archer questions p2

The nurse is preparing to assess a child with cystic fibrosis at the outpatient clinic. The nurse anticipates that the primary healthcare provider (PHCP) will order which routine laboratory test? A. Blood glucose B. Total cholesterol C. 24-hour urine D. Blood cultures

Choice A is correct. Diabetes mellitus is a common co-morbidity associated with cystic fibrosis (CF). The damage that CF may cause to the pancreas may induce diabetes. Thus, random blood glucose levels and quarterly hemoglobin A1C levels are commonly ordered throughout the course of the illness. A random blood glucose level greater than 200 mg/dL may suggest the presence of diabetes. Choices B, C, and D are incorrect. These laboratory tests are not routinely ordered for a client with CF. Blood cultures are only indicated if bacteremia is suspected.

A patient presents with enlarged tonsillar nodes. Acutely infected nodes would be: A. Firm but movable and tender B. Hard and nontender C. Fixed and soft D. Irregular and hard

Choice A is correct. Infected lymph nodes are usually tender. Choice B is incorrect. Infected lymph nodes are usually tender. Choice C is incorrect. Lymph nodes are movable. Choice D is incorrect. Lymph nodes are usually not irregular in shape.

The nurse is caring for a client who is receiving prescribed oprelvekin. Which of the following client findings would indicate a therapeutic response? A. Hemoglobin (Hgb) 14 g/dL B. White Blood Cell (WBC) 6,500 mm3 C. Platelets 155,000 mm3 D. Prothrombin Time (PT) 11 seconds

Choice C is correct. Oprelvekin is a hematopoietic agent used to stimulate the production of platelets. This platelet count is normal (150-400 mm3 is the optimal range) and, thus, is a therapeutic finding. Choices A, B, and D are incorrect. Oprelvekin is a hematopoietic agent used to stimulate the production of platelets. While all of these laboratory values are normal, they are not relevant to the therapeutic benefit of oprelvekin.

Which of the following are true regarding physiological changes during pregnancy? Select all that apply. A. Increase in heart size B. Increase in gastric motility C. Reduced renal threshold for glucose D. Decreased basal metabolic rate

Choices A and C are correct. There is an increase in heart size during pregnancy, as well as a heart position shift upward and to the left due to the displacement of the diaphragm as the uterus enlarges (Choice A). The renal threshold for glucose is reduced during pregnancy (Choice C). Choice B is incorrect. There is a decrease in gastric motility, which can sometimes cause poor appetite. Choice D is incorrect. There is an increased basal metabolic rate as metabolic function increases during pregnancy.

Which of the following statements about calcium are true? sata A. Calcium increases vitamin D levels. B. 50-70% of serum calcium is ionized in the serum. C. Albumin and calcium levels can be directly correlated. D. Calcium that is bonded to protein can pass through capillary walls.

Choices B and C are correct. These are true statements. 50-70% of serum calcium is ionized in the serum (Choice B). Due to the protein-binding ability of calcium and albumin, calcium levels can be directly correlated (Choice C).

Which of the following are bypasses in fetal circulation? Select all that apply. A. Ductus arteriosus B. Foramen ovale C. Ductus pulmonic D. Foramen aortic

Choices A and B are correct. The ductus arteriosus is a bypass in fetal circulation. It connects the pulmonary artery to the aorta (choice A). The foramen ovale is a bypass in fetal circulation. It is an opening between the right and left atriums of the heart (choice B). Choice C is incorrect. There is no ductus pulmonic; this is not a bypass in fetal circulation. Choice D is incorrect. There is no foramen aortic; this is not a bypass in fetal circulation.

The nurse is planning a staff development conference about the causes of labor dystocia. It would be correct for the nurse to identify which of the following may cause a delayed progression during labor? Select all that apply. A. Magnesium sulfate infusion B. Oxytocin infusion C. Uterine overdistention D. Hypoglycemia E. Epidural analgesia

Choices A, C, D, and E are correct. Magnesium sulfate relaxes the uterus and may decrease the intensity of uterine contractions. A decrease in intensity will decrease the progression of labor. Often when magnesium sulfate is infused, oxytocin may be used in conjunction. Uterine overdistention is a cause of labor dystocia because when the uterus is stretched, it does not contract properly. Hypoglycemia is a cause of delayed labor progression because of the maternal fatigue it induces. While epidural analgesia provides effective pain control, the decrease in sensation will also decrease the woman's drive to push and interfere with the internal rotation mechanism. Choice B is incorrect. Oxytocin infusion would progress labor as it stimulates uterine contractions. This medication is often used to remedy labor dystocia.

You are working in the pediatric cardiac ICU and are caring for a 2-year-old who is two weeks post-op from a bidirectional Glenn procedure. You are getting ready to discharge the patient home today and are preparing discharge instructions for the family. Which of the following are important points to include? Select all that apply. A. Avoid any play for at least 6 weeks post operatively. B. Do not go into crowded places for 2 weeks post operatively. C. Avoid sunlight directly on the incision site. D. Do not get any immunizations for 2 months following surgery.

Choices B, C, and D are correct. Avoiding crowds post-operatively will help minimize the chance of infection. It is essential to avoid direct sunlight on the incision site to optimize healing and minimize scarring. Getting immunizations in the immediate post-operative phase when the patient's immune system is still compromised can be dangerous. After the 2-months have passed, all vaccines should continue on a regular schedule. Choice A is incorrect. It is not appropriate to ask a 2-year-old to avoid any play for six weeks. Instead, the nurse should instruct the parents on selecting appropriate play activities and avoiding those where the child could fall. For example, coloring would be a better choice than biking.

Which of the following most impacts the client's food preferences? A. Culture and cultural background B. The frequency of grocery shopping C. The availability of foods locally D. The costs associated with food

Choice A is correct. Culture and cultural background have the most impact on the client's food preferences. Other factors that impact the client's food preferences include religious practices, age, level of development, and also one's taste preferences (likes and dislikes). Although the frequency of grocery shopping, the availability of foods locally, and the costs associated with food impact the client's access to as well as affordability of cooking, these factors do not impact the client's food preferences of likes and dislikes.

A nurse is preparing a client's intravenous (IV) infusion. As the nurse was preparing to attach the distal end of the IV tubing to the client's needleless access device, the exposed tubing slipped and hit the top of the client's bedside table. Which of the following is the most appropriate action by the nurse? A. Replace the IV tubing with new tubing B. Discard the client's current needleless access device and replace it with a new one C. Wipe the distal end of the tubing with povidone-iodine to render it sterile D. Clean the needleless access device with an alcohol swab

Choice A is correct. The nurse should replace the IV tubing as the existing tubing has now been contaminated and places the client at increased risk for systemic infection due to direct infusion into the bloodstream.

As you are bathing your client and providing nail care, you notice that the client's nails look abnormal. You would document this nail abnormality as: A. Onychomycosis B. Onychomadesis C. Onychorrhexis D. Onychia

Choice A is correct. You would document this nail abnormality as onychomycosis. Onychomycosis is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque/yellow, and crumbling. Since Onychomycosis is the most common cause of nail dystrophy presenting to the outpatient department, a nurse plays a crucial role in the diagnosis, management, and education of the clients. Dermatophytes (Trichophyton) cause 90% of these toenail infections. The remaining 10% are caused by non-dermatophytes (Saprophytes) and yeast (Candida). The prevalence of onychomycosis in patients between 20 to 60 years of age is 20%, whereas prevalence in older adults > 70 years of age is about 50%. The nurse should be aware of the risk factors and educate at-risk clients regarding foot care. Some common risk factors for onychomycosis include immunosuppression, diabetes mellitus, age greater than 70, persistently wet feet, repetitive nail trauma, tight-fitting footwear, HIV infection, prolonged steroid use, peripheral vascular disease, and genetics. Often, patients are asymptomatic. But the quality of life can be substantially decreased because of onychomycosis. Clients may have low self-esteem and feel embarrassed about having thick, discolored nails. Also, they may report mild pain and discomfort. Diagnosis is based on history and clinical exam. Diagnosis can be confirmed by demonstrating dermatophytes in KOH preparation of nail scrapings. The condition is often challenging to treat. Recurrence and failures may be in the range of 20 to 50% (i.e., the cure rate is approximately 50%). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil). Duration of treatment of toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails. Most antifungal treatments may have liver toxicity; therefore, liver function tests may have to be monitored. Terbinafine is contraindicated in clients with baseline liver disease. Choice B is incorrect. Onychomadesis is the falling off and the separation of the nails from the nail bed. It is not the appearance of the affected nail in the exhibit. The cause of onychomadesis is often idiopathic (unknown). However, in children, it may occur as a rare complication 4 to 6 weeks following Hand, Foot, and Mouth disease. Choice C is incorrect. Onychorrhexis is the formation of vertical ridges on the nails or brittle nails that tend to break easily. The pins are not thick and discolored, as shown in the exhibit. Onychorrhexis occurs due to disordered keratinization in the nail matrix. Causes include the normal aging process, recurrent nail trauma, anemia, hypothyroidism, and eating disorders. Choice D is incorrect. Onychia is an inflammation of the nail folds. It does not appear in the exhibit provided. Onychia is not the infection of the nail itself, but rather a disease of the surrounding tissue of the nail plate.

You are caring for a 12-year-old patient with a history of seizures. During her stay, you notice that she begins staring blankly. During this period, you are unable to get her attention, and she does not speak. You suspect that this is a: A. Petit mal seizure B. Simple partial seizure C. Grand mal seizure D. Myoclonic seizure

Choice A is correct. The petit mal (or absence) seizure is characterized by blank staring and an impaired level of consciousness. This type of seizure usually begins between the ages of 3 and 15 years. Choice B is incorrect. In the simple partial (or Jacksonian) seizure, the patient will be in an awake state but will exhibit abnormal motor or autonomic behaviors that can affect any part of the body. Choice C is incorrect. The grand mal (or tonic-clonic) seizure is the type of seizure in which there is a rapid extension of the arms and legs with sudden jerking and eventual loss of consciousness of the patient. It is often accompanied by incontinence and post-ictal confusion. Choice D is incorrect. During the myoclonic seizure, the patient may be awake or with short periods of loss of consciousness. During this seizure, the patient will have abnormal motor behavior in one or more muscle groups that lasts a few seconds to a few minutes.

The nurse is caring for a client who is receiving prescribed methylergonovine. Which of the following client findings would indicate a therapeutic response? A. Increased blood pressure B. Decreased post-partum bleeding C. Decreased uterine tone D. Increased urinary output

Choice B is correct. Methylergonovine is an alkaloid medication used to manage postpartum hemorrhage (PPH). This medication causes vasoconstriction, therefore, decreasing postpartum bleeding. Choices A, C, and D are incorrect. The most common adverse effect associated with this medication is hypertension. This is due to the medication's vasoconstrictive effects. The medication therapeutically should cause an increase in uterine tone, therefore, reducing bleeding. This medication would not directly impact urinary output.

The nurse is caring for a client that is hypothermic and receiving warmed IV fluids. The nurse understands that rewarming must be done slowly due to which primary reason? A. To prevent burns in the patient. B. To prevent ventricular fibrillation and cardiovascular collapse. C. To prevent frostbite. D. To avoid muscle spasms.

Choice B is correct. Rewarming must be done slowly because the hypothermic client is especially susceptible to the development of ventricular fibrillation and cardiovascular collapse if warmed blood is returned rapidly to a cold heart. Choice A is incorrect. Preventing burns is a responsibility of the nurse when warming a patient but it is not the main reason why rewarming should be done slowly. Choice C is incorrect. Frostbite is a product of hypothermia to the extremities, not rewarming. Choice D is incorrect. Muscle spasms cannot be caused by rewarming.

The client is admitted to a long term care facility. The nurse in charge is encouraging autonomy in the client. Which activity should the nurse introduce to the client? A. Have the client plan her meals. B. Let the client decorate her room. C. Make the client in charge of setting her appointment with the hair dresser. D. Let the client choose social activities she would like to join.

Choice D is correct. Choosing social activities in the facility promotes the client's freedom of choice and does not risk her safety. Choice A is incorrect. The client cannot do meal planning on her own and needs the assistance of a nutritionist or dietician. Choice B is incorrect. Having the client decorate her room may pose a risk to both the client and others as the client may arrange things in a way that is conducive to trips and falls. Choice C is incorrect. The client may find it difficult to contact the hairdresser and set an appropriate appointment.

When compared to younger adults, the nurse recognizes that the older clients have variations in pulse with: A. Food intake B. Heat C. Respirations D. Exercise

Choice D is correct. Exercise increases the heart rate because of increased metabolic demands. Aging adults have a normal pulse range of 60-100 beats/minute. However, the maximum heart rate in older adults is much lesser with exercise. In older adults, the radial artery may stiffen from peripheral vascular disease. With exercise, a variation in the pulse is noted in older adults compared to younger adults. The pulse rate of older adults takes longer to rise to meet sudden increases in demand, takes longer to return to resting state, and tends to be lower than that of younger adults. Choices A and B are incorrect. Certain types of food may cause changes within the body (such as salty foods can increase blood pressure and affect heart rate). Also, internal temperature changes may cause an increase in heart rate. However, overall food intake and heat are not causes for variations in pulse. Choice C is incorrect. Sinus arrhythmia, a variation in pulse with respiration, is common among children, not older adults.

