Clinical Judgment
A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse? Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment. Place the client on NPO status, and notify the health care provider immediately. Administer an antiemetic to reduce the nausea, and send the client to physiotherapy. Notify the dietitian to change the diet to clear fluids, and cancel physiotherapy until the client's strength resumes.
Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment. Explanation: Gathering information regarding possible causes of nausea helps identify changes and factors that relate to the changes. Modifying the schedule helps. Although administering an antiemetic may be beneficial, movement and activity immediately afterward will not be helpful, because the medication has not yet taken effect. Diet is not the issue, so the diet-related choice is not correct. Nausea and weakness are not an emergency and do not require immediate notification of the health care provider.
The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. What should the nurse do next? Apply heat to the abdomen in the area of the pain. Contact the surgeon to request a prescription for a narcotic for the pain. Maintain the client in a recumbent position. Place the client on nothing-by-mouth (NPO) status.
Place the client on nothing-by-mouth (NPO) status. Explanation: The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not prescribe narcotic medication before surgery. The nurse can place the client in a position that is most comfortable for the client. Heat is contraindicated because it may lead to perforation of the appendix.
A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is starting the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which client? middle-aged stable client with bladder cancer awaiting surgery client who had an ileal conduit 3 days ago elderly client just admitted for an acute stroke middle-aged client who had a kidney transplant 3 days ago
middle-aged stable client with bladder cancer awaiting surgery Explanation: The charge nurse should assign the new nurse to the middle-aged client newly diagnosed with bladder cancer awaiting surgery, as this client has a condition common to the genitourinary floor and is of low acuity and stable. The charge nurse should assign the agency nurse to the client who had an ileal conduit. That condition has lesser acuity. The charge nurse should assign the experienced nurse to the most acute clients: the middle-age kidney-transplant recipient.
A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect? crackles auscultated halfway up lungs, previously in bases blood pressure 140/80 mm Hg PaO2 80 mm Hg trace peripheral edema, previously +2
trace peripheral edema, previously +2 Explanation: The therapeutic effect of furosemide is to mobilize excess fluid. The client's peripheral edema should decrease, indicated by changing from +2 to trace. As furosemide decreases fluid in the lungs, the client's crackles should decrease, not continue to progress. If furosemide is attaining a therapeutic effect, the blood pressure should decrease into normal range and the oxygen level should increase to above 90%.
A 74-year-old client receiving fluphenazine decanoate therapy develops pseudoparkinsonism, and is ordered amantadine hydrochloride. With the addition of this medication, the client reports feeling dizzy when standing. Which response by the nurse is best? "I will talk to your doctor about taking you off of one of these medications." "When you change positions, do so slowly." "Do you have any slurred speech or weakness in one extremity?" "If this happens just after taking the medicine, consider taking the medication at bedtime."
"When you change positions, do so slowly." Explanation: Both the fluphenazine decanoate and amantadine hydrochloride can have orthostatic hypotensive effects. Clients should be educated about this side effect especially in the elderly. Telling the client to change positions slowly will help ease the dizziness. If the dizziness is prolonged, the client should report those results to their practitioner. The client does not need a dose change or taken off the medication. The symptoms reported are orthostatic hypotensive effects not signs and symptoms of a stroke. The client could consider taking the medications at bedtime, but symptoms will likely persist. It would be safer to teach the client how to deal with symptoms as they occur.
The nurse is prioritizing care for several clients. Which client should the nurse assess first? the client with stridor who just received the first dose of an antibiotic the client with chest pain improving after medication the client with a blood pressure of 150/90 mmHg the client with bilateral wheezing receiving a breathing treatment
the client with stridor who just received the first dose of an antibiotic Explanation: The highest priority client is the client with stridor who started an antibiotic. Stridor is an assessment finding indicating an extremely narrowed airway. This may indicate an anaphylactic reaction to the antibiotic. The nurse must intervene to prevent anaphylactic shock. The airway is the top priority. Next, the nurse should assess the client with wheezing. Finally, the clients with improving chest pain and elevated blood pressure should be assessed.
A nurse is assessing the family of a 10-year-old child brought into the emergency department with severe injuries. Which statement made by the parents could indicate child abuse? "My child fell off his bike and into the street." "The injury happened a few days ago but I didn't think it was bad." "You should ask my child about his injuries. They will know best what happened." "I don't know what I will do if something happens to my child."
"The injury happened a few days ago but I didn't think it was bad." Explanation: A delay in seeking treatment for a child's serious injuries is a sign of abuse. Anxiety is expected and is a normal response. The parent's specific description of the origin of the injury is not congruent with child abuse. In abuse cases, vague descriptions of the injuries are more common than detailed ones, and abusers often prevent a child from explaining the nature of their injuries rather than encouraging it.
