabilitation programs Colonoscopies Regular cancer screenings

Choices B, D, and E are correct. Secondary prevention strategies use screening tests that aim to detect cancer at an early stage. This makes it possible to treat cancer early and increases the chance of a cure. A pap smear is a secondary prevention strategy because it is a screening test to detect cervical cancer early (Choice B). Colonoscopy is a secondary prevention strategy because it detects pre-cancerous colon polyps before they progress to colon cancer (Choice D). Regular screenings, such as mammograms, colonoscopies, and pap smears, can help detect cancer early when it's most treatable. The specific screening recommendations vary depending on age, sex, and other factors, so it's important to discuss screening options with a healthcare provider (Choice E). Choices A and C are incorrect. Alcohol is implicated as a carcinogen in a variety of cancers. Eliminating alcohol is a primary prevention strategy (Choice A). Rehabilitation programs are a tertiary prevention strategy (Choice C).

The nurse cares for a client receiving positive end-expiratory pressure (PEEP) while being mechanically ventilated. The nurse understands that this setting is used to A. give a set amount of inspiratory pressure. B. prevent closure of the small airways during expiration. C. allow spontaneous breaths between mandatory ones. D. deliver a preset tidal volume with each breath.

Choice B is correct. Positive end-expiratory pressure (PEEP) is used in clients with acute respiratory distress syndrome (ARDS) because it improves lung compliance and oxygenation. This is accomplished by adding pressure at exhalation to keep the alveoli open. PEEP is a setting that may be added to a variety of ventilator modes. Choices A, C, and D are incorrect. PEEP does not give an amount of pressure upon inspiration. This description is appropriate for pressure support ventilation which provides pressure when the client takes a spontaneous breath. A client allowed to take spontaneous breaths between mandatory ones is a SIMV and AC modes feature. The critical difference between SIMV and AC is that when a client takes a spontaneous breath, they are forced to take in the prescribed tidal volume, whereas SIMV they can take in their own tidal volume during that spontaneous breath. PEEP does not have anything to do with tidal volumes, and giving a preset tidal volume with each breath would be an appropriate description for the AC mode.

The nurse is explaining immunizations to the parent of a pediatric patient. What type of acquired specific immunity would the Varicella vaccine fall under? A. Natural active immunity B. Artificial active immunity C. Passive natural immunity D. Passive artificial immunity

Choice B is correct. The Varicella vaccine contains a live chicken-pox virus. Artificial active immunity refers to the immunization of the specific antigen known to cause illness. This includes live and attenuated vaccines. Choice A is incorrect. Natural active immunity is achieved when there is contact with the infecting antigen through clinical infections. Choice C is incorrect. Passive natural immunity is when the benefits are passed down from the mother via transplacental and colostrum transfer. Choice D is incorrect. Passive artificial immunity refers to the short-term freedom that occurs upon the injection of serum antibodies from an individual who is immune to the body of someone who was not making these antibodies.

The nurse is caring for a client receiving mechanical ventilation. Which essential item should the nurse keep at the bedside? A. Bag valve mask B. Nasal cannula oxygen C. Chest tube D. Tracheostomy set

Choice A is correct. A nurse must keep a bag valve mask for a client receiving mechanical ventilation at the bedside. This allows the nurse to promptly ventilate the client if there is a power failure or significant difficulty with mechanical ventilation. Choices B, C, and D are incorrect. Nasal cannula oxygen is not necessary for a client receiving mechanical ventilation. If a client is receiving mechanical ventilation, their oxygenation needs far exceed what a nasal cannula may deliver. Oxygen should be on hand - not nasal cannula oxygen (choice B). A chest tube is not necessary to keep at the bedside for a client receiving mechanical ventilation (choice C). A tracheostomy set is not necessary to keep at the bedside either. This will be a supply item essential if a client is recovering from a thyroidectomy or if the client has epiglottitis (choice D).

The nurse has taught a client scheduled for a liver biopsy. Which of the following statements by the client would indicate a correct understanding of the teaching? A. "I will not be conscious during this procedure." B. "I should not take any acetaminophen one week before this procedure." C. "I will need to cough and deep breathe every two hours after this procedure." D. "I may be asked to breathe in and hold my breath before the insertion of the needle."

Explanation Choice D is correct. A liver biopsy is performed with the client conscious using local anesthesia (lidocaine). During the procedure, the client is asked to take a deep breath and hold it to ensure appropriate needle placement. Choice A is incorrect. A liver biopsy is performed without general anesthesia. The client is given a local anesthetic agent to attenuate the pain from the needle insertion. Choice B is incorrect. Acetaminophen is appropriate for the client to take because it does not cause any risk of bleeding. NSAIDs and anticoagulants should be withheld one week before this procedure to reduce the risk for intra- and post-procedure bleeding. Choice C is incorrect. Coughing and straining immediately after this procedure is contraindicated. This may increase the risk for post-procedure bleeding and can increase discomfort.

positive end-expiratory pressure (PEEP)