You are caring for a client in the step-down unit who tells you that they are an active member of the Seventh-Day Adventist church. When their breakfast tray comes up, you see the following items. Knowing the religious dietary preferences of these clients, which items should the nurse remove from the breakfast tray? Select all that apply A. Coffee B. Bacon C. Scrambled eggs D. Pancakes

Choices A and B are correct. Members of the Seventh-Day Adventist church are not permitted to consume alcohol or caffeinated beverages. Due to this dietary preference, the nurse should remove the coffee from the client's breakfast tray. Furthermore, Seventh-Day Adventists are usually lacto-ovo vegetarians, and pork is avoided for those who consume meat. Therefore, the nurse should remove the bacon from the breakfast tray. Choice C is incorrect. Scrambled eggs would be allowed for lacto-ovo vegetarians. Choice D is incorrect. Pancakes would not violate any of these dietary restrictions.

You are completing a health history of a 4-year-old male at the primary care office. When checking with his mother about milestones in fine motor development. You would expect that the 4-year-old is able to do which of the following? Select all that apply. A. Complete a puzzle with 5 or more pieces B. Copy a triangle onto a piece of paper C. Dress himself D. Use a fork to eat dinner

Choices A, B, C, and D are all correct. These are all fine motor skills that are expected in preschool-age children, who are 3 to 5 years old. Other fine motor developmental milestones include: pasting things onto paper, completing puzzles with 5 or more pieces, cutting out simple shapes with scissors, and brushing their teeth.

The nurse is assessing a client with preeclampsia. Which clinical findings should the nurse anticipate? Select all that apply. A. Hyperreflexia B. Headache C. Uncontrolled vomiting D. Epigastric pain E. Glycosuria

Choices A, B, and D are correct. Hyperreflexia, headache, and epigastric pain are typical symptoms of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Hyperreflexia is a common finding and may occur with ankle clonus. These findings arise because of neuromuscular irritability. Other findings associated with preeclampsia include hypertension, facial swelling, and proteinuria. Choice C is incorrect. Uncontrolled vomiting is the defining characteristic of hyperemesis gravidarum. Glycosuria is not specific to preeclampsia. This finding could be expected or concerning for diabetes mellitus. Proteinuria would be found in preeclampsia.

The nurse is developing a plan of care for a patient who has a halo vest immobilizer (halo brace) following a cervical spine fracture. Which of the following should the nurse include in the patient's plan of care? Select all that apply. A. Pin care every shift B. Neck flexion and extension exercises C. Taping the wrench to the vest D. Report loosening of the pins E. Use straws when providing liquids

Choices A, C, D, and E are correct. A halo vest immobilizer is used to stabilize cervical spinal cord injuries. The goal is to stabilize the spinal cord using external fixation. Pin care should be completed every shift using sterile gauze and the prescribed solution. If the client should have the wrench taped to the front of the vest or at the head of the bed in case the device needs to be taken down for emergent cardiopulmonary resuscitation. Loosening of the pins is the most common complication and should be addressed immediately. The client should use a straw for drinking as moving the neck to swallow liquids is not permitted. Choices B are incorrect. The primary goal for a patient with a halo vest immobilizer device is to stabilize the cervical spine. These exercises would be contraindicated as they could worsen the underlying injury.

A nurse is reviewing prescriptions for assigned clients. Which prescriptions require follow-up with the primary healthcare provider? A client with: Select all that apply. A. congestive heart failure prescribed diltiazem. B. hypertension prescribed clonidine. C. diabetes insipidus prescribed hydrocortisone. D. pulmonary emboli prescribed clopidogrel. E. atrial fibrillation prescribed amiodarone. F. bacterial cystitis prescribed valacyclovir.

Choices A, C, D, and F are correct. A patient with congestive heart failure should not be prescribed calcium channel blockers because of their negative inotropic effects, worsening heart failure. Further, hydrocortisone would be indicated to treat adrenal insufficiency, whereas vasopressin would be used for diabetes insipidus. Additionally, clopidogrel is an antiplatelet medication and is used in the prevention of stroke where a patient with a pulmonary embolism requires anticoagulants or thrombolytics. Finally, antibiotics such as ceftriaxone are indicated for bacterial cystitis, not antivirals such as valacyclovir.

The nurse overhears unlicensed assistive personnel (UAP) telling a client that they will have to get a feeding tube if they do not start eating more at mealtimes. The nurse recognizes that the UAP has Select all that apply. A. committed battery. B. emotionally abused the client. C. committed assault. D. been negligent. E. demonstrated libel.

Choices B and C are correct. The UAP has committed assault, and they have also emotionally abused the client. Charge-like emotional abuse occurs when someone causes another person, like a client, to feel fearful and threatened. Assault is conduct that makes an individual fearful and apprehensive.

Which of the following educational points are correct when teaching a patient about iron supplementation? Select all that apply. A. Take the iron supplement 30 minutes after a meal. B. Drink a glass of orange juice with your iron supplement. C. Report any black stools to your doctor. D. Drink the iron suspension with a straw.

Choices B and D are correct. Orange juice is high in vitamin C, which will help increase the absorption of iron. Also, this will make taking the supplement easier on the stomach and many say it helps with the bad taste (Choice B). If the healthcare provider orders an oral suspension iron supplementation, you should teach your patient to drink it through a straw to avoid staining their teeth. Alternatively, if you are administering the medication to a young child who cannot drink through a straw, you can pull it up in a syringe and squirt it into the back of their mouth behind their teeth (Choice D). Choice A is incorrect. Taking an iron supplement on a full stomach will not allow for proper absorption. You must educate the patient to take their iron supplement on an empty stomach. Choice C is incorrect. Black stools are an expected side effect of iron supplementation. Patients do not need to report black stools to their doctor if they are taking an iron supplement. The nurse should warn them to expect this side effect so that they are not alarmed.

The nurse is preparing a staff in-service regarding conductive hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that apply. A. Presbycusis B. Prolonged exposure to noise C. Foreign body D. Ototoxic substance E. Cerumen

Choices C and E are correct. Conductive hearing loss is typically reversible and caused by cerumen, foreign body, tumor, edema, and acute infection. Choices A, B, and D are incorrect. These are all causes of sensorineural hearing loss, which is often irreversible.

A mother in a pediatric clinic asks the nurse about the soft spots on her baby's head, and when they are going to harden. The nurse's most appropriate response would be: A. "These soft spots are called fontanels. The one on the front closes at 12-18 months, and the one on the back closes at 2 months." B. "These soft spots are called fontanels. The one on the front closes at 2 months, and the one on the back closes at 12-18 months." C. "These soft spots are called fontanels. The one on the front closes at 12-18 months, and the one on the back closes at 6 months." D. "These soft spots are called fontanels. The one on the front closes at 9 months, and the one on the back closes at 2 months."

Choice A is correct. Fontanels are soft. Anterior fontanels close at 12 - 18 months and posterior fontanels close at 2 months age. Fontanels facilitate the bony plates of the baby's skull to flex and allow the baby's head through the birth canal.

The primary healthcare provider (PHCP) prescribes the client's chest tube discontinuation. The nurse should place which supply item at the bedside for this procedure? A. Suture removal kit B. Bag valve mask (BVM) C. Nasal cannula oxygen D. Wall suction with tubing

Choice A is correct. If the PHCP prescribes a chest tube to be discontinued, nursing should have pertinent supplies such as a suture removal kit, occlusive gauze, dry sterile gauze, tape, biohazard bag and a clamp. A suture removal kit is necessary because the chest tube is sutured into place. Choices B, C, and D are incorrect. A BVM is not pertinent in the discontinuation of a chest tube. This device is always at the bedside and necessary for a client receiving mechanical ventilation. Nasal cannula oxygen is not prescribed during or after the removal of a chest tube. If the chest tube is to be removed, this indicates improvement in their condition. If the client should experience complications following the removal of a chest tube, high flow oxygen will likely be utilized - not nasal cannula oxygen. Wall suction and tubing are not necessary to remove a chest tube. This may be necessary to operate the chest tube - but not for its removal.

The nurse is reviewing the laboratory results of a patient scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)? A. Glycosylated hemoglobin (HbA1c) of 7.2% B. International Normalized Ratio (INR) of 3.5 C. Hematocrit (Hct) of 42% D. Blood urea nitrogen (BUN) level of 5

Choice B is correct. An INR of 3.5 seconds is elevated and needs to be reported because the client may bleed. Choice A is incorrect. The HbA1c is elevated but would not impact a client scheduled for surgery. Choice C is incorrect. The hematocrit of 42% is within normal limits. Choice D is incorrect. A BUN level of 5 is decreased but poses no threat to the client.

The nurse is caring for a client who has rubella. The nurse should isolate the client using which of the following? A. Airborne precautions B. Droplet precautions C. Contact precautions D. Standard precautions

Choice B is correct. Rubella is known as German measles and requires droplet precautions. The nurse is right to wear a surgical mask when engaging with the client. The transmission mode for rubella is a droplet mode of communication where the spread occurs with particle drops larger than 5 microns.

Which of the following nursing diagnoses is appropriate for a client who has serum albumin of 2.8 g/dL and serum prealbumin of 17? A. At risk for renal calculi related to the albumin and prealbumin levels. B. At risk for hyperalbuminemia related to the albumin and prealbumin levels. C. At risk for hypoalbuminemia related to the albumin and prealbumin levels. D. At risk for the loss of muscle mass related to the albumin and prealbumin levels.

Choice D is correct. The nursing diagnosis that is appropriate for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17 is "at risk for the loss of muscle mass related to the albumin and prealbumin levels." These levels indicate that the client is affected by low albumin levels (hypoalbuminemia). Hypoalbuminemia can lead to the loss of muscle mass, poor wound healing, and other complications.

The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern? A. Headache and nausea B. Scant blood on the AV fistula C. Potassium 3.7 mEq/L D. Hemoglobin 8.8 mg/dL

Choice A is correct. Headache and nausea may be a manifestation associated with dialysis disequilibrium syndrome (DDS). This is a complication experienced by clients undergoing their first dialysis and may range from mild to severe. Choices B, C, and D are incorrect. Scant blood on the AV fistula is a benign finding. Bleeding is a complication following hemodialysis, but scant blood is not indicative of such a complication. The potassium level is normal (3.5 - 5.0 mEq/L) and does not require follow-up. Low hemoglobin is expected in end-stage renal disease (ESRD) as the kidneys cannot secrete an appropriate amount of erythropoietin, stimulating the production of red blood cells.

You have just arrived to begin your shift and are receiving report regarding a 24-month-old pediatric client. Which of the following would you immediately question? A. An oral temperature of 98.6 degrees Fahrenheit B. A respiratory rate of 28 respirations per minute C. An apical heart rate of 113 beats per minute D. A blood pressure of 97/66 (76) mm Hg

Choice A is correct. Although a temperature of 98.6 degrees Fahrenheit may initially appear to be normal, it is the patient's age and the manner in which this temperature was taken which makes this answer incorrect. While oral temperatures are considered the standard for noninvasive temperature measurement, oral temperatures are contraindicated in children under the age of five due to inaccuracy. For these children, rectal measurement remains the clinical gold standard. You should make it a priority to assess this child and recheck the client's temperature using a rectal thermometer (unless there is a contraindication to this method). Choice B is incorrect. The average respiratory rate for a child ranging from 12 to 36 months ranges from 20 to 30 respirations per minute. The respiratory rate of 28 respirations per minute provided in the question falls within this range and is therefore acceptable. Choice C is incorrect. A finding of an apical cardiac heart rate of 113 beats per minute is within the normal range of a 24-month-old child, as the average range is between 80 and 130 beats per minute. Therefore, nothing about this finding is alarming. Choice D is incorrect. When assessing the systolic blood pressure of a 24-month-old pediatric client, normal systolic blood pressure ranges from 70 to 110 mm Hg. Here, the client's systolic blood pressure is 97 mm Hg, therefore falling within that range. Additionally, the diastolic blood pressure of 66 mm Hg is within normal limits, as is the mean arterial pressure of 76 mm Hg. This finding is within normal limits for this client based on the client's age.

The pediatric nurse is reading the chart for a newly admitted child suffering from intussusception. The nurse knows that this disorder is characterized by: A. The telescoping of one area of the intestines into another B. The absence of alveoli in one segment of the lobe C. A twisted colon D. The prolapse of the rectum

Choice A is correct. Intussusception generally occurs as a result of a blockage in the intestines, which results in the telescoping of one portion of the bowel into another part of the colon. This disorder occurs more frequently in children, often males. Choice B is incorrect. Intussusception is the telescoping of the intestine and does not have to do with alveoli. Choice C is incorrect. Twisted bowel is simply a twist or loop in the gut and is not known as intussusception. Choice D is incorrect. Rectal prolapse occurs from chronic constipation and weakened anal sphincter.

The nurse has instructed a client who is scheduled to have a transesophageal echocardiogram (TEE). Which of the following statements by the client would indicate a correct understanding of the teaching? A. "I will need to take antibiotics for one week following this test." B. "This test will determine if I have any blood clots in my heart." C. "I will receive general anesthesia for this procedure." D. "I may feel a flushing sensation when the contrast dye is given."