A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today but had to cancel the appointment when the child became ill. Which action should the nurse take? Instruct caregivers to call for a refill when the low-volume alarm sounds. Explain that the medication should be discontinued during illness. Arrange for the pump to be refilled in the hospital. Reschedule the pump refill for the day of discharge.
Arrange for the pump to be refilled in the hospital. Explanation: To prevent baclofen withdrawal, pump refills are scheduled several days before anticipated low-volume alarms. The nurse should make it a high priority to have the pump refilled as soon as possible. Discontinuing baclofen suddenly can result in a high fever, muscle rigidity, change in level of consciousness, and even death. Waiting until the child leaves the hospital for a refill may lead to a low dose or withdrawal. Waiting for the low-volume alarm puts the client at risk because medication and team members who can refill the pump may not be readily available under all circumstances.
When performing a heel stick on a newborn, the nurse is unable to obtain an adequate sample. What should the nurse do? Attempt the heel stick in a new location. Call the health care provider. Perform venipuncture instead. Place a cold compress on the heel.
Attempt the heel stick in a new location. Explanation: If unable to obtain an adequate sample from a heel stick, using a different site, placing foot in a dependent position, and warming the heel are recommended. If none of this works, then venipuncture can be done. There is no need to call the health care provider and a cold compress decreases blood flow to the area instead of increasing blood flow.
A client is experiencing an acute hemolytic reaction. What actions should the nurse take? Select all that apply. Dispose of the blood container and tubing. Check for low back pain. Discontinue the intravenous line the blood was transfusing through. Notify the health care provider. Assess for anxiety and mental status changes.
Check for low back pain. Assess for anxiety and mental status changes. Notify the health care provider. Explanation: The intravenous line is needed to give fluids and medications through. The blood container and tubing need to be sent back to the blood bank for repeat typing and culture. Low back pain is a symptom of acute hemolytic reaction. Anxiety and mental status changes are symptoms of acute hemolytic reaction. The health care provider needs to be notified because he/she may need to see the client and order further treatments.
The nurse caring for a client with an arteriovenous (AV) fistula notes that the fingers distal to the fistula are cold to the touch and the capillary refill time is greater than 3 seconds. What is the priority action by the nurse? Contact the healthcare provider. Turn the client on the left side. Assess client's blood pressure. Keep arm elevated.
Contact the healthcare provider. Explanation: Cold fingers and slow capillary refill time to the fingers distal to an AV fistula is an indication of arterial steal syndrome. The healthcare provider should be contacted immediately. Assessing the blood pressure will not add relative data as blood pressure does not impact arterial steal syndrome. Keeping the arm elevated and/or turning the client on the left side will not help to resolve the arterial steal syndrome.
A client receiving a continuous infusion of lidocaine for ventricular dysrhythmias states "I am so tired. Even my vision is blurry." What is the nurse's best action? Administer zolpidem. Ask the client the date of the most recent eye exam. Decrease the lidocaine infusion rate. Cluster activities to allow the client uninterrupted rest time.
Decrease the lidocaine infusion rate. Explanation: Side effects of lidocaine include lightheaded, euphoria, shaking, low blood pressure, drowsiness, confusion, weakness, blurry or double vision, and dizziness. Serious reactions such as seizures, bradycardia, and heart block are possible if lidocaine reaches toxic levels. The nurse should recognize these potential adverse effects and the lidocaine infusion should be decreased while lidocaine blood levels are checked to determine if the cause of the tiredness and blurred vision is a lidocaine toxicity. Knowing when the client's most recent eye examination was completed and allowing the client to rest or administering zolpidem will not address the problem of potential lidocaine toxicity and may lead to the more serious toxic reactions.
A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do? Continue the infusion until the remaining 300 mL is infused. Notify the health care provider (HCP), and obtain prescriptions to alter the flow rate of the solution. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution. Change the filter on the tubing, and continue with the infusion.
Discontinue the current solution, change the tubing, and hang a new bag of TPN solution. Explanation: IV fluids should not be infused for longer than 24 hours because of the risk for bacterial growth in the solution. The appropriate action for the nurse to take is to discontinue the current TPN solution, change the tubing, and hang a new bag of solution. Changing the filter does not decrease the risk for contamination. Notifying the HCP for a change in flow rate is not an acceptable solution.
A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse? Monitor vital signs. Administer a bolus of normal saline solution. Maintain a patent airway. Administer epinephrine.
Maintain a patent airway. Explanation: The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client's vital signs should be monitored, but not as the first action.