PEEP is a setting that may be added to a mechanical ventilator, CPAP, or BiPAP. PEEP is commonly prescribed for clients with acute respiratory distress syndrome (ARDS) because PEEP prevents alveolar collapse, allowing for better gas exchange, thus, improving oxygenation. The increase in pressure may cause a client to develop a stress ulcer. This puts the client at risk for bleeding. The nurse should obtain a prescription for a proton pump inhibitor (pantoprazole) or histamine antagonist (famotidine) to prevent a stress ulcer. Antiemetics such as ondansetron or promethazine would not prevent a gastric ulcer. Additional Info ✓ PEEP is a setting that may be added to a mechanical ventilator, CPAP, or BiPAP ✓ PEEP is commonly prescribed for clients with acute respiratory distress syndrome (ARDS) because PEEP prevents alveolar collapse, allowing for better gas exchange, thus, improving oxygenation ✓ By improving gas exchange, therapeutically, the client will enjoy increased oxygen and less lactic acid from the stress of breathing (clients with low pulmonary compliance will have an increase in their breathing, thus, creating lactate and sending the client into acidosis ✓ PEEP can cause decreased venous return and lower the mean arterial pressure ✓ The blood pressure should be monitored closely for a client receiving PEEP because of the risk of hypotension ✓ PEEP also raises the client's risk for a stress ulcer ✓ 5-15 cm H2O is the range for PEEP that may be adjusted

The nurse is teaching parents of a child diagnosed with varicella. Which of the following information should the nurse include? Select all that apply. Your child may return to school once the lesions have crusted. Your child should take the entire course of antibiotics. Acetaminophen may be used for fever. Baths with baking soda may help with the itching. Do not use any aspirin or ibuprofen during the illness.

Additional Info ✓ Varicella is a highly contagious viral infection primarily spread by aerosolized droplets and direct contact with the lesions. ✓ Treatment is symptomatic with prescribed acetaminophen and therapeutic baths with cool water and uncooked oatmeal or baking soda. ✓ Prescribed antivirals, such as valacyclovir, may shorten the symptoms' duration. ✓ The client should be isolated using airborne and contact precautions until the lesions have crusted over.

An 8-month-old infant has been brought into an emergency department (ED) for acute diarrhea and decreased oral intake. Which assessment finding would an ED nurse anticipate? A. Skin tenting B. Low hematocrit C. Bulging anterior fontanels D. Weight gain

Choice A is correct. Decreased skin turgor is often present in dehydrated infants, resulting in the child's skin taking longer than average to return to a normal state after it has been pinched into a tent-like position. This response, known as skin tenting, would be an anticipated symptom in an infant with dehydration. Skin tenting in an individual with decreased skin turgor is demonstrated in the illustration above. Choice B is incorrect. Dehydration and the related fluid volume loss result in increased hematocrit, not decreased. Dehydration lowers the water content in the body, including blood plasma levels. Lower plasma levels increase the ratio of red blood cells to blood volume, falsely increasing hematocrit levels (hemoconcentration). Choice C is incorrect. Depressed anterior fontanelles are expected from a dehydrated infant. Bulging fontanelles are noticed in increased intracranial pressure and may suggest infections such as meningitis. Choice D is incorrect. Weight loss occurs during diarrhea and dehydration. Weight gain would not arise.

The nurse has just finished assisting the surgeon with inserting a chest tube in a client with a pneumothorax. Which assessment finding indicates that the procedure has produced its desired effect? A. Consolidation is seen in the chest x-ray. B. Clear breath sounds are auscultated bilaterally. C. There is rapid bubbling in the suction chamber of the chest drainage system. D. There is crepitus at the insertion site.

Choice B is correct. Bilateral breath sounds indicate that both the clients' lungs have expanded, which is the procedure's objective. A pneumothorax produces diminished or absent breath sounds in the affected lung. Once the chest tube has exerted its desired effect, the lung sounds should become clear. Choice A is incorrect. Consolidation occurs when fluid or exudates are present in the lungs, indicating pneumonia. This shows a deterioration in the status of the client. Choice C is incorrect. Rapid bubbling in the suction chamber indicates an air leak. This is not an indication that the treatment is effective, as this is a complication of the therapy. Choice D is incorrect. Crepitus indicates subcutaneous emphysema, indicating oxygen escape into the surrounding tissues. This complication is associated with a chest tube, not a therapeutic finding.

The nurse has provided discharge instructions to the parents of an infant with a newly applied Pavlik harness. Which of the following statements by the parents would indicate effective teaching? Select all that apply. "I will remove the harness during feedings." "I will check for red areas under the straps and at the skin folds." "I will take off the harness while my baby is napping." "I will dress my baby in tight clothing." "I will gently massage the skin under the straps to stimulate circulation." "When I change my baby's diaper, I should pull their legs."