Choice B is correct. A transesophageal echocardiogram (TEE) is advantageous because it views the left atrial appendage, which is the major reservoir for thromboembolism. This test may be done before cardioversion to determine if anticoagulation is necessary.

The nurse is caring for a client with diabetic ketoacidosis (DKA) receiving intravenous (IV) regular insulin. The most recent potassium was 2.9 mEq/L. The nurse should take which priority action A. Notify the primary healthcare provider (PHCP) B. Stop the regular insulin infusion. C. Obtain a 12-lead electrocardiogram (ECG) D. Assess the client's urine output (UOP)

Choice B is correct. The most common complication associated with DKA treatment with regular insulin is hypokalemia and hypoglycemia. Stopping the regular insulin infusion is essential as this is the direct cause of the critically low potassium.

The nurse is caring for a patient who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings would be essential for the nurse to follow-up? A. Incisional pain level of "6" on a 1-10 scale. B. An oral temperature of 99.5 degrees Fahrenheit. C. A heart rate of 112 beats-per-minute (BPM). D. Hypoactive bowel sounds in all four quadrants.

Choice C is correct. Immediately following abdominal surgery, shock (distributive, hypovolemia) is a concern to the nurse. A heart rate of 112 would indicate tachycardia, which is one of the earliest manifestations of shock, and the nurse needs to assess the client further. Choice B is incorrect. A low-grade temperature is an expected finding following surgery because of the inflammation. Choices A and D are incorrect. Incisional pain and hypoactive bowel sounds are all expected findings in the immediate post-operative period.

The nurse is assessing a client with peripheral arterial disease (PAD). Which of the following findings would the nurse expect to observe? Select all that apply. A. Decreased peripheral pulses B. Pain with ambulation C. Reddish-brown ankle discoloration D. Bilateral dependent edema E. Protruding veins in the leg

Choices A and B are correct. Peripheral arterial disease (PAD) is characterized by atherosclerosis in the lumen of the peripheral arteries. PAD symptoms include pain in the extremities that may be exacerbated by walking and are relieved by rest (claudication). Decreased peripheral pulses are a consistent manifestation of PAD.

The nurse is caring for a client experiencing an adrenal crisis (Addisonian crisis). The nurse should be prepared to administer which intravenous fluid? A. Lactated Ringers (LR) B. 0.9% saline C. Dextrose 5% in water (D5W) D. Dextrose 5% in water and Lactated Ringers (D5LR)

Choice B is correct. A client experiencing an adrenal crisis (Addisonian crisis) tends to have significant hypovolemia and hyponatremia. Because of the deficiency of steroid hormones, distributive shock may follow. Restoring the circulatory volume is essential in the management of this crisis. Isotonic solutions such as 0.9% saline or D5NS ( dextrose 5% in water combined with 0.9% saline) must be used. Isotonic saline can address both hypovolemia and hyponatremia in the adrenal crisis. If there is concomitant hypoglycemia, the D5NS solution is preferred to increase the glucose, sodium, and circulatory volume. Choices A, C, and D are incorrect. Although lactated ringers (LR) is an isotonic solution, it is inappropriate in managing an adrenal crisis because the client is experiencing concomitant hyponatremia. LR will not correct the hyponatremia ( Choice A). D5W is hypotonic and would be detrimental if given by itself because it would increase the free water and lower the sodium further by dilution ( Choice C). D5LR has a limited benefit in an adrenal crisis because of its inability to raise sodium levels ( Choice D).

At 2100, you administered a mildly sedating medication to your client per an order written by the attending health care provider (HCP) earlier today. Upon your reassessment of this client at 2200, you find the client restless, agitated, and hyperactive. Which of the following is the best choice to describe what has most likely occurred? A. An allergic reaction B. An idiosyncratic reaction C. An adverse effect D. A medication error

Choice B is correct. An idiosyncratic reaction is an abnormal and unexpected response to a medication, other than an allergic reaction, that is peculiar to an individual client. This type of reaction is nearly always unpredictable. Although a wide variety of idiosyncratic (i.e., unpredictable) drug reactions may occur, some examples include Stevens-Johnson syndrome or exfoliative dermatitis. Based on the answer choices, this is most likely what has occurred in this client. Therefore, Choice B is correct.

The nurse is discussing acute osteomyelitis with staff members. The nurse would be correct to state which of the following? A. "IV antibiotic therapy is typically given for seven to fourteen days." B. "The most common cause of acute osteomyelitis is a virus." C. "A significant fever is present with typically greater than 101°F (38.3°C)." D. "Petechiae on the affected extremity is a common finding."

Choice C is correct. Acute osteomyelitis is manifested by localized bone pain, a fever, and swelling to the affected extremity. Choices A, B, and D are incorrect. Osteomyelitis is a serious infection that requires six to twelve weeks of antibiotic therapy. The most common cause of osteomyelitis is staphylococcal bacteria. Petechiae are small reddish-purplish dots usually found with some conditions, such as a fat embolism. This is not a manifestation associated with osteomyelitis.

While monitoring a client with myocardial infarction, who is receiving tissue plasminogen activator (tPA), the nurse should plan to prioritize which of the following? A. Observe for neurological changes B. Monitor for any signs of renal failure C. Observe for signs of bleeding D. Check the client's food diary

Choice C is correct. Bleeding is the priority concern for any patient who is taking a thrombolytic medication. Choices A and B are incorrect. Although neurological status and renal function are monitored, they are not the primary concern. Choice D is incorrect. The client's food diary is not related to the use of this medication.

The home health nurse is visiting an elderly client for the first time in his home. Upon assessment of the client, the nurse notices that the client has been taking 12 prescription medications and five over the counter medications. What is the nurse's most appropriate action? A. Check for drug interactions. B. Check for side effects from the medications C. Check for any medication duplication. D. Ask the client if there are family members helping him with his medications.

Choice C is correct. Checking for any duplication in medication should be the first action of the nurse to eliminate the risk of adverse effects on the client.

The parents of a 2-month-old infant brought their child to the outpatient clinic due to fever, telling the nurse that the child had a Diphtheria, Tetanus, and Pertussis (DTaP) vaccination injection one week prior. The parents ask the nurse if the fever is related to the DTaP vaccination. What would be the nurse's most appropriate response? A. "The fever after a DTaP injection usually occurs within the first 2 hours of immunization." B. "Fever is rare in a child after a DTaP immunization." C. "Fever after the DTaP injection is usually low-grade and appears within the first two days." D. "The child's fever should be treated."

Choice C is correct. Fever after a DTaP injection is low-grade and is expected within 24-48 hours of the vaccination. Choice A is incorrect. Fever after a DTaP injection is usually low-grade and typically occurs within 24-48 hours following the vaccination. Generally, most side effects are mild to moderate and only last between 1 to 3 days. Choice B is incorrect. Fever following a DTaP vaccination is usually low-grade and, if present, typically occurs within 24-48 hours of the vaccination. Studies have shown that 7% to 26% of pediatric clients experience fever symptoms following DTaP administration. Choice D is incorrect. The fever should be reported to the health care provider (HCP) so an antipyretic may be prescribed.

The nurse is caring for a pregnant client with heart disease undergoing labor. All of the following are appropriate nursing interventions, except: A. Attach the client to a cardiac monitor and place an external fetal monitor. B. Manage pain early in labor. C. Use controlled pushing efforts. D. Encourage ambulation.

Choice D is correct. Bed rest should be maintained to conserve energy and decrease cardiac stress. Choice A is incorrect. The client and the fetus should be monitored frequently to assess for fetal distress and cardiac stress. Attaching the client to a cardiac monitor and placing an external fetal monitor ensures that the staff closely follows them. Choice B is incorrect. Pain increases cardiac stress in labor. The client should have adequate pain control; an epidural might be prescribed to control pain. Choice C is incorrect. Controlled pushing efforts decrease cardiac stress and conserve the client's energy.

The nurse is instructing the parents of a child with asthma about a peak flow meter. Which statement, if made by the parents, would indicate effective teaching? A. "Before use, I should put the sliding marker at the top of the numbered scale." B. "I should have my child sit at a 45-degree angle while performing this procedure." C. "My child should inhale as quickly as they can through the mouthpiece." D. "I should record the highest of the three readings."

Choice D is correct. The child's highest reading out of three times should be recorded (not the average). It is important that between each measurement, a 30-second rest is taken by the child. Choices A, B, and C are incorrect. The peak flow meter is a great tool for the client to determine the control of their asthma. Prior to the child measuring their peak flow, the device should be reset by sliding the marker (or arrow) on the meter by placing it at the bottom of the numbered scale. The child should not be sitting for this measurement; rather, they should be standing upright to allow for maximum chest expansion. The peak flow meter measures expiratory volume, so the child should be instructed to blow as hard and quickly as possible.

The nurse is caring for a client newly admitted to the mental health unit with bulimia nervosa. Which client statement requires immediate follow-up? A. "These sores in my mouth hurt." B. "When can I weigh myself?" C. "I hate my life and wish it was over." D. "I feel really dizzy right now."

Choice D is correct. The physical needs of the client with a mental health disorder prioritize over psychosocial needs. The client experiencing dizziness is highly concerning because this could be suggestive of severe dehydration or other electrolyte imbalances. Choices A, B, and C are incorrect. Dental caries, sores in the oral mucosa, electrolyte disturbances, dehydration, irregular menses, and calluses on the fingers are all manifestations associated with bulimia nervosa. A client expressing self-negating statements requires follow-up but does not prioritize over the client endorsing dizziness.

When interpreting results from a direct Coombs test, you know that a positive result indicates which of the following? Select all that apply. A. Maternal antibodies are present on the infant's red blood cells. B. Antibodies are present in the maternal serum. C. The infant is at risk for erythroblastosis fetalis. D. The mother is at risk for Rh immunization.

Choices A and C are correct. A direct Coombs test measures maternal antibodies, specifically IgG, that are present on the infant's red blood cells (Choice A). The presence of these antibodies is what causes erythroblastosis fetalis; therefore, the direct Coombs test indicates erythroblastosis fetalis (Choice C). Choice B is incorrect. The direct Coombs test does not measure antibodies in the maternal serum. Instead, the indirect Coombs test does this. Choice D is incorrect. The indirect Coombs test will check to see if the mother is at risk for Rh immunization.

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? image said: Heparin Induced Thrombocytopenia (HIT). Select all that apply. A. Discontinue the heparin infusion B. Obtain an immediate activated partial thromboplastin time (aPTT) C. Assess the client's intravenous site for bleeding D. Prepare to administer a unit of packed red blood cells E. 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.

When teaching parents about normal developmental aspects in children, which statements by the parents indicate further teaching is needed? Select all that apply. A. "When my 2-year-old touches his penis. I push his hand away and tell him not to do that." B. "I should wean my baby by 5 months and encourage her to use a sippy cup." C. "I will explain sexuality to my 10-year-old in a factual manner when she asks me questions." D. "I will explain body changes to my 11-year-old before it happens in order to help relieve her fears." E. "I want to teach my 10-year-old about contraception and ways to avoid STDs." F. "I should allow my teenager to establish his own beliefs and morals without sharing my personal beliefs."

Choices A, B, E, and F are correct. A- Self-manipulation of the genitals is normal behavior. Parents should never make the child feel like it is a bad thing. B- Parents should avoid the early weaning of infants to prevent oral deprivation. E- Parents should explain contraception and STIs to their adolescent children. F- Parents should share their beliefs and moral system with their children. Choices C and D are incorrect. Parents should give their children the desired information about sexuality in a clear, factual manner and provide them with information about body changes before they experience them to help reduce fears.

The nurse is discussing risk factors for breast cancer at a local community college. Which of the following should the nurse include in the presentation? Select all that apply. A. Nulliparity B. Multiparity C. Early menarche D. Overweight or obesity E. Multiple sexual partners F. Human papillomavirus

Choices A, C, and D are correct. Risk factors for breast cancer include: Female Age: For a woman living in the United States, the lifetime risk of 1 in 8 Race: White women are more likely to develop breast cancer, but Black women are more likely to die because they tend to develop breast cancer at an age younger than 40 and are more aggressive. Asian, Hispanic, and Native American women have a lower risk of developing and dying from breast cancer. Early menarche (<12 years), late menopause (>55 years) Nulliparity or first pregnancy after 30 years Personal history of breast cancer Genetic risk factors Family history in first-degree relatives (mother, sister, daughter) Family history of other cancer Mutations in the BRCA1 and BRCA2 genes Mutations in other genes: CHEK-2 gene, ATM (ataxia-telangiectasia mutated) gene, PTEN gene Previous irradiation of the chest area as a child or a young woman as a treatment for another cancer (such as Hodgkin's disease or non-Hodgkin's lymphoma) Previous abnormal breast biopsy results Atypical hyperplasia increases the risk four to five times. Fibrocystic changes without proliferative changes do not change breast cancer risk. Long-term hormone replacement therapy with estrogen and progesterone Excessive alcohol consumption Overweight or obesity Physical inactivity Choices B, E, and F are incorrect. These are not risk factors for breast cancer. Multiparty is a protective factor for breast cancer. HPV and multiplied sexual partners are risk factors for cervical cancer.