A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel (UAP) has positioned the oxygen mask (view the figure). What does the nurse assessing the infant determine about the UAP's mask selection? It is appropriate for the neonate. The mask is too small. The mask is too large. The mask requires a soft cloth cover.
It is appropriate for the neonate. Explanation: The correct size covers the nose but not the eyes. The mask is too large if it covers the neonate's eyes. Masks that are too small may pinch the nose. Masks should fit snugly against the cheeks and chin. It is not necessary to cover the mask with a soft cloth. If the mask fits snugly, it will not be as likely to rub the skin.
A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? Reduce the client's anxiety. Maintain adequate oxygenation. Decrease chest pain. Maintain adequate circulating volume.
Maintain adequate oxygenation. Explanation: Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.
An adult client with lymphoma reports cough, difficulty swallowing, and shortness of breath. On physical exam the client's face and neck are swollen and the upper extremities are cyanotic. What is the nurse's best course of action? Monitor the respiratory pattern of the client continually. Reassure the client that that this is to be expected with this type of cancer. Limit physical activities. Limit activities to bed rest.
Monitor the respiratory pattern of the client continually. Explanation: The client has symptoms of superior vena cava syndrome. The symptoms are not expected side effects. The client should be monitored for respiratory distress. Activities may be limited, but the priority action of the nurse is early recognition of impending respiratory distress.
A client with gestational diabetes has just birthed a 10 lb, 2 oz (4601 g) neonate at 39 weeks' gestation. Which nursing intervention would be the priority in caring for the infant? Feed the infant a D50W solution. Prepare to administer insulin to the neonate. Teach the mother about the nutritional needs of the neonate. Obtain a serum neonatal glucose level.
Obtain a serum neonatal glucose level. Explanation: The priority nursing intervention is to monitor the neonate's serum glucose level due to the increased risk of hypoglycemia. During pregnancy, the fetus secretes high levels of insulin to counteract the high maternal glucose levels. This elevated insulin secretion, in the neonate, can lead to severe hypoglycemia after birth. While it is important to discuss the neonate's nutritional needs with the mother, it is not an immediate priority. Infants birthed to diabetic mothers will probably require early feedings but determining the infant's blood glucose is a higher priority. Feeding the infant D50W would be inappropriate. The newborn of a mother with diabetes may develop hyperbilirubinemia, but not as quickly as hypoglycemia may develop. Since the neonate is at risk for hypoglycemia, insulin would not be appropriate.
A client in a long-term care facility has signed a form stating that the client does not want to be resuscitated. The client develops an upper respiratory infection that progresses to pneumonia. The client's health rapidly deteriorates and is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case? Pharmacologic interventions should not be initiated. The wishes of the client's family should be followed. The client should be resuscitated if the client experiences respiratory arrest. The client should be treated with antibiotics for pneumonia.
The client should be treated with antibiotics for pneumonia. Explanation: The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.
A nurse is assessing a client using a tracheostomy tube. The client has bilateral rhonchi in the upper lobes of the lungs and is unsuccessful in coughing up secretions. Which action should the nurse take? Encourage the use of the incentive spirometer. Use a sterile suction kit to suction the client. Teach the client pursed lip breathing. Call respiratory therapy for a breathing treatment.
Use a sterile suction kit to suction the client. Explanation: The priority for this client is suctioning to remove secretions in the upper airway if the client is unable to cough adequately. The other interventions will not effectively assist the client to maintain a patent airway.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention? serving small portions of bland food administering metoclopramide and dexamethasone as ordered encouraging rhythmic breathing exercises withholding fluids for the first 4 to 6 hours after chemotherapy administration
administering metoclopramide and dexamethasone as ordered Explanation: The nurse should assign highest priority to administering an antiemetic, such as metoclopramide, and an anti-inflammatory agent, such as dexamethasone, because it may reduce the severity of chemotherapy-induced nausea and vomiting. This intervention, in turn, helps prevent dehydration, a common complication of chemotherapy. Serving small portions of bland food, encouraging rhythmic breathing exercises, and withholding fluids for the first 4 to 6 hours are less likely to achieve this outcome.
During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently? test urine for ketones. weigh the client. administer oral hydrocortisone. assess vital signs.
assess vital signs. Explanation: Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until the client is stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in their urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to palpate the abdomen. insert a rectal tube. auscultate bowel sounds. change the client's position.
auscultate bowel sounds. Explanation: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.
A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates an emergency cesarean birth may be necessary at this time? decreased amount of vaginal bleeding maternal heart rate of 65 beats/minute increased maternal blood pressure of 150/90 mm Hg fetal heart rate of 80 beats/minute
fetal heart rate of 80 beats/minute Explanation: A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean birth to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate the delivery of the neonate.