Choices B and E are correct. Frequent skin assessments should occur by the parents because the straps may dig into the skin, causing breakdown. This should be reported to the PHCP for a potential adjustment of the straps. Gentle massage of the skin under the straps to stimulate circulation is permitted. Choices A, C, D, and F are incorrect. These statements indicate ineffective teaching and require follow-up. The harness should not be removed during feedings or while the infant is napping. The harness should be applied as directed by the prescriber, but generally, it is worn 24 hours a day. The healthcare provider should remove, adjust, and apply the harness. Tight clothing is discouraged because this may cause the knees to come together, negating the therapeutic use of the harness. The legs of the infant should not be pulled during a diaper change because this may cause further injury to the hip. It is recommended that the diaper change be performed by lifting the baby from under the buttocks and slide the diaper under. The diaper should be under the harness - not over.

The nurse should instruct the client that the prescribed etanercept INCREASE THE RISK FOR INFECTION Prior to the first dose, the nurse should ensure the client has had a NEGATIVE PPD TEST After administering the medication, the nurse should ASSESS FOR AN INJECTION SITE REACTION

Etanercept is a tumor necrosis factor (TNF) blocking agent used to treat autoimmune disorders such as psoriasis or rheumatoid arthritis (RA). This medication increases the client's risk of infection, requiring baseline testing for TB, such as a PPD. If the client has latent TB, it may be activated again. Etanercept does not cause weight gain or raise blood glucose. This would be true if the client were prescribed a corticosteroid which may be used in exacerbations of RA. A lipid panel has no relevance to etanercept. Etanercept is administered subcutaneously at a 45 to a 90-degree angle. This medication is not administered in the deltoid; this would be appropriate for an intramuscular injection. Aspiration for subcutaneous injections is unnecessary as piercing a blood vessel is rare. The most common adverse effect of this medication is injection site reaction (redness, pain, discomfort). The area should not be rubbed or massaged as it could worsen the injection site reaction.

The nurse is caring for a client who has been diagnosed with septic shock. The nurse understands that which of the following is considered a key characteristic of septic shock? A. Low respiratory rate B. Decreased serum lactate levels C. Elevated serum bicarbonate levels D. Hypotension despite adequate fluid replacement

Explanation Choice D is correct. Hypotension is a hallmark feature of septic shock, and despite receiving intravenous fluids, the blood pressure remains low due to widespread vasodilation and reduced vascular tone. Choice A is incorrect. Septic shock is associated with increased rather than decreased respiratory rate as the body tries to compensate for inadequate tissue perfusion and oxygenation. Choice B is incorrect. Septic shock is characterized by elevated serum lactate levels, not decreased levels. Elevated lactate levels indicate tissue hypoperfusion and anaerobic metabolism. Choice C is incorrect. Septic shock is associated with metabolic acidosis, which would result in decreased serum bicarbonate levels, not elevated levels.

Which of the following statements, if made by the client, would require follow-up? A. "I am planning to stop smoking cigarettes." B. "I should sleep on my stomach." position C. "I have decided to purchase a firm mattress." D. "I will bend my knees when lifting objects."

Choice B is correct. This statement requires follow-up because if a client sleeps on their stomach (prone positioning) results in excessive lumbar lordosis, which would increase the stress on the client's lower back. This client would benefit from sleeping in either a supine or side-lying position with a pillow between the knees and hips flexed. Choice A is incorrect. Nicotine has been shown to decrease circulation to vertebral disks. Smoking avoidance/cessation should be included in teaching for clients with low back pain. Choice C is incorrect. This client would benefit from the use of a firm mattress to provide adequate support to muscles, ligaments, and joints. Choice D is incorrect. The nurse should include information regarding proper body mechanics to limit stress on this client's lower back. The client should be instructed to avoid low back strain by bending at the knees (not the waist) when lifting objects and to stand up slowly with the item held close to the body.

A nurse is caring for a client with acute respiratory failure in the intensive care unit (ICU). The nurse would anticipate which of the following arterial blood gas (ABG) results? A. pH 7.29, PCO2 56, PaO2 83, HCO3 22 B. pH 7.38, PCO2 40, PaO2 92, HCO3 25 C. pH 7.49, PCO2 30, PaO2 96, HCO3 28 D. pH 7.50, PCO2 44, PaO2 93, HCO3 34

Choice A is correct. The nurse should anticipate receiving arterial blood gas results indicative of respiratory acidosis, such as those presented in Choice A. Typically, respiratory acidosis is caused by a decrease in the client's respiratory rate or volume (hypoventilation) due to central nervous system, pulmonary, or iatrogenic conditions. Choice B is incorrect. This result is indicative of a normal arterial blood gas result. Choice C is incorrect. This arterial blood gas result indicates respiratory alkalosis. Clients at risk for respiratory alkalosis include those experiencing hyperventilation (i.e., a client experiencing a panic attack), as this rapid, shallow breathing pattern causes the loss of carbon dioxide (CO2) and subsequent alkalotic pH change. Choice D is incorrect. This arterial blood gas result indicates metabolic alkalosis. The nurse would not anticipate receiving this type of ABG result, as metabolic alkalosis is typically found in clients following prolonged vomiting, hypovolemia, diuretic use, and/or hypokalemia.