The nurse is instructing a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements by the client would require follow-up? Select all that apply. A. "I can take my morning antidepressant with a sip of water." B. "I may feel a flushing sensation as the contrast dye is given." C. "I should be able to drive home after this procedure." D. "I will need one treatment for my depression to go into remission." E. "I may experience some confusion after this procedure."

Choices B, C, and D are correct. ECT is a safe therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder and significant psychosis. Clients do not receive contrast dye ( Choice B) for this procedure; instead, this procedure involves no imaging and requires general anesthesia. Driving home after the procedure is prohibited because of the post-procedural confusion from general anesthesia and the ECT procedure itself ( Choice C). Clients may experience remission after several treatments, but one treatment is highly unlikely to bring remission ( Choice D). Instead, one session of ECT may bring some symptom improvement Choices A and E are incorrect. Antidepressants and antipsychotics may be given concurrently with ECT and may be taken with a sip of water on the day of the procedure ( Choice A). ECT works by producing a minor seizure. Any medications that interfere with ECT seizures such as anticonvulsants and benzo-diazepines ( BZDs) should not be given concurrently. However; antidepressants do not interfere with the ECT mechanism and should be given because holding antidepressants may cause a flare of depression if ECT did not work as expected. Holding anti-depressants may also precipitate withdrawal symptoms. Updated evidence-based information recommends concurrent use of antidepressants with ECT. Post-procedural confusion is the most common unwanted effect of this procedure as it is linked to the general anesthesia used and the procedure itself ( Choice E).

When evaluating developmental milestones for a 6-month-old child, which of the following should the nurse screen during a routine office visit? A. Standing while holding onto something/someone B. Creeping C. Rolling over D. Sitting up

Choice C is correct. Rolling over begins between 4 and 6 months of age. The early years of a child's life are crucial for their health and development. Healthy development means that children of all abilities, including those with special health care needs, can grow up where their social, emotional, and educational needs are met. It is important to encourage regular well-child visits so that healthcare professionals can help monitor for expected developmental milestones. If a milestone is missed or delayed, this could indicate an underlying problem. When the screening tool is used, a formal developmental evaluation may be necessary if an area of concern is found. During the developmental evaluation, a specialist looks more closely at the child's development and performs a more in-depth assessment to try and pinpoint the cause of the problem. Choice A is incorrect. Standing occurs between 8 and 10 months of age. Choice B is incorrect. Creeping begins between 9 and 10 months. Choice D is incorrect. Sitting up without support occurs between 8 and 9 months of age.

The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first? A. Administer PRN analgesic. B. Obtain STAT EKG. C. Encourage ambulation. D. Discuss the pain with the patient.

Choice D is correct. Shoulder pain may occur following a cesarean section due to gas or referred pain from the surgery. The nurse should assess the patient's pain to determine the cause before administering medications or other interventions. Choice A is incorrect. The nurse should first assess the patient's pain to determine the cause before administering pain medication. Choice B is incorrect. The nurse should first assess the patient's pain. If assessment data indicates the patient's pain is cardiac, an EKG may be indicated. Choice C is incorrect. Ambulation may help if the patient's pain is related to gas/indigestion, but the nurse should first assess the patient's pain before implementing this intervention.

The nurse is caring for a patient with a nasogastric tube. Irrigation should be performed every 4 hours to assess for NG tube patency. The nurse should instill how many milliliters of water or normal saline? A. 15 - 25 mL B. 20 - 30 mL C. 20 - 40 mL D. 30 - 50 mL

Choice D is correct. NG tubes should be watered every 4 hours with 30 - 50 mL of water or normal saline. Choices A, B, and C are incorrect. These are the inaccurate measurements necessary.

The nurse is assessing a client with Lyme disease. Which of the following would be an expected finding? Select all that apply. A. Lymphadenopathy B. Fatigue C. Petechial rash D. Arthralgias E. Hemoptysis

Choices A, B, and D are correct. Classic features of Lyme disease include erythema migrans which is a bullseye type appearing rash. Additional features of Lyme disease include myalgias, arthralgias, fatigue, lymphadenopathy, and conjunctivitis.

The nurse reviews a patient's lab results and notes that their potassium level is 5.6 mEq/L. They are looking at the cardiac monitor. The nurse will most likely observe what change first correlating with this lab value? A. Narrow and peaked T waves B. ST elevation C. Peaked P waves D. Noticeable U Waves

Choice A is correct. A potassium level over 5.5 mEq/L is indicative of hyperkalemia and is known for causing cardiac events. At this level, the nurse may notice narrow and peaked T waves. Choice B is incorrect. ST-elevation is seen less commonly in hyperkalemia than tall, narrow T waves. Choice C is incorrect. Peaked P waves are mostly seen with high right atrial pressure or atrial dilation. Choice D is incorrect. U waves are not always seen but are sometimes noticeable as the repolarization of the Purkinje fibers. They are not a sign of hyperkalemia.

The nurse is assessing a patient who has a suspected retinal detachment. Which of the following patient statements would be consistent with this diagnosis? A. "My vision has a cloudy appearance." B. "I have intense pain above my eyebrow." C. "I am having trouble with my peripheral vision." D. "I can see bright flashes of light."

Choice D is correct. A retinal detachment is a medical emergency as it may become progressive and give the client blindness in the affected eye. The client may experience a loss of vision that appears as if a curtain is closing, or they may experience bright flashes of light.

The nurse cares for a client with a potassium of 5.7 mEq/L. The nurse understands that this potassium level may be caused by Select all that apply. A. Cushing's disease. B. nasogastric tube suctioning. C. salt substitutes. D. hyperinsulinism. E. adrenal insufficiency.

Choices C and E are correct. The client's high potassium level, 5.7 mEq/L is concerning. Salt substitutes contain potassium which makes them more palatable. Excessive intake may lead to hyperkalemia. Adrenal insufficiency causes hyperkalemia because of the insufficient amount of aldosterone, which causes potassium elimination. Less aldosterone, and less potassium elimination, equates to hyperkalemia. Choice A, B, and D are incorrect. Cushing's disease is likely to cause hypokalemia, not hyperkalemia. In this disease, the adrenal glands produce too much aldosterone. Aldosterone causes the body to excrete potassium, putting clients with Cushing's disease at risk for excessive potassium losses leading to hypokalemia. The client with an NG tube to continuous suction will likely experience hypokalemia, not hyperkalemia. NG tube suction removes all of the gastric contents, which are rich in potassium. With those excessive potassium losses, the client becomes hypokalemic. Hyperinsulinism is likely to experience hypokalemia, not hyperkalemia. Insulin facilitates the movement of insulin into cells. With it comes potassium, and therefore when there is too much insulin as there is in hyperinsulinism, too much potassium is moved into the cells, and the serum potassium level drops, causing hypokalemia.

The nurse is caring for a client who is receiving the prescribed hydromorphone. Which of the following side effects should the nurse look for in the client? Select all that apply. A. Urinary incontinence B. Pupil dilation C. Diarrhea D. Altered level of consciousness (LOC) E. Constipation

Choices D and E are correct. Hydromorphone is a potent opioid indicated for pain. Side effects include constipation, altered level of consciousness, pupil constriction, and urinary retention. Choices A, B, and C are incorrect. Urinary incontinence, pupil dilation, and diarrhea are not expected while a client is receiving hydromorphone.

The nurse is caring for a group of assigned clients. Which of the following actions by the nurse is an example of a nurse-initiated intervention? Select all that apply. A. The nurse administers 1000 mg of ciprofloxacin to a client with pneumonia. B. The nurse consults with a psychiatrist for a client suspected of pain medication abuse. C. The nurse checks the skin of bedridden clients for signs of breakdown. D. A nurse assists an orthodox Jewish client with ordering a kosher meal. E. The nurse records the intake & output of a client as prescribed by her physician. F. The nurse provides teaching to a client on how to care for a newly placed ostomy.

Choices C, D, and F are correct. Nurse-initiated interventions, also known as independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of client needs that are written on the nursing care plan, as well as other activities that nurses can initiate without the direction or supervision of another healthcare personnel. The nurse can take initiative independently by monitoring clients' skin for breakdown, assisting a client to order an appropriate meal, and providing education to clients and family members. Choices A, B, and E are incorrect. Administration of medications and initiation of intake-output monitoring are dependent interventions because these actions require a physician's order or physician supervision. Consulting with a psychiatrist is a collaborative intervention, not an independent nursing action.

The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply. A. A client who had rectal surgery and a post-operative abscess B. A child who has pneumonia C. An older client who is post-myocardial infarction (MI) D. A teenager with leukemia, a neutrophil count of 500/microliter, and is receiving erythropoietin for anemia E. An adult patient with acute pancreatitis and has disseminated intravascular coagulation (DIC)

(Choice A) Rectal temperature should not be used in clients with a history of rectal surgery. Because of the risk of disruption of surgical anastomosis, it is preferred to refrain from rectal temperature checks in such clients. Additionally, the rectal temperature should not be used in clients with diarrhea and newborns under 12 weeks. Many healthcare providers prefer axillary temperature screening in newborns because of the theoretical risk of rectal perforation. However, if an accurate temperature reading is desired in a newborn, rectal temperature may be performed because the available evidence does not substantiate the fears of rectal perforation using a rectal thermometer. (Choice C) The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve. Therefore, patients who are post-MI should not have a rectal temperature taken. (Choice D) Assessing a rectal temperature is contraindicated in neutropenic patients. A leukemia client with neutropenia and anemia shouldn't be subjected to rectal temperature checks. A normal absolute neutrophil count should be more than 1500/ microfiber ( 1500/ul). A neutrophil count less than 1500/ul is mild neutropenia, whereas a count less than 500/ul is severe. Neutropenia predisposes to infections, and any invasive procedures with the potential to introduce pathogens into the body must be avoided. (Choice E) Assessing rectal temperature is also avoided in those with certain neurologic disorders and patients with thrombocytopenia (low platelet count). Acute pancreatitis can be complicated with DIC in severe cases. Disseminated intravascular coagulation (DIC) causes consumptive thrombocytopenia. Thrombocytopenia increases the bleeding risk when invasive procedures are performed. Therefore, a client with acute pancreatitis and DIC should not get a rectal temperature assessment.

The nurse is caring for a four-year-old child. While developing a plan of care, the nurse recognizes the child is in which stage of Erikson's stages of psychosocial development? A. Initiative vs. Guilt B. Autonomy vs. Shame and Doubt C. Industry vs. Inferiority D. Trust vs. Mistrust

Choice A is correct. Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds, so this is correct for your four-year-old client. In Initiative vs. Guilt, children assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval and may feel a sense of guilt. Choice B is incorrect. Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years, so this is not the correct developmental stage/care plan for a 4-year-old patient. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, leading to a sense of autonomy. When unsuccessful, they think they are failures, resulting in shame and self-doubt. Choice C is incorrect. Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds. Children need to cope with new social and academic demands at this stage. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, resulting in inferiority. Choice D is incorrect. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. In this stage, children develop confidence when caregivers provide reliability, care, and affection. When infants do not have that, they will build mistrust.

The nurse is preparing to administer prednisone 5 mg to a client with hyperparathyroidism. The nurse understands that prednisone is given to the client because: A. Prednisone increases the client's immune function B. Prednisone increases the client's Vitamin D levels C. Prednisone decreases GI absorption of calcium D. Prednisone decreases the release of calcium by the bones

Choice C is correct. Prednisone decreases the absorption of calcium in the gastrointestinal system thereby reducing serum calcium levels in the patient with hyperparathyroidism. Choice A is incorrect. Prednisone is an immunosuppressant. It does not promote immune function. Choice B is incorrect. Prednisone does not have any effect on Vitamin D levels. Choice D is incorrect. Etidronate (Didronel) and calcitonin are drugs that prevent the release of calcium from the bones, not prednisone.

You are caring for a patient with a new order for nitroglycerin ointment one inch applied to the skin twice a day to prevent angina. To use nitroglycerin correctly, you know to: A. Apply it only to the upper chest B. Rub the ointment into the skin until it disappears C. Rotate the application sites D. Cover the application site with a gauze dressing

Choice C is correct. Topical nitroglycerin is used to help prevent/ treat anginal symptoms in coronary artery disease. To apply nitroglycerin correctly, be sure to rotate the application sites with each application to avoid irritation from the medication. The medication comes with a supply of paper applicators with a small ruler on the paper for proper measurement of the drug. Apply the appropriate amount of ointment on the paper and apply the cream to an area of the skin. Choices A, B, and D are incorrect. Do not rub the cream on the skin until it disappears. Tape the paper into place, and do not cover it with gauze. The cream is usually applied to the chest, back, upper arms, or other torso parts.