The nurse is prioritizing care of a client in the immediate postpartum period. What is the nurse's priority assessment? Select all that apply. electrocardiogram (ECG) urinary output blood pressure height of fundus blood glucose level
height of fundus blood pressure urinary output Explanation: A focused physical assessment should be performed every 15 minutes for the first 1 to 2 hours postpartum, including an assessment of the fundus, lochia, perineum, blood pressure, pulse, and bladder function. A blood glucose level needs to be obtained only if the client has risk factors for an unstable blood glucose level, or if she has symptoms of an altered blood glucose level. An ECG would be necessary only if the client is at risk for cardiac difficulty.
A nurse is assessing a client with nephrotic syndrome. The nurse should assess the client for which condition? increased serum albumin level massive proteinuria hematuria weight loss
massive proteinuria Explanation: Nephrotic syndrome is characterized by massive proteinuria caused by increased glomerular membrane permeability. Other symptoms include peripheral edema, hyperlipidemia, and hypoalbuminemia. Because of the edema, clients retain fluid and may gain weight. Hematuria is not a symptom related to nephrotic syndrome.
A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? nonrebreather mask simple mask nasal cannula venturi mask
nonrebreather mask Explanation: A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.
Which activity would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? teaching a client how to change an ileostomy pouch taking a client's apical pulse before the nurse administers digoxin performing a dressing change for a client whose incision is infected and requires irrigation obtaining a client's routine glucose reading using a glucometer
obtaining a client's routine glucose reading using a glucometer Explanation: It is most appropriate for the nurse to delegate the activity of obtaining a client's routine glucose reading. The nurse is responsible for performing assessments and analyzing the data on which treatment decisions are based; the nurse should assess and evaluate the client's apical pulse before administering the digoxin. The dressing of an incision that is infected and requires irrigation should be changed by the nurse so that the nurse can perform the irrigation and evaluate tissue healing. It is the responsibility of the nurse, not the UAP, to teach the client.
The nurse is scheduling postural drainage treatments for a client. What would be the most appropriate time of day to implement this? one hour after a meal before bedtime one hour before a meal immediately upon awakening
one hour before a meal Explanation: Productive coughing induced by postural drainage may cause nausea and vomiting. Upon awakening, mucus secretions are plentiful and very tenacious, so postural drainage at this time would not be beneficial. Approximately 1 hour before meals is a preferred time for postural drainage; the resulting cough and mucus production will be less likely to affect the client's dietary intake. Before bedtime will result in increased discomfort, and one hour after a meal places the client at risk for aspiration.
A client is readmitted to the facility with a warm, tender, reddened area on the right calf. Which contributing factor should the nurse recognize as most important? history of increased aspirin use a history of diabetes mellitus an active daily walking program recent pelvic surgery
recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.
A client has been hospitalized with myxedema coma. What acid-base imbalance would be expected in this client? respiratory stress respiratory acidosis metabolic acidosis respiratory alkalosis
respiratory acidosis Explanation: The client's respiratory drive is depressed, resulting in alveolar hypoventilation, progressive carbon dioxide retention, narcosis, and coma. These symptoms, along with cardiovascular collapse and shock, require aggressive and intensive therapy if the client is to survive.
The nurse finds a visitor unconscious with spontaneous breathing sitting in a chair in the waiting room. What priority action(s) will the nurse implement? Select all that apply. Ask other visitors in the hallway what happened. Call a rapid response team. Place the visitor on the floor. Notify the nursing supervisor. Attempt to identify the visitor.
Attempt to identify the visitor. Call a rapid response team. Explanation: The nurse will need to attempt to identify the visitor and call a rapid response team. The visitor is breathing and sitting in a chair, so the team will change positions with care. The supervisor will be notified through the call of the rapid response team. Asking other visitors for help is not appropriate for the care of the unconscious person
The nurse is reviewing the physician's order written for a postmenopausal client: "calcitonin salmon nasal spray 200 IU, one spray every day." What is the appropriate action to be taken by the nurse regarding this order? Ask the physician why this medication was ordered for a postmenopausal client. Clarify with the physician that the spray should be given in only one nostril per day. Inform the physician that the medication is not a nasally applied medication. Remind the physician that this medication can be purchased over-the-counter.
Clarify with the physician that the spray should be given in only one nostril per day. Explanation: Calcitonin salmon nasal spray should be administered in only one nostril per day. Many preprinted order sheets automatically print "administer in both nostrils" when a nasal spray is ordered. Nurses must be familiar with the directions for each medication they give before administering medications. The other options are incorrect because calcitonin salmon nasal spray is prescribed to postmenopausal clients for the treatment of osteoporosis and requires a physician's order.