The nurse is caring for a patient who has just returned from an intravenous urography procedure. Which of the following nursing interventions is most important at this time? A. Assess the venipuncture site for redness B. Monitor urinary output C. Instruct the client to remain motionless D. Encourage the patient to drink at least 1 L of fluid

Choice D is correct. The dye used during intravenous urography is sometimes nephrotoxic. Thus patients should be encouraged to increase fluids unless contraindicated. Choice A is incorrect. While the venipuncture site should always be monitored, some redness is expected and not alarming. Therefore, this is not a necessary action. Choice B is incorrect. Monitoring urinary output is a critical nursing intervention because it may be the first sign of nephrotoxicity. However, increasing fluids is more urgent. Choice C is incorrect. This client does not need to remain motionless following an intravenous urography procedure.

The nurse is discussing infection control with a group of nursing students. It would be correct to state that droplet precautions are used for which condition? Select all that apply. A. Influenza B. Viral meningitis C. Pertussis D. Hepatitis C E. Lyme disease

Choices A and C are correct. Conditions requiring droplet precautions include influenza and pertussis. Choices B, D, and E are incorrect. Viral meningitis in adults, Hepatitis C, and Lyme disease are not spread by droplets and require only standard precautions. Meningitis may be secondary to bacteria [Neisseria meningitidis (meningococci) or E.coli, or Streptococcus pneumoniae (pneumococci)] or viruses (enteroviruses are the most common cause. Rare viral causes include mosquito-borne viruses, herpes simplex viruses, mumps). Bacterial meningitis with meningococci requires droplet precautions because meningococci spread through large droplets. Clients with meningococcal meningitis should be placed on droplet precautions (private room, mask) until they have completed 24 hours of appropriate antibiotic treatment. Viral meningitis and pneumococcal meningitis do not require droplet isolation. In adults with viral meningitis, standard precautions are sufficient. In infants and young children, viral meningitis requires contact precautions as well. Since most viral meningitis cases are due to enteroviruses that may be passed in the stool, clients with viral meningitis should be instructed to wash their hands thoroughly with soap and water after using the toilet.

The nurse is caring for a client prescribed lithium. Which laboratory tests would be necessary for the nurse to monitor? Select all that apply. A. Troponin B. Creatinine C. Thyroid-stimulating hormone D. Sodium E. Potassium

Choices B, C, and D are correct. Essential labs to monitor while a client takes lithium include the lithium level, thyroid panel (lithium may cause hypothyroidism), creatinine (risk of nephrotoxicity), and sodium (hyponatremia may precipitate lithium toxicity). Choice A is incorrect. Troponin is a cardiac marker and not relevant to lithium therapy. Potassium levels would not influence lithium the way sodium does. Thus, sodium is the essential electrolyte to monitor.

The nurse is teaching a review course on foods appropriate to treat hypoglycemia. It indicates appropriate understanding if an attendee states that which item should be provided? Select all that apply. A. Slice of chicken breast B. 1 tablespoon of honey C. ½ cup of regular soda D. ½ cup of juice E. Two hardboiled eggs

Choices B, C, and D are correct. The guidelines for treating hypoglycemia adhere to the rule of 15s. The rule of 15s calls for administering 15 grams of quick-acting carbohydrates and rechecking the client's glucose in 15 minutes. These food items contain at least 15 grams of quick-acting carbohydrates. The nurse needs to assess the client, and if the client is passive or unconscious, they should not be given anything by mouth because of the risk of aspiration. Choices A and E are incorrect. A chicken breast and a hard-boiled egg are dense in protein and very low in carbohydrates and would not be helpful for a client. The client requires a quick-acting (simple) carbohydrate and not a protein.

The nurse is developing a plan of care for a client diagnosed with Kawasaki disease. Which of the following should the nurse include in the client's plan of care? A. Initiate contact precautions B. Obtain a 12-lead electrocardiogram C. Offer soft foods and liquids D. Implement fluid restriction E. Administer aspirin, as prescribed

Choices B, C, and E are correct. Kawasaki disease is an autoimmune disorder that occurs primarily in individuals younger than five. This disease process may consequently cause inflammation of the coronary arteries leading to aneurysms. Thus, an electrocardiogram should be performed along with an echocardiogram. Soft foods and liquids should be offered because of the chapping of the lips. Fluids would be encouraged because of the fever commonly associated with Kawasaki disease. Finally, treatment for this disease includes either medium to high dose aspirin or intravenous immunoglobin. Choices A and D are incorrect. Kawasaki disease is an inflammatory condition causing systemic vasculitis. Thus, standard precautions are applicable for this disease. Fluid restrictions are not helpful in an individual with Kawasaki disease, and the nurse should encourage more fluids because of the fever associated with this syndrome.

While working in a pediatric cardiac intensive care unit, you are caring for a child diagnosed with tetralogy of Fallot. Upon entering the room in the morning for your first assessment you find the child crying, cyanotic, and tachycardic. You recognize this as a hypercyanotic tet spell. Place the following actions in order of priority: -Administer 100% oxygen -Place the infant in the knees to chest position -Administer an IV fluid bolus -Administer morphine sulfate -Document the event

Correct answer: The priority in a hypercyanotic tet spell is to place the child in a knee to chest position. Tet spells occur when the infant with tetralogy of Fallot becomes acutely cyanotic due to infundibular spasm usually associated with feeding or crying. When this spasm occurs, there is decreased flow from the right ventricle due to the obstruction, resulting in severe hypoxia. Putting the child in a knee-chest position increases the intrathoracic pressure and increases blood flow to the lungs, therefore increasing oxygenation to body tissues. The next priority action is to administer 100% oxygen to assist in meeting the child's oxygenation requirements and relieving the hypoxia quickly. The following priority action is to administer morphine sulfate. This is the drug of choice for tet spells because it helps to calm the child down while simultaneously reducing the infundibular spasm that causes right ventricular outflow obstruction and, therefore, the hypercyanotic tet spell. The next priority nursing action is to administer an IV fluid bolus. This increases preload and consequently, cardiac output, helping to increase perfusion and oxygenation to the tissues. Lastly, the nurse should document the event, actions taken, and the patient's response.

The nurse in charge of the labor and delivery department is making the patient assignments for the day. Which patient should the most experienced nurse receive? A. A 40-week pregnant patient attached to the fetal monitor having late decelerations. B. A 39-week pregnant patient in labor with contractions 3 minutes apart C. A 33-week pregnant patient with triplets who is on bed rest. D. A 26-week pregnant patient who is having Braxton Hicks contractions.

Choice A is correct. Late decelerations are a sign of fetal distress, indicating that the life of the fetus is threatened. The most experienced nurse should be assigned to this patient. Choice B is incorrect. Labor contractions 3 minutes apart are a sign of normal progression of labor. This does not necessitate the most experienced nurse. Choice C is incorrect. The patient with triplets is not in any kind of imminent danger. This client would not need the most experienced nurse to take care of her. Choice D is incorrect. Braxton Hicks contractions are not real contractions of labor. They are irregular and occur throughout the pregnancy. The most experienced nurse is not needed for this patient.

The nurse is caring for a child with nephroblastoma. The nurse plans to take which action? A. Post a sign that states, "Do not palpate abdomen" B. Recommend foods low in protein C. Insert an indwelling urinary catheter D. Initiate fluid restrictions

Choice A is correct. Nephroblastoma (Wilms tumor) is the most common childhood cancer. Common treatments include surgical removal followed by chemotherapy. Nursing care involves minimal manipulation of the abdomen (no palpation) and a posted sign. It is essential to keep the encapsulated tumor intact.

The nurse preceptor observes a newly hired nurse care for a client with a myxedema coma. It would require follow up by the nurse preceptor if the newly hired nurse is observed A. applying a cooling blanket to the client. B. requesting a prescription for hydrocortisone. C. removing the water pitcher from the bedside. D. placing an oral endotracheal tube at the bedside.

Choice A is correct. One of the clinical features of a myxedema coma is hypothermia. Passive warming of the client is an effective treatment measure for this emergency. Cooling the client would require follow-up as this would worsen the hypothermia. Choices B, C, and D are incorrect. Immediate treatments for myxedema are hydrocortisone and levothyroxine. A corticosteroid is necessary to administer until adrenal insufficiency is excluded. The corticosteroid is also helpful in correcting the hyponatremia that is a feature of this condition. The client with a myxedema coma has a decreased mental status and is at risk for aspiration. The water pitcher should be removed from the bedside as IV fluids are given to restore the circulating volume. Advanced airway equipment such as an oral endotracheal tube should be available as severe hypoventilation may manifest with this condition.

The nurse is caring for a patient with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins including a minimal amount of serous exudate. Which of the following interventions is contraindicated for this patient? A. Apply TED hose to bilateral legs B. Assess the need for smoking cessation C. Physical therapy consult D. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler

Choice A is correct. The patient is presenting with signs of arterial insufficiency. The application of compression (TED hose) to the extremities is contraindicated in cases of severe arterial problems and should not be applied until cleared by the healthcare provider. The physician may want to make sure that the perfusion is adequate before clearance is given to apply a compression device. Choices B, C, and D are incorrect. These are appropriate and indicated for a patient with peripheral arterial disease (PAD). Smoking is a significant risk factor for developing arterial problems. Patients with PAD should be counseled to stop smoking (Choice B). Exercise improves the PAD symptoms. Most PAD patients do not get enough exercise; nurses should encourage patients to participate in physical therapy and to ambulate frequently throughout the day (Choice C). The ankle-brachial index (ABI) is a non-invasive way to calculate the relative severity of PAD (Choice D).

The nurse is supervising a student assisting a client with their newly prescribed crutches. Which action by the student requires follow-up by the nurse? The student A. positions the handgrips so that the axillae support the client's body weight. B. demonstrates the proper crutch stance at 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot. C. observes two to three finger widths between the crutch pad and the client's axilla. D. instructs the client to dry crutch tips with a paper towel if they become wet.

Choice A is correct. This action is incorrect and requires follow-up. This is an incorrect positioning for crutches, as the axillae should not support the client's body weight. The hands should support the client's body weight as weight supported in the axilla may cause nerve injury.

The nurse is working the night shift in the ER when a patient is suddenly rushed in with burns on his legs and torso. The nurse notices that the wounds appear moist and pale white with a sluggish capillary refill. The nurse can classify the injury as which of the following? A. Deep-partial B. Full-thickness C. Superficial-partial D. Superficial

Choice A is correct. Wounds that appear moist and pale white with sluggish capillary refill are classified as deep-partial. Choice B is incorrect. Full-thickness burns involve the destruction of the epidermis and the entire dermis, as well as possible damage to the subcutaneous layer, muscle, and bone. Eschar is found on the skin and appears leathery. Choice C is incorrect. Superficial-partial burns are characterized by blister formation, exudation, and collections of tissue fluid. Choice D is incorrect. Superficial burns are characterized by the redness of the skin. It involves only the epidermal layer of the skin.

Your client has continuous intravenous fluid replacement at 75 mL per hour. At 2 pm, the client complains about the intravenous line and states, "The IV is hurting me." You assess the site and note that it is red with a streak. You palpate the area and you can barely feel a venous cord. What would you suspect and what is the first thing that you would do? A. Grade 3 phlebitis: You would immediately stop the intravenous fluid infusion. B. Grade 4 phlebitis: You would immediately place a cool compress on the site. C. Infiltration: You would immediately stop the intravenous fluid infusion. D. Catheter embolus: You would immediately tourniquet the area distal to the site.

Choice A is correct. You would suspect a grade 3 phlebitis and you would immediately stop the intravenous fluid. Grade 3 phlebitis is characterized by pain, a visible streak, site redness, and a palpable venous cord less than 1 inch. Grade 4 phlebitis is characterized by pain, a visible streak, site redness, a palpable venous cord more than 1 inch, and possible drainage. Lastly, as with all intravenous therapy, any suspicion of a complication is immediately addressed with the discontinuation of the intravenous line.

The health care team is determining a prenatal client's estimated due date (EDD). Which of the following is the most accurate method used to determine the estimated due date? A. Nagele's Rule B. Embryonic ultrasound C. Early hCG levels D. Chadwick's sign

Choice B is correct. An early ultrasound is the most accurate way to determine the estimated due date. One study found that birth occurred within seven days of the estimated due date determined by ultrasound alone. Choice A is incorrect. Nagele's rule is not the most accurate way to determine a prenatal client's due date. Choice C is incorrect. hCG levels vary from woman to woman and are not accurate in predicting a due date. Choice D is incorrect. Chadwick's sign can be used as a probable sign of pregnancy, but it does not help determine a due date.

The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis? A. Basic metabolic panel (BMP) B. B-type natriuretic peptide (BNP) C. Lipid profile D. Troponin

Choice B is correct. B-type natriuretic peptide (BNP) is a commonly ordered test for clients who may have heart failure. Elevations indicate worsening of heart failure as it is indicative of fluid retention. Choices A and C are incorrect. BMP and lipid profile tests are incorrect to confirm the diagnosis. Choice D is incorrect. A troponin laboratory test would be prescribed for acute coronary syndrome (ACS).

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

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

A toddler is brought to the family clinic by her parents due to her poor sleeping within the past two weeks and intense perianal itching and scratching. Based on the purported symptoms, the nurse in the clinic would suspect which condition? A. Anal fissure B. Enterobiasis C. Giardiasis D. Celiac disease

Choice B is correct. Enterobiasis is an intestinal infestation by the pinworm Enterobius vermicularis, usually in children, but adult members of their household and caregivers are also at risk. The primary symptom is perianal itching due to female pinworms leaving the intestine through the anus and depositing their eggs on the surrounding skin while the infected individual sleeps. Most cases are in school-aged and young children, with thumb-sucking being a primary risk factor. Choice A is incorrect. An anal fissure is an acute longitudinal tear or a chronic ovoid ulcer in the squamous epithelium of the anal canal. It causes severe pain, sometimes with bleeding, particularly with defecation. Diagnosis is by inspection. Choice C is incorrect. Giardiasis is one of the most common causes of waterborne disease worldwide (especially in areas of poor sanitation) caused by the protozoan Giardia duodenalis. Symptoms include watery malodorous diarrhea, abdominal cramps and distention, flatulence, eructation, intermittent nausea, epigastric discomfort, and sometimes low-grade malaise, fatigue, anorexia, and/or failure to thrive. Choice D is incorrect. Celiac disease is a hereditary disorder in genetically susceptible people caused by intolerance to gluten, resulting in mucosal inflammation and villous atrophy, which causes malabsorption. Symptoms usually include diarrhea and abdominal discomfort. Diagnosis occurs via small-bowel biopsy and resolves with a strict gluten-free diet.

The nurse works on a medical/surgical unit and cares for a patient receiving digoxin and furosemide. Which of the following, if reported by the patient, must be assessed immediately? A. Night sweats and headache. B. Vomiting and halos around lights. C. Stomach upset and headache. D. Low blood pressure and dark urine.

Choice B is correct. Furosemide causes the patient to lose potassium. Digoxin, if taken when the patient has a low potassium level, can become toxic and show signs/symptoms of nausea, vomiting, and halos around lights. Furosemide and digoxin are often used together but may require more frequent evaluation of digoxin, potassium, and magnesium levels. Patients are encouraged to notify their healthcare provider if they experience any symptoms such as weakness, tiredness, muscle pains or cramps, nausea, decreased appetite, visual problems, or irregular heartbeats. Choices A and C are incorrect. While night sweats, headaches, and upset stomach are essential symptoms and should not be ignored; these symptoms are not the most urgent symptoms that need to be assessed. Choice D is incorrect. Low blood pressure and dark urine are symptoms of dehydration. These symptoms should be assessed, but are not the most urgent.

Your newly assigned client has a history of chronic obstructive pulmonary disease (COPD). When you enter his room, you find his oxygen is running at 6 L/min, his color is flushed, and his respirations are 8/min. What should you do first? A. Place client in high Fowler's position B. Lower the oxygen rate C. Take baseline vital signs D. Obtain an EKG

Choice B is correct. Low oxygen level stimulates respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe. This can lead to increased hypoventilation and possibly the development of or worsening of respiratory acidosis can occur. Left untreated, this can result in a patient's death. Individuals with COPD experience lowered oxygen tension and increased carbon dioxide retention during sleep, especially during REM sleep, when neuromuscular control usually is depressed. This can result in pulmonary spasms and transient pulmonary hypertension. Choice A is incorrect. Although High-Fowler's position is recommended, it is not the first action that should be taken. Choice C is incorrect. Baseline vitals are taken on admission to the unit. Choice D is incorrect. While an EKG may be ordered if symptoms do not resolve, the first nursing action should be to lower the O2 rate and see if there is an improvement in the patient's status.

A prenatal client is worried about her fetus' activity, so she performs a "kick count". She informs the nurse that while laying down, she felt ten kicks in one hour. The nurse should tell this client that: A. She'll need to come into the clinic and have a non-stress test performed. B. Ten kicks in an hour is a reassuring finding. C. She is dehydrated and should drink more water before re-trying the kick count. D. She should get up and walk for ten minutes and then re-try the test.

Choice B is correct. This is a reassuring finding. Ten kicks noticed during a 1 - 2 hour period are considered normal. Choices A, C, and D are incorrect. These interventions are not necessary.

While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's priority action? A. Percuss over the area to assess for dullness B. Notify the primary healthcare provided (PHCP) C. Gently palpate the abdomen to assess for tenderness D. Ask the patient about recent bowel movements

Choice B is correct. Upon auscultation, the nurse should suspect this client is presenting with an abdominal aortic aneurysm (AAA) due to the bruit or swooshing sound. The nurse should immediately notify the patient's healthcare provider of this urgent situation. An AAA Rupture can occur spontaneously or with trauma. If the aneurysm bursts, it may cause life-threatening bleeding. The aneurysm should be assessed immediately to determine the need for surgical intervention. Choices A, C, and D are incorrect. If a bruit is heard upon auscultation of the abdominal aorta, the nurse should suspect an aneurysm and not perform percussion or palpation due to the risk of rupture. Asking the patient about bowel movements (choice D) would be appropriate for assessing the patient's gastrointestinal system but would not be the highest priority for a suspected aneurysm. ADDITIONAL INFO Assessment findings concerning an abdominal aortic aneurysm (AAA) include a bruit in the abdominal region. The PHCP should order a computed tomography (CT) scan to verify the presence of an AAA. If the client has had a rupture, manifestations include gnawing-like back (or flank) pain that may radiate to the groin or buttocks.

During nursing school, you have been taught to be open and frank with all clients, even when information may be upsetting and distressing to the client. By doing this, you are following the ethical principle of: A. Beneficence B. Veracity C. Nonmalficence D. Fidelity

Choice B is correct. You follow the ethical principle of veracity when you are open, frank, and truthful with all clients, even when information may be upsetting and distressing to the client. Choice A is incorrect. You are not following the ethical principle of beneficence when you are open, frank, and truthful with all of your clients, even when information may be upsetting and distressing to the client. Beneficence is defined as "doing good" for our patients. Choice C is incorrect. You are not following the ethical principle of nonmaleficence when you are open, frank, and truthful with all of your clients, even when information may be upsetting and distressing to the client. Nonmaleficence is defined as "doing no harm" to our patients. Choice D is incorrect. You are not following the ethical principle of fidelity when you are open, frank, and truthful with all of your clients, even when information may be upsetting and distressing to the client. Fidelity is defined as being faithful to our promises to our patients.

The right brake on your client's wheelchair is not holding as strong as the left brake. What is your priority action? A. Ask the client if this just happened today. B. Immediately remove the wheelchair from use. C. Try to tighten the brake up with a simple tool. D. Call the physical therapist for another device.

Choice B is correct. Your priority action is to immediately remove the wheelchair from use as soon as you notice that the right brake on your client's wheelchair is not holding as strong as the left brake. Before any piece of medical equipment, including all assistive devices, is used the piece of equipment must be inspected; when there is any irregularity, as the right brake on your client's wheelchair not holding as strong as the left brake, it is not your role or responsibility to attempt to fix it because you are not competent to do so; therefore, you must immediately remove it from use and then notify the appropriate person or department and advise them that the piece of medical equipment needs a safety check and repair.

A nurse is doing an assessment on a client who is 6-hours postpartum after delivering a full-term infant. The client verbalized feeling dizzy and faint. Which is the most appropriate nursing action? A. Place the client in Trendelenburg's position B. Review the pre-delivery hemoglobin and hematocrit C. Instruct the client to get out of bed slowly and ask for help when ambulating D. Inform the nursery nurse to delay rooming-in until the client is stable

Choice C is correct. In the first 8 hours postpartum, orthostatic hypotension is a regular occurrence that may be manifested by feeling faint or dizzy. The nurse should reassure the client that this is normal and focus on the client's safety. The client should always be instructed to get help when getting out of bed and ambulating until the symptoms subside.

Morphine sulfate is contraindicated among lactating women due to which of the following? A. Crosses the placental barrier. B. Mostly excreted in breast milk. C. Excreted in the breast milk. D. Reduces milk production.

Choice C is correct. Morphine sulfate is contraindicated among lactating women because morphine sulfate is excreted in breast milk. Although, 90% of morphine sulfate is excreted in the urine. Choice A is incorrect. Although morphine sulfate crosses the placental barrier, after delivery the infant will not be affected. Choice B is incorrect. Although morphine sulfate is excreted in the breast milk, the vast majority of morphine sulfate, about 90%, is excreted in the urine. Choice D is incorrect. Morphine sulfate does not reduce milk production. Therefore, morphine sulfate is not contraindicated for this reason.

A registered nurse has encountered an ethical dilemma regarding euthanasia in the medical unit earlier in the day. The nurse verbalizes to the manager that she is concerned about what she witnessed. The manager should suggest which resource for the RN to utilize? A. Rights for the Mentally Ill B. Client's Bill of Rights C. Code of Ethics D. Nurse Practice Act (NPA)

Choice C is correct. The Code of Ethics for nurses provides ethical guidelines regarding nursing practice. Choice A is incorrect. The Rights for the Mentally Ill provides people with mental illness the civil liberties that are due to them. Choice B is incorrect. The client's Bill of Rights outlines the rights that are due to them when admitted and seeking health care. Choice D is incorrect. The Nurse Practice Act describes the scope of nursing practice. It directs the philosophy and standards of nursing.

The nurse is caring for a 13-year-old male child in the pediatric unit with a left-side below the knee cast. The boy reports pain and numbness of the foot. The nurse notes that the toes of the left foot are cold. Which of the following actions should the nurse take first? A. Remove the cast. B. Have the child ambulate. C. Notify the physician. D. Elevate the leg on two pillows.

Choice C is correct. The client is already showing the signs of compartment syndrome. The client has pain, numbness, and cold feet (low perfusion). Pain, pulselessness, pallor, paresthesias, and paralysis are the "5 Ps" associated with compartment syndrome. Compartment syndrome is an emergency. The nurse should be able to recognize signs and symptoms of compartment syndrome and notify the physician STAT. Compartment syndrome often results after trauma and is more common in the anterior compartment of the leg. Following a trauma, there may be decreased intra-compartmental space or increased intra-compartmental fluid volume (due to fracture, hematoma, etc). Because the surrounding fascia is noncompliant, the compartment pressure increases. In normal circumstances, there is a balance between venous outflow and arterial inflow. But increasing compartmental pressure results in a reduction of venous outflow. Consequently, venous pressure increases, further fueling an increase in compartmental pressure. Once compartmental pressure increases more than arterial pressure, arterial blood flow gets affected, and ischemia ensues. If ischemia lasts longer, irreversible necrosis/death of the tissue occurs.

A labor and delivery nurse is caring for a G4P3 client currently in active labor. More specifically, the client is undergoing a trial of labor after cesarean(TOLAC). All three of the client's prior deliveries were cesarean sections. During the TOLAC, the client screams out, reporting severe abdominal pain, describing the pain as "ripping" or "tearing" in nature. Upon assessment, the client complains of sudden hypotension, lightheadedness, and dizziness. Fetal bradycardia is suddenly noted by the nurse. The charge nurse immediately tells the unit secretary to contact the provider on call. Which of the following should the nurse perform first? A. Prepare the client for an immediate vaginal delivery B. Start a second large bore IV C. Increase the rate of the client's intravenous fluids D. Assess the client's contraction pattern

Choice C is correct. The client's presentation is consistent with a ruptured uterus (sudden onset of severe pain and cessation of previously present uterine contractions). A uterine rupture is an emergency and must prompt immediate action. A delay in delivery, resuscitation, or surgery increases maternal and fetal risk. A uterine rupture will typically be associated with fetal bradycardia. Thus, the initial treatment is an emergent cesarean delivery. Immediate delivery and treatment of maternal hemorrhage are the two most critical interventions. Uterine structures are hypervascular during pregnancy, and a rupture puts the client at significant risk of severe hemorrhage, with hypotension and hemorrhagic shock to follow. The nurse should anticipate these complications. The nurse should increase the rate of IV fluids to counteract the hypovolemia due to blood loss. A blood transfusion should be considered for clients with significant blood loss. Choice A is incorrect. Due to the client's ruptured uterus, the client cannot deliver this baby vaginally or spontaneously due to the ruptured uterus. Treatment of uterine rupture is immediate laparotomy with cesarean delivery and, if necessary, hysterectomy. Choice B is incorrect. Although not the immediate priority, a uterine rupture requires simultaneous delivery and treatment of maternal hemorrhage. Placing a second large-bore intravenous line should is still a priority. If large-bore intravenous access cannot be obtained, central venous access with a large bore sheath introducer should be considered. Initial resuscitation is often provided by infusing Lactated Ringers electrolyte solution. Brisk and large volume blood loss should prompt early blood transfusion, so the nurse should ensure the client has been typed and crossed, applicable consents have been signed, and the blood bank has been made aware of the impending situation. Choice D is incorrect. Due to the rupture of the client's uterus, the contraction pattern will likely no longer be able to be assessed. Additionally, the total cessation of contractions on the client's exam further indicates a complete uterine rupture.

A 35-year-old patient presents to the emergency department complaining of fever, chills, and headaches for the past two days. There is a pink, macular rash on the palms, wrists, and soles of the feet. Which statement by the patient would indicate to the nurse a potential medical emergency? A. "I am allergic to amoxicillin." B. "There have been cases of hand-foot-mouth in the child's daycare recently." C. "I went hiking 2 weeks ago." D. "I switched my laundry detergent last week because of my sensitive skin."