A pediatric client is to receive an oral antibiotic dose. The client's meal tray is due to be delivered in 30 minutes. Which action shows how the nurse should coordinate the antibiotic dose with the client's meal? Give the medication 15 minutes before the client receives the meal. Give the dose now before the tray arrives. Wait to give the medication when the food arrives. Retime the medication, and administer 2 hours after the meal.
Give the dose now before the tray arrives. Explanation: Most oral pediatric medications are administered on an empty stomach. They are not usually administered with milk or formula because these can affect gastric pH and alter drug absorption. Because a child's meals usually contain milk or a milk product, the nurse would not administer the drugs with meals or even ½ hour after meals.
The health care provider (HCP) prescribes mirtazapine 30 mg orally at bedtime for a client diagnosed with depression. Which nursing action is indicated? Question the HCP's prescription. Request to give the medication in the morning. Give the medication in three divided doses. Give the medication as prescribed.
Give the medication as prescribed. Explanation: The nurse should give the medication as prescribed. Mirtazapine is given once daily, preferably at bedtime to minimize the risk for injury resulting from postural hypotension and sedative effects. The usual dosage ranges from 15 to 45 mg. There is no reason to question the HCP's prescriptions. The nurse should administer the medication as prescribed. Requesting to give the medication in three divided doses is inappropriate and demonstrates the nurse's lack of knowledge about the drug.
A client with a well-managed ileostomy has the sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. What should the nurse tell the client to do? Increase fluid intake to 3 L per day. Use 30 mL of milk of magnesia daily. Take an antiemetic. Notify the health care provider (HCP).
Notify the health care provider (HCP). Explanation: The sudden onset of abdominal cramps, vomiting, and watery discharge with no stool from an ileostomy are likely indications of an obstruction. It is imperative that the HCP examine the client immediately. Although the client is vomiting, the client should not take an antiemetic until the HCP has examined the client. If an obstruction is present, ingesting fluids or taking milk of magnesia will increase the severity of symptoms. Oral intake is avoided when a bowel obstruction is suspected
During dialysis, a client has disequilibrium syndrome. What should the nurse do first? Slow the rate of dialysis. Administer oxygen per nasal cannula. Reassure the client that the symptoms are normal. Place the client in a modified Trendelenburg position.
Slow the rate of dialysis. Explanation: If disequilibrium syndrome occurs during dialysis, the most appropriate intervention is to slow the rate of dialysis. The syndrome is believed to result from too-rapid removal of urea and excess electrolytes from the blood; this causes transient cerebral edema, which produces the symptoms. Administration of oxygen and position changes do not affect the symptoms. It would not be appropriate to reassure the client that the symptoms are normal.
A child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child? hypercalcemia hypokalemia hyperphosphatemia hypernatremia
hypokalemia Explanation: Hypokalemia occurs when insulin administration causes glucose and potassium to move into the cells. Insulin administration doesn't directly affect calcium levels. Hypophosphatemia — not hyperphosphatemia — may occur with insulin administration because phosphorus enters the cells with insulin and potassium. Insulin administration doesn't directly affect sodium levels.
A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities? teaching a client who has asthma how to use a rescue inhaler referring a client who reports joint pain to a healthcare provider specialist obtaining a rubella titer on a woman who is planning to start a family administering digoxin to a client who has heart failure
obtaining a rubella titer on a woman who is planning to start a family Explanation: Obtaining a rubella titer is a primary prevention activity. Rubella may cause birth defects when contracted during the first 3 months of pregnancy. Identifying those who do not have an immunity and then providing the vaccine is a primary prevention activity. The remaining selections fall under secondary and tertiary prevention.
Which equipment should the nurse plan to use to help prevent external rotation of the client's right leg postoperatively? a rubber air ring a high footboard a metal bed cradle sandbags
sandbags Explanation: It is best to support the client's leg in its proper anatomic position and to prevent external rotation by supporting the leg with sandbags. A trochanter roll can also be used. Sandbags should be placed along the length of the thigh and lower leg.A footboard, rubber air ring, or metal frame will not help prevent external rotation of the leg.
A client underwent insertion of a nasogastric (NG) tube for partial bowel obstruction the previous evening. The nurse notes that the tube is not secured to the client's face. How will the nurse proceed? Verify placement of the tube. Call the healthcare provider immediately. Securely tape the tube in place. Note the findings on the client's flow sheet.