Choice C is correct. The patient is experiencing symptoms of Rocky Mountain Spotted Fever (RMSF): fever, chills, headache, and a macular rash that appears on the palms of hands, wrists, soles of feet, and ankles within ten days of exposure. RMSF occurs due to Rickettsia rickettsii bacteria that can be transmitted to humans via the Ixodes tick (deer tick). The patient has been hiking, which puts them at risk for coming into contact with ticks. RMSF is hard to diagnose in the early stages and without treatment can be fatal. Choice A is incorrect. An amoxicillin allergy is vital for the nurse to be aware of, but does not indicate an emergency. The nurse should ask about the patient's reaction to amoxicillin and document it in the patient's chart. The patient has been experiencing symptoms for several days and there is no information provided that suggests the patient received any antibiotics recently. Choice B is incorrect. Hand-foot-mouth disease is a common childhood virus that may be transmitted to adults but typically results in a blistering rash, not macular. It is not a medical emergency and usually resolves on its own with only supportive treatment. Choice D is incorrect. Allergic contact dermatitis is a hypersensitivity reaction of the skin that can result from changing laundry detergents. The area of rash is usually limited to the skin that is exposed to allergens, so the patient would have a more widespread outbreak if this were the cause. It is not often accompanied by the patient's other symptoms of fever, chills, or headache, and would not be a medical emergency.

Select the parenting style that is accurately paired with one of its advantages. A. The democratic style of parenting: It is relatively quick and easy to solve problems. B. The autocratic style of parenting: It gives the impression that the family is strong. C. The permissive style of parenting: It facilitates satisfaction among the members of the family. D. The laissez-faire style of parenting: It gives the impression that the family is loving.

Choice C is correct. The permissive style of parenting, like other parenting styles, has its advantages and its disadvantages. The permissive style of parenting facilitates satisfaction among the members of the family, however, it is disadvantageous because it can lead to undesirable behaviors because young children of the family may need more structure and clearer boundaries to develop appropriate behaviors. Choice A is incorrect. The democratic style of parenting is not a quick and easy way to solve problems; the democratic style of parenting is time-consuming but it also allows all members of the family to have input and a voice that is heard. Choice B is incorrect. The autocratic style of parenting does not give the impression that the family is strong; the impression that it gives is one that the family is rigid and highly structured. Choice D is incorrect. The laissez-faire style of parenting does not give the impression that the family is loving; the impression that it gives is one of being lazy and not caring.

The nurse is caring for an 8 year old boy in the pediatric unit. The nurse, when caring for this age group should be aware that: A. The child will do something for another if that person does something for the child. B. The child now follows social standards for the good of all. C. The child wants to follow rules because of a need to be seen as "good." D. The child finds satisfaction in following rules.

Choice C is correct. The school-age children ages 7-10 find a need to follow the rules as they want to be a "good" person in their eyes, and for others. Choice A is incorrect. This pertains to the pre-conventional stage of moral development. The child will carry out actions to satisfy his needs. If a person does something for the child, the child will do something for the person. This applies to children ages 4-7 years old. Choice B is incorrect. This is the post-conventional stage. It applies to adolescents. The child now follows social standards for the good of all people. Choice D is incorrect. This applies to the 10-12 years old age group. This is where the child finds satisfaction in following rules.

A patient receiving intermittent feedings through a nasogastric tube must have their residual volumes checked before administering more formula. Which is the best rationale for checking residual capacity? A. Evaluate electrolyte status B. Observe the color of the stomach contents C. Confirm placement of the nasogastric tube D. Evaluate absorption from the last feeding

Choice D is correct. Stomach contents should be aspirated before administration of the next feeding to ensure absorption is occurring as expected. Overfilling a stomach could lead to enlargement and increased risk of aspiration. Choice A is incorrect. Checking residual volume will not aid a nurse in evaluating a patient's electrolyte status. Choice B is incorrect. While the nurse needs to note the color of the residual volume to rule out any abnormal findings, such as frank bleeding, this is not the best rationale for checking residual capacity. Choice C is incorrect. Confirming nasogastric tube placement is an essential step in administering more formula to a patient. However, it is not the best reason for checking residual volume.

You are caring for a group of psychiatric mental health clients. One of these clients, who has anger management and aggressive behavior concerns, has not yet gained telephone privileges. You notice that the nursing assistant on the unit is escorting this client to the telephone. After you talk to the client about the telephone privileges, the nursing assistant tells you that, "It is unfair for this client to not be able to use the telephone when other clients are free to do so." What should you determine about this nursing assistant's comment? A. This comment clearly shows that the nursing assistant is favoring this client. B. This comment indicates that the nursing assistant is ensuring equal rights. C. This comment indicates that the nursing assistant is preventing discrimination. D. This comment indicates a learning need relating to the therapeutic milieu.

Choice D is correct. This comment indicates a learning need relating to the therapeutic milieu for this nursing assistant. A therapeutic milieu has consistent boundaries that are adhered to by all members of the healthcare team. A milieu environment is planned and maintained in a manner that eliminates all possible stressors so that psychiatric mental health clients with emotional and behavioral issues can concentrate their energies and thoughts on the things impacting them rather than external stressors, such as changing and inconsistent rules and boundaries that have been eliminated from the environment of care. Choice A is incorrect. This comment indicates something else, although, at first glance, it may appear that the nursing assistant is favoring this client by not adhering to the client's established boundaries. Choice B is incorrect. Although at first glance, it may appear that the nursing assistant is ensuring the equal rights of all clients, this action indicates that this nursing assistant is not adhering to the client's established boundaries. Choice C is incorrect. Although at first glance, it may appear that the nursing assistant is preventing discrimination and ensuring the equal rights of all clients, this action indicates that this nursing assistant is not adhering to the client's established boundaries.

Which lab value alteration is likely a result of corticosteroid treatment in a type 1 diabetic patient diagnosed with pneumonitis? A. Potassium 5.1 mEq/L (5.1 mmol/L) B. Sodium 138 mEq/L (138 mmol/L) C. Albumin 3.5 g/dL (5.07 µmol/L) D. Glucose 200 mg/dL (11.1 mmol/L)

Choice D is correct. Type 1 diabetes is characterized by hyperglycemia secondary to the body's inability to create insulin. Corticosteroids cause a rise in blood sugar even in a non-diabetic patient by increasing insulin resistance and triggering the liver to release additional glucose. Prednisone and other steroids can cause a spike in blood sugar levels by making the liver resistant to insulin. Steroids can make the liver less sensitive to insulin because they cause it to keep releasing sugar, even if the pancreas is also releasing insulin. This continued release of sugar triggers the pancreas to stop producing the hormone. Choices A, B, and C are incorrect. Changes in sodium, albumin, and potassium would not be expected findings in this scenario.

Which of the following growth milestones are expected for female adolescents? Select all that apply. A. Menarche B. Thelarche C. Deepening voice D. Development of facial hair

Choices A and B are correct. A is correct. Menarche is defined as the first occurrence of menstruation, or the first time a female gets her period. This is one of the most important milestones of female adolescents. It typically occurs about two years after thelarche, or the beginning of breast development. B is correct. Thelarche is defined as the beginning of breast development at the onset of puberty. This is a significant milestone for female adolescents. It can occur anywhere between 8 years of age and 13-years-old, as there is significant individual variation. Choice C is incorrect. A deepening voice is a characteristic of male development during adolescence. This is not typical for females to experience. Choice D is incorrect. Growing facial hair is a characteristic of male development during adolescence. This is not typical for females to experience.

While working in the neonatal intensive care nursery, you are assigned to take care of a baby who is 31 weeks gestation. Which of the following complications must you know to monitor given the baby's gestational age? Select all that apply. A. Hypoglycemia B. Hypothermia C. Birth injuries D. Fat wasting

Choices A and B are correct. Infants born before 37 weeks gestation have low stores of glucose and therefore hypoglycemia is a common complication of prematurity. Blood glucose should be monitored closely (Choice A). Preterm infants are at risk for poor thermoregulation and hypothermia due to decreased stores of muscle and fat. Their body temperatures should be regulated via incubator, radiant warming, bundling, or other methods of temperature control, as indicated (Choice B). Choice C is incorrect. Birth injuries are not a common complication for preterm infants as they are typically small and don't experience issues during vaginal delivery. This would be a complication to monitor for an infant that is large for gestational age. Choice D is incorrect. Fat and muscle wasting are not a common complication of preterm infants. They do not have large muscle and fat stores to begin with. This is common in a baby born post-term, who has wasted fat and muscle stores while in utero.

While working in the emergency department, you are assessing a 3-month-old infant who was brought in by parents for poor feeding, irritability, and vomiting. Upon auscultating the heart sounds, you note a machine-like murmur. Which conditions does the nurse suspect? SATA A. Patent Ductus Arteriosus (PDA) B. Congestive Heart Failure (CHF) C. Aortic Stenosis D. Ventricular Septal Defect (VSD)

Choices A and B are correct. The objective here is to identify that a patent ductus arteriosus can lead to congestive heart failure and must be suspected in an infant presenting with the symptoms mentioned in the question. The nurse does suspect a patent ductus arteriosus (PDA) (Choice A), due to the presence of a machine-like murmur, a hallmark sign of a PDA. The nurse also suspects congestive heart failure (CHF) due to the classic presenting symptoms in the infant: poor feeding, irritability, and vomiting. Symptoms of congestive heart failure in infants with congenital heart disease are often misdiagnosed and treated as septicemia so, one should be aware of this presentation. PDA is an acyanotic type of congenital heart disease. Ductus arteriosus is the communication between the pulmonary artery and the aorta. Soon after a term birth, functional closure of the ductus arteriosus occurs from vasoconstriction. In some cases, it remains open (patent) and is referred to as PDA. A small PDA often does not cause any problem. If the PDA is large, it results in significantly increased pulmonary blood flow. A large left to right shunt through a PDA causes left atrial and left ventricular enlargement. The left ventricular end-diastolic pressure increases and eventually the left ventricle fails to handle the increased volume overload resulting in CHF. In 80% of infants with critical acyanotic congenital heart disease, congestive heart failure is the presenting symptom. Difficulty in feeding is common. This is often associated with tachypnea, sweating, and subcostal retraction. One should suspect congenital heart disease in such an infant if the feeding takes more than 30 minutes. A history of feeding difficulty often precedes overt congestive heart failure, even if only by six to 12 hours. Signs of congestive heart failure on physical exam include an S3 gallop and pulmonary rales. Congenital heart defects (CHD) are classified into two main categories: acyanotic and cyanotic. In acyanotic defects, congestive heart failure is the most common symptom. Whereas in cyanotic heart defects, the main concern is hypoxia. Choice C is incorrect. Aortic stenosis is the narrowing of the aortic valve. Critical aortic stenosis can cause congestive heart failure in an infant, but this would result in a systolic murmur, not a machine-like murmur, so the nurse does not suspect this. Choice D is incorrect. A ventricular septal defect (VSD) is an abnormal opening between the left and right ventricles. A large VSD can cause congestive heart failure in an infant but this would result in a pan-systolic murmur, not a machine-like murmur, so the nurse does not suspect this.

The nurse is caring for a client with an acute exacerbation of Bell's palsy. Which of the following prescriptions would the nurse anticipate? Select all that apply. A. Prednisone B. Donepezil C. Pyridostigmine D. Valacyclovir E. Topiramate

Choices A and D are correct. Bell's palsy classically causes facial nerve paralysis. It is usually idiopathic. However, etiologies such as herpes simplex virus may be present. Exacerbations of Bell's palsy are treated with corticosteroids (prednisone, choice A) and antivirals (valacyclovir, choice D). Corticosteroids decrease facial nerve inflammation, and antivirals address the possible underlying viral etiology. Choices B, C, and E are incorrect. Donepezil is an acetylcholinesterase inhibitor utilized to manage dementia in Alzheimer's disease (choice B). Although Donepezil does not decrease the progression of Alzheimer's disease, it does help symptoms by improving cognition and behavior. Pyridostigmine is an acetylcholinesterase inhibitor indicated for improving muscle strength in myasthenia gravis (choice C). Topiramate is an anticonvulsant indicated for epilepsy and migraine headache prevention (choice E).

You are reinforcing education to a group of parents after an outbreak of pediculosis capitis at the local elementary school. Which of the following points should you include? Select all that apply. A. Teach your children not to share hats or combs to prevent the spread of lice. B. It is important to apply the permethrin cream once as soon as you can. C. Parents will need to manually remove the lice with a fine-tooth comb 2-3 times/day until there are no visible lice. D. Anyone can get lice, it is not indicative of a dirty house.

Choices A and D are correct. You must educate parents to teach their children not to share hats or combs to prevent the spread of lice. Pediculosis capitis, or mites, is transmitted from person to person either through direct contact with the scalp or through personal items. Children may not understand why sharing hats or combs is terrible, so parents must talk with them about it (Choice A). Anyone can get lice; it is not indicative of a dirty house or child. Parents and children often feel embarrassed over having insects in their home and fear the reaction of their peers, friends, and family. The nurse should educate the community that anyone can contract lice and that it is not a reflection of how clean their home environment is (Choice D). Choice B is incorrect. While it is essential to apply permethrin cream to the scalp to kill the lice, it will be necessary to apply twice, not once. The first application will be immediately and then the second will be in 7-10 days. This is to prevent the recurrence of any lice. Choice C is incorrect. It is essential to teach the parents to remove the lice and mites with a fine-tooth comb manually, but only once per day is necessary, not 2-3 times/day.

he nurse is caring for an assigned client. Which prescription requires clarification with the primary healthcare provider (PHCP) based on the laboratory data? Calcium- 9.7 mg/dL Potassium- 3.3 mEq/dL Sodium- 145 mEq/dL BUN- 18 mg/dL Creatinine- 2.0 mg/dL Select all that apply. A. Furosemide 40 mg PO Daily B. Metformin 1-gram PO Daily C. Ibuprofen 800 mg PO Daily PRN Pain D. Citalopram 20 mg PO Daily E. Lisinopril 20 mg PO Daily

Choices A, B, C, and E are correct. Furosemide, Metformin, Ibuprofen, and Lisinopril are all medications that may lead to nephrotoxicity. Nephrotoxic medications require the nurse to closely monitor the client's creatinine (normal 0.6 - 1.2 mg/dL). The laboratory data showed hypokalemia and increased creatinine, which should prompt the nurse to clarify the prescriptions with the PHCP. Choice D is incorrect. Citalopram is an antidepressant that does not cause nephrotoxicity. Based on the laboratory data, this medication should be okay to administer to the client.

The nurse is caring for a client with a port. Which of the following actions would be appropriate to take? Select all that apply. A. Access the port using sterile technique. B. Flush the port with heparin prior to de-access. C. Access the port using a 16-gauge catheter. D. Have the client wear a mask during the dressing change. E. Aspirate for blood return prior to medication administration.

Choices A, B, D, and E are correct. A port is a central venous line that is useful for individuals receiving chemotherapy. The nurse should utilize an aseptic technique to prevent central line-associated bloodstream infections (CLABSIs) when the port is accessed. This includes the nurse and the client wearing a mask as well as the nurse using sterile gloves. Occlusion is a common complication with a port, and prior to de-accessing, the nurse should flush heparin. Further, the client should be instructed to wear a mask to prevent contamination during dressing changes. Finally, the nurse must verify appropriate access by aspirating for blood return prior to medication administration. Choice C is incorrect. The nurse utilizes a non-coring needle to access a port. A 16-gauge catheter will be an option if a nurse starts a large-bore peripheral IV. When a port is accessed, it is accessed with a non-coring needle that is 0.5 to 2 inches, with the gauge being 19 to 22.

The nurse assists a client with left-sided weakness. Which of the following actions should the nurse perform when assisting this client in ambulating with a cane? Select all that apply. A. Place a gait belt around the client's waist. B. Stand on the client's left side during ambulation. C. Instruct the client to put the cane in the left hand. D. Measure the cane from the client's wrist crease. E. Instruct the client to put the cane in the right hand. F. Instruct the client to look down while ambulating.

Choices A, B, D, and E are correct. When instructing a client to ambulate with a cane, the nurse should apply a gait belt to the client's waist. The nurse should stand on the client's left (weaker) side if the client has difficulty. The client should have the cane in their right hand (stronger side), and the height of the cane should be measured from the client's wrist crease. Choices C and F are incorrect. The client should have the cane on the unaffected/stronger side. In this question, it would be the right side. Finally, the client should be instructed to look ahead as they ambulate - not down at the ground.

A patient has completed a living will stating that he does not want intubation, mechanical ventilation, or artificial nutrition/hydration should he become unable to communicate his preferences related to medical care. However, the patient's adult children have expressed their opposition to the patient's wishes. Which are appropriate nursing actions? Select all that apply. A. Notify the patient's physician, the nursing supervisor, and the risk manager. B. Explain to the patient's family that the living will cannot be changed at this point. C. Encourage the family to discuss their feelings to try to resolve this issue D. Request a consult with the facility ethics committee if needed. E. Advise the patient to just go along with the wishes of his adult children.

Choices A, C, and D are correct. Should such a conflict be observed, the nurse should notify the patient's physician, the nursing supervisor, and the risk manager. It is also important to encourage the family to discuss the issue among themselves and with the above individuals, to resolve the conflict. A consult with the ethics committee may also be indicated. Choice B is incorrect. The patient may revoke or change an advance directive at any time, either orally or in writing. Choice E is incorrect. By law, the patient has a right to autonomy and self-determination, including the right to choose and refuse treatment.

The nurse is assessing a client with diabetic ketoacidosis (DKA). Which of the following would be an expected finding? A. Thready pulse B. Jugular venous distention (JVD) C. Coarse tremors D. Tachycardia E. Orthostatic hypotension

Choices A, D, and E are correct. A client presenting with DKA will have signs and symptoms of dehydration that range from mild to severe. Tachycardia is a common finding in DKA because of the fluid volume deficit. This, in turn, causes a client to have a thready pulse. Orthostatic hypotension is also a common finding because of dehydration. Choices B and C are incorrect. JVD is a finding associated with fluid volume overload. A client with DKA will not have this sign because DKA is associated with dehydration. Coarse tremors would be a neurological finding that would be concerning for neurodegenerative diseases such as Parkinson's. Coarse tremors are not an expected finding with DKA.

Which of the following findings would lead you to suspect non-accidental trauma in your 1-year-old burn victim patient? Select all that apply. A. Scalding on the anterior trunk B. Circumferential burns on the feet C. Same thickness of skin damage throughout the burn D. Burns to the soles of the feet

Choices B and C are correct. B is correct. Circumferential burns on the feet would lead you to suspect non-accidental trauma in a 1-year-old. As a mandatory reporter, you are required to report these suspicions. Circumferential burns are full-thickness burns affecting the entire circumference of an area. They are very dangerous and can cause serious complications. In this case, it is unlikely a one-year-old could inflict a circumferential burn of the feet to themselves accidentally. This burn pattern can be caused by holding the child's feet in scalding water. C is correct. A burn that has the same thickness of skin damage throughout the burn is suspicious for non-accidental trauma. In an accident where something such as boiling water was spilled, the water will cool as it moves and leaves different levels of tissue damage in different areas. Likewise, if the child splashes in a bathtub with water that is too hot, areas will be affected differently. If the burn has the same thickness of skin damage throughout, it is suspicious for being non-accidental. Choice A is incorrect. It is more likely for a 1-year old to spill something on their anterior trunk accidentally. If they pull down on anything, such as a pot on the stove, it can spill onto their torso and burn them. Burns on the posterior surface of a one-year-old would be suspicious for non-accidental trauma. Choice D is incorrect. Burns to the soles of the feet are not necessarily a concern for non-accidental trauma. The child could have stepped onto something hot causing the burns accidentally. Areas of suspicion should include the back, buttocks, inside of the thighs, and genitalia.

Which of the following are considered early signs of heart failure in a pediatric patient? SATA A. Bradycardia B. Tachypnea C. Diaphoresis D. Weight loss

Choices B and C are correct. Tachypnea is an early sign of heart failure. The child's body is working hard to compensate for the decrease in cardiac output, so they breathe more quickly to try and make up for the decreased oxygen delivery (Choice B). Diaphoresis is a ubiquitous sign of heart failure, especially in the infant. The child's body is fatigued as it works hard, trying to compensate for the decreased cardiac output. Therefore they sweat profusely during exertion and sometimes even at rest (Choice C). Choice A is incorrect. Bradycardia is a late and ominous sign of heart failure. Tachycardia is an early sign of heart failure. Due to the decrease in cardiac output, the child's body compensates and increases the heart rate to try to keep up. This is why tachycardia is an early sign of heart failure. Choice D is incorrect. Weight gain rather than weight loss would be an early sign of heart failure. The child's body will be retaining fluids as the perfusion to their kidneys decreases. When kidney function starts to decline, such as in early heart failure, then there will be a sudden weight gain.

The nurse is instructing unlicensed assistive personnel (UAP) on how to modify activities of daily living for a client receiving a continuous infusion of heparin. The nurse should instruct the UAP to Select all that apply. A. obtain the client's temperature rectally. B. use a soft-bristled toothbrush for oral care. C. use an electric razor when shaving. D. use a lift sheet when repositioning the client. E. use an emery board instead of nail clippers.

Choices B, C, D, and E are correct. This risk of bleeding is substantial for a client receiving a continuous infusion of heparin. The UAP should be instructed to perform oral care with a soft bristle toothbrush to prevent gingival bleeding. An electric razor is preferred over a traditional razor because of the decreased risk of trauma. A lift sheet should be used to reposition the client over sliding the client, reducing the risk of shearing injuries. Nail clippers may cause skin trauma. Thus, an emery board is preferred.

The nurse is caring for a patient who is experiencing status epilepticus. Which of the following actions should be prioritized by the nurse? Select all that apply. A. Administer prescribed carbamazepine. B. Notify the rapid response team (RRT). C. Obtain a prescription for lorazepam. D. Loosen any restrictive clothing. E. Review the client's most recent phenytoin level.

Choices B, C, and D are correct. A client experiencing status epilepticus will require aggressive treatment as this is a persistent seizure that continues to recur despite treatment or a seizure that has lasted more than five minutes. The RRT should be notified as this is a medical emergency and requires evaluation by the RRT team. Obtaining a prescription for a parenteral benzodiazepine such as lorazepam is appropriate and should be completed by the nurse. Benzodiazepines are key in terminating a seizure. Central to caring for a client with a seizure is, placing them on their side and loosening any restrictive clothing. Choices A and E are incorrect. The client will likely require antiepileptic drugs to prevent future seizures; however, this is not the priority as carbamazepine is a maintenance drug used for seizure prevention. Additionally, reviewing drug levels that may assist in determining why a seizure may have occurred is not a priority during this medical emergency. The normal phenytoin level is 10-20 mcg/mL.

You are caring for a 25-year-old asthmatic. According to the National Asthma Education Prevention Program Expert Panel Report-3 (NAEPP EPR-3), you know that the following are risks for death due to asthma: SATA A. Living in a rural area B. Recent withdrawal from corticosteroids C. 3 or more ED visits for asthma in the past year D. Problems with the perception of obstruction of airflow

Choices B, C, and D are correct. Asthma is a chronic inflammatory airway disease. Chronic inflammation tends to limit airflow, increase respiratory symptoms, and produce hyperresponsive airways. When working with asthma patients, it is essential to know the risk factors for death due to asthma. These risks include previous ICU admission for asthma, two or more hospitalizations for asthma in the past year, three or more ED visits for asthma in the past year, one hospitalization or ED visit for asthma in the past month, difficulty with perception of asthma symptoms (mainly airflow obstruction), inner-city residence, low socioeconomic status, illicit drug use, and comorbid cardiovascular, lung, or chronic psychiatric disease. Asthma patients with any of these risk factors should be monitored very carefully. Choice A is incorrect. Living in a rural area is not a risk for asthma death; instead, the inner-city residence is the risk factor.

The nurse is caring for several geriatric clients. Which of the following should the nurse include in the teaching plan for older clients with altered immune responses? Select all that apply. A. It is normal to run a slightly higher than normal temperature. B. If arthritis pain begins to bother you, the doctor can prescribe something for pain. C. I'd like to talk to you about ways to manage stress. D. It is very important to eat a well-balanced diet.

Choices B, C, and D are correct. Many elderly clients suffer from chronic pain ( for example; arthritic pain). Chronic pain and continuous stress can negatively affect the immune system. Uncontrolled and persistent pain can trigger a stress response. Stress is associated with an increase in cortisol. Chronic cortisol elevation causes reduced immune response. Therefore, the nurse should discuss the strategies to manage pain and stress appropriately. Additionally, the nurse should also educate the elderly clients to maintain a well-balanced diet to promote a healthy immune system

Which of the following signs and symptoms indicate right-sided heart failure in a pediatric patient? Select all that apply. A. Grunting B. Nasal flaring C. Ascites D. Hepatosplenomegaly

Choices C and D are correct. Ascites is indicative of right-sided heart failure. This would be due to the right ventricle not pumping sufficient amounts of blood to the lungs; therefore, the blood backs up in the body causing an increased amount of fluid in the interstitial space. Any signs or symptoms involving an increase in fluid status are indicative of right-sided heart failure (Choice C). Hepatosplenomegaly is indicative of right-sided heart failure. This would be due to the right ventricle not pumping sufficient amounts of blood to the lungs, and therefore blood backs up in the body causing an increased amount of fluid in the liver and spleen, which leads to their enlargement. Any signs or symptoms involving an increase in fluid status would be indicative of right-sided heart failure (Choice D). Choice A is incorrect. Grunting is a sign of left-sided heart failure in an infant. It is a classic sign of respiratory distress in an infant. This is a serious finding and should be reported to the health care provider immediately. Respiratory signs and symptoms indicate left-sided heart failure because the blood is backing up in the lungs due to the inability of the left ventricle to pump sufficient amounts out to the body. Choice B is incorrect. Nasal flaring is a sign of left-sided heart failure in an infant. It is a classic sign of respiratory distress in an infant. Respiratory signs and symptoms indicate left-sided heart failure because the blood is backing up in the lungs due to the inability of the left ventricle to pump sufficient amounts out to the body.