Verify placement of the tube. Explanation: The NG tube placement should be verified prior to re-taping the NG tube; the other options require verification of the NG tube placement first and the healthcare provider will need to know.
2/10/2017 2100 18-year-old college student presents to the emergency department with a severe headache and onset of bizarre behavior that started approximately five hours ago. Client is oriented to person, but not place or time. Physical assessment includes petechiae. Oral temperature is 104° F (40° C). HR: 128/bpm. RR: 24/min, O2: 95% on room air. Lumbar puncture ordered. Client is being evaluated for bacterial meningitis.What is the most important action by the nurse? administer an analgesic per order administer the meningitis vaccination per order prepare this client for endotracheal intubation obtaining I.V. access in preparation of antibiotic administration
obtaining I.V. access in preparation of antibiotic administration Explanation: This client's rapid course, and petechiae suggest that they are at risk for a fulminant presentation of meningitis, which can include circulatory collapse. Intravenous access may be needed, not only for immediate antibiotics to address the infection, but also for fluids and vasopressors. The client does not currently require intubation. Immunization will not prevent disease in persons who have already been exposed. An analgesic may be given, but I.V. access is the top priority.
What assessment findings would lead the nurse to suspect that the client has an addiction to a pain medication? Select all that apply. Client compulsively uses the pain medication. Client requests acetaminophen instead of the pain medication. Client continues use of pain medication despite of risk of harm. Client tapers off pain medication. Client loses control of use of pain medication.
Client compulsively uses the pain medication. Client loses control of use of pain medication. Client continues use of pain medication despite of risk of harm. Explanation: The hallmarks of addiction include compulsive use, loss of control of use, and continued use despite risk of harm. A client who has addictive behavior would know what is effective for them and ask for that medication; usually do not ask for pain medications less effective than what they have been abusing, and the client usually does not taper off pain medication, will continue to use.
Which client will the community health nurse visit first? the client with a random blood glucose level of 110 mg/dL the client with type 1 diabetes mellitus with acute visual changes the client newly diagnosed with type 2 diabetes mellitus the client with type 1 diabetes mellitus requiring wound care for a leg ulcer
the client with type 1 diabetes mellitus with acute visual changes Explanation: The highest priority client is the one with acute vision problems. The other clients need to be seen but are not emergent.
A nurse is preparing to administer diazepam 1 mg I.V. The available dose is diazepam 2 mg/ml vial. After drawing 0.5 ml of medication into a syringe, what is the next action by the nurse? Perform safety checks and administer the medication to the client. Ask another nurse to witness 0.5 ml medication waste into the sink. Return 0.5 ml medication to client's medication drawer for later use. Place the vial containing the remaining 0.5 ml in the sharps container.
Ask another nurse to witness 0.5 ml medication waste into the sink. Explanation: Diazepam is a controlled substance. Federal law requires close monitoring of all controlled substances to prevent diversion or misuse. After drawing up the ordered dose, the nurse would ask another nurse to witness the waste of the remaining medication into the sink or other approved waste container per the facility policy. Controlled substances are not placed in the sharps container to prevent diversion. Controlled substances require double-locked storage to prevent diversion and would not be stored in the client's medication drawer. The nurse would complete safety checks and administer the medication after another nurse witnessed waste of the remaining controlled substance.
The nurse caring for the laboring client performs a sterile vaginal exam. Exam results are dilated 10 cm, effaced 100%, and +2 station. What is the priority nursing intervention? Assess for rupture of the membranes. Initiate oxytocin infusion. Prepare for birth of the neonate. Call anesthesia to give epidural anesthesia.
Prepare for birth of the neonate. Explanation: A client who is fully dilated is about to begin pushing. Appropriate actions for this time include assessing vital signs every 15 minutes, positioning for effective pushing, and preparing for delivery. Oxytocin is administered to induce labor or to help the uterus contract after birth; it would be inappropriate to administer to a client entering the second stage of labor. It is inappropriate to insert an epidural when the client is ready to start pushing. Status of membranes would have been determined during the sterile vaginal exam.
The nurse is preparing to clean around a client's G-tube that was placed 1 week ago and change the gauze dressing. Based on the type of procedure, what type of precautions are needed? Sterile procedure, airborne precautions Clean procedure, contact precautions Clean procedure, universal precautions Sterile procedure, droplet precautions
Clean procedure, universal precautions Explanation: Site care for a recently placed G-tube is a clean procedure, not a sterile procedure. Care should be taken not to introduce bacteria into the fresh site, but sterile gloves and sterile procedure is not necessary or recommended. Universal precautions are required, as the nurse will come into contact with blood and/or bodily fluids while cleaning around the G-tube. Droplet, contact, and airborne precautions are not indicated, because these are for a variety of infectious diseases such as methicillin-resistant Staphylococcus aureus, influenza, measles, meningitis and tuberculosis, not for wound care.
The unlicensed assistive personnel (UAP) records a capillary blood glucose of 253 mg/dL (14.04 mmol/L) and the nurse administered insulin for coverage to the client. The UAP reports to the nurse that the blood glucose was incorrect. What actions should the nurse take? Select all that apply. Reprimand the UAP for the incorrect blood glucose. Obtain a current blood glucose level. Report the incident to the healthcare provider. Complete an incident report. Observe the client for hypoglycemia.
Obtain a current blood glucose level. Observe the client for hypoglycemia. Report the incident to the healthcare provider. Complete an incident report. Explanation: The nurse should obtain a current blood glucose level to ascertain whether the blood glucose level is higher or lower than the amount stated, and this will guide the nurse in correcting the error. Observe for hypoglycemia because the nurse administered insulin to the client and the client's blood glucose may drop drastically. Report the incident to the healthcare provider so an order can be given, and complete an incident report recounting the incident. Reprimanding the UAP for the incorrect blood glucose will not correct the incident.
A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client? Start an IV and give penicillin G every 4 hours until birth. Administer tocolytics as prescribed until the active lesions are healed. Administer valacyclovir 500 mg orally every 6 hours while in active labor. Prepare the client and partner for a cesarean birth as soon as possible.
Prepare the client and partner for a cesarean birth as soon as possible. Explanation: For a client with active genital herpes lesions, cesarean birth helps avoid infection transmission to the neonate, which would occur during a vaginal birth. Penicillin G is given for a bacterial colonization of group B streptococcus. Tocolytics are given to stop labor; they are not appropriate treatment. Valacyclovir is a treatment for an active herpes infection, but would not work in time for the client to deliver vaginally.
A client who was prescribed clozapine 2 months ago arrives in the clinic and informs the nurse that the they have been feeling extremely fatigued and feverish and has a sore throat. The nurse observes that the client has two small ulcerations of the oropharynx. Which does the nurse suspect may be occurring with this client? agranulocytosis dystonic reaction tardive dyskinesia thiamine deficiency
agranulocytosis Explanation: Clozapine has a potential side effect of agranulocytosis, which can develop suddenly or over a period of time. It is characterized by fever, malaise, a sore throat with ulcerations, and leukopenia. The drug must be immediately discontinued. It is important for the client to have weekly blood counts for 6 months of therapy and then every 2 weeks. Thiamine deficiency is exhibited by shortness of breath and other symptoms of congestive heart failure. Tardive dyskinesia is a side effect of antipsychotic medications and is characterized by lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet. Dystonic reactions are an extrapyramidal side effect characterized by spasms in several muscle groups.
A nurse is assigned to care for a client with dependent personality disorder. Which intervention should the nurse include in this client's care plan to promote independence? spending long periods of unscheduled time with the client avoiding discussion of the client's feelings of helplessness scheduling competitive activities so the client can test skills helping the client identify preferences, such as choosing which clothing to wear
helping the client identify preferences, such as choosing which clothing to wear Explanation: Helping the client identify preferences promotes development of independent decision-making skills, which the client with dependent personality disorder lacks. To demonstrate availability during set times in a structured relationship, the nurse should spend scheduled, not unscheduled, time with the client and should set limits on the amount of time the nurse spends with the client. Activities in which the client can succeed would be more appropriate than competitive ones, which this client would find too threatening. To promote rapport and convey empathy, the nurse should acknowledge the client's helpless feelings, not avoid discussing them.
Immediately after receiving an injection of bupivacaine, the client becomes restless and nervous and reports a feeling of impending doom. What should the nurse do next? Administer epinephrine. Reassure the client that it is normal to feel restless before a procedure. Assess the client's vital signs. Ask the client explain these feelings.
Assess the client's vital signs. Explanation: The nurse should assess the client's vital signs because there is a likelihood of having a reaction to the bupivacaine. If the client's vital signs are abnormal, immediate intervention may be necessary. Although the nurse may ask the client to continue to describe feelings, this is not likely to be a psychosocial reaction. Simple reassurance is inappropriate in most clinical situations and can be dangerous if physiologic causes of restlessness are overlooked. The nurse should not administer epinephrine until vital signs have been assessed.
After a local factory explodes, a nurse begins to triage the victims. Victim 1 is initially unconscious and not breathing. After the victim's airway is opened, the victim resumes spontaneous respirations at a rate of 18 and has a capillary refill time of less than 2 seconds, but remains unconscious. What color tag should the nurse use for this victim? green red yellow black
red Explanation: According to the SMART (Simple Triage And Rapid Treatment) method, the nurse should use a red tag for this client. The red tag is for clients who require immediate medical attention to survive. Although indicators of the client's respiration and circulation status are within normal range, the client's mental status is compromised, and further treatment may be needed to prevent death. A yellow tag is given when the client has serious, potentially life-threatening injuries that would be treated immediately if there were capacity to do so but the client can likely survive without immediate treatment. Because this client is unconscious, the client's condition may not be stable enough to warrant a yellow tag and the associated delay in treatment. A green tag is given for relatively minor injuries whose status is unlikely to deteriorate; the client may be able to engage in self-care, and the injuries can wait until more serious injuries are cared for. Black tags are given to deceased victims and to clients who are unlikely to survive due to the severity of their injuries and the level of available care. Palliative care should be provided to clients with black tags.
A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse? Question the client in front of her partner. Collaborate with the interprofessional team to make a referral to social services. Contact hospital security to monitor the partner. Confront the partner.
Collaborate with the interprofessional team to make a referral to social services. Explanation: Collaborating with others in the health care team, and the provider to make a referral to social services will create a plan, and provide support for the client. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Confrontation will most likely provoke anger in the suspected abuser. Questioning the woman in front of her partner doesn't allow her the privacy required to address this issue, and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security
A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first? the client admitted for unstable angina who underwent percutaneous coronary intervention (PCI) with stenting yesterday the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block the client with a history of heart failure who has bibasilar crackles and pitting edema in both feet the client with a history of cardioversion for sustained ventricular tachycardia 2 days ago
the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block Explanation: The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client's rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block). The client who underwent cardioversion 2 days ago has likely had the underlying reason for the sustained ventricular tachycardia corrected. The client with a history of heart failure may have chronic bibasilar crackles and pitting edema of both feet. Therefore, assessing this client first is not necessary. The client who underwent PCI with stenting was at risk for reperfusion arrhythmias and/or bleeding from the arterial puncture site but could be considered to be stable 24 hours post-procedure.
A nurse is caring for a client with a prescription for morphine delivered by continuous intravenous infusion. Which intervention is most important to include in the plan of care? Assist with a naloxone challenge test before therapy begins. Obtain baseline vital signs before initiating the infusion. Discontinue the drug immediately if signs of dependence appear. Change the administration route to PO if the client can tolerate fluids.
Obtain baseline vital signs before initiating the infusion. Explanation: Morphine may cause respiratory depression and contributes to a decrease in blood pressure. The nurse should obtain the client's baseline blood pressure and pulse and respiratory rates before administering the infusion and then continue to monitor vital signs throughout therapy. A naloxone challenge test may be administered before using an opioid antagonist, not an opioid agonist. The nurse would not discontinue an opioid agonist abruptly, because withdrawal symptoms may occur. Morphine is commonly used as a continuous infusion in clients with severe pain regardless of the ability to tolerate fluids; it would not be discontinued when a client's ability to tolerate fluids returns.
A client diagnosed with an empyema is scheduled for a thoracentesis. The nurse should prepare the client for this procedure with which action? Prepare to transport the client to the catheterization laboratory. Start a peripheral I.V. line and administer the necessary sedative drugs. Remove the water pitcher and remind the client not to eat or drink anything for 6 hours. Position the client sitting upright on the edge of the bed and leaning forward.
Position the client sitting upright on the edge of the bed and leaning forward. Explanation: This procedure can be done at the bedside. The nurse should help to position the client correctly. The best position for the procedure is to place the client in a sitting position with arms raised and resting on an overbed table. This position helps to spread out the spaces between the ribs for needle insertion. It is not necessary for the client to receive a sedative or be sent to the catheterization lab. The client does not have to be NPO for this procedure.
Twelve hours after cardiac surgery, the nurse assesses a 3-year-old who weighs 33 lb (15 kg). The nurse should notify the surgeon about which clinical finding? fluctuations of fluid in the collection chamber of the chest drainage system strong peripheral pulses in all four extremities alterations in levels of consciousness a urine output of 60 mL in 4 hours
alterations in levels of consciousness Explanation: Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in level of consciousness. An adequate urine output for a child over 1 year should be 1 mL/kg per hour. Therefore, 60 mL/4 hr is satisfactory. Strong peripheral pulses indicate adequate cardiac output. Drainage from the chest tube should show fluctuation in the drainage compartment of the chest drainage system. The fluid level normally fluctuates as proof that the apparatus is airtight. On about the third postoperative day, the fluctuation ceases indicating the lungs have fully expanded.
