EXAM 1- COMPREHENSIVE
A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction? 1. "I should leave the harness on during diaper changes." 2. "I will adjust the harness straps every 3-5 days." 3. "I will inspect the skin under the straps 2-3 times daily." 4. "The harness should keep my baby's legs bent and spread apart."
DDH is instability or dislocation of the hip joint that may be present at birth or develop during the first few years of life. Nonsurgical treatment methods such as the Pavlik harness are most successful when initiated during the first 6 months of life. After this time, surgery is generally required. The Pavlik harness is the most common tool used to treat early DDH. It maintains the infant's hips in a slightly flexed and abducted position (ie, legs bent and spread apart), allowing for proper hip development (Option 4). Pavlik harnesses are typically worn for 3-5 months or until the hip joint is stable. The straps are assessed every 1-2 weeks by the health care provider (HCP) and adjusted as necessary to account for infant growth. However, parents should not alter the strap placements at home as incorrect positioning can lead to damage to the nerves or vascular supply of the hip (Option 2). Care of the infant wearing a Pavlik harness includes the following: Assess skin 2-3 times daily for redness or breakdown under the straps (Option 3) Dress the child in a shirt and knee socks under the harness to protect the skin Apply diapers underneath the straps to keep the harness clean and dry Leave the harness on at all times, unless otherwise indicated by the HCP (Option 1) Educational objective: The Pavlik harness is used in the treatment of DDH; it maintains the infant's hips in a slightly flexed and abducted position to allow for proper joint development. Strap adjustments should be performed by the HCP to allow for proper positioning and avoid nerve or vascular damage.
The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer? Click the exhibit button for additional information. Vital signs Temperature 100.9 F (38.3 C) Blood pressure 125/75 mm Hg Heart rate 109/min Respirations 15/min SpO2 100% Progress notes 0800 Fundus +2 above umbilicus with moderate tenderness to palpation. Small to moderate amount of foul-smelling lochia rubra noted with no clots. Perineal care provided. _________________, RN 1. Acetaminophen PO PRN for fever 2. Clindamycin IV every 8 hours 3. Lactated Ringer IV bolus once 4. Methylergonovine PO every 4 hours
Postpartum endometritis Risk factors Cesarean delivery Chorioamnionitis Group B Streptococcus colonization Prolonged rupture of membranes Operative vaginal delivery Clinical features Fever >24 hours postpartum Uterine fundal tenderness Purulent lochia Etiology Polymicrobial infection Treatment Clindamycin & gentamicin Postpartum endometritis occurs when the endometrium (uterine lining) becomes infected after birth, often beginning at the placental site. Endometritis is characterized by uterine tenderness and subinvolution, foul-smelling or purulent lochia, fever, tachycardia, and chills. Cesarean birth is a primary risk factor, particularly if performed emergently or after prolonged labor. The infection is usually polymicrobial and requires treatment with broad-spectrum antibiotics (eg, IV clindamycin plus IV gentamicin). Antibiotic administration is a priority because it treats the primary cause of endometritis and prevents complications related to the spread of infection (eg, abscess, peritonitis) (Option 2). Antibiotics are required until approximately 24 hours after symptoms resolve. (Option 1) Antipyretics (eg, acetaminophen) and other comfort measures (eg, repositioning, oral hydration, pain medication) can be provided after antibiotic therapy is initiated. (Option 3) IV fluid administration (eg, Lactated Ringer IV bolus) is a supportive measure used to help resolve tachycardia and promote adequate hydration, but it does not take priority over antibiotic administration. (Option 4) To promote uterine involution, uterotonics (eg, PO methylergonovine) may be prescribed. Although uterine involution can promote drainage of purulent lochia, methylergonovine does not take priority over antibiotics, which are needed to treat the cause of infection. Educational objective: Postpartum endometritis is an infection of the endometrium (uterine lining) and is characterized by fever, chills, tachycardia, uterine tenderness, and foul-smelling or purulent lochia. The nurse's priority intervention is initiation of broad-spectrum antibiotics to treat the infection and reduce the risk of complications (eg, abscess, peritonitis). Subsequent interventions include antipyretics, IV fluids, and (possibly) uterotonics for uterine subinvolution.
A client is admitted with a pulmonary embolus. The nurse assesses restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety. Arterial blood gases indicate respiratory alkalosis and hypoxemia. When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority? 1. Activity intolerance related to imbalance between oxygen supply and demand 2. Acute pain related to inspiration and inflammation of pleura 3. Anxiety related to fear of the unknown, chest pain, and dyspnea 4. Impaired gas exchange related to ventilation-perfusion imbalance
Pulmonary embolism (PE) is usually caused by a dislodged thrombus that travels through the pulmonary circulation, becomes lodged in a pulmonary vessel, and causes an obstruction to blood flow in the lung. The nursing diagnosis of impaired gas exchange involves an alteration in the normal exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, resulting in inadequate oxygenation and hypoxemia (respiratory alkalosis, pO2 <80 mm Hg, restlessness, dyspnea, and tachycardia). Impaired gas exchange related to a ventilation-perfusion (V/Q) imbalance is the highest priority nursing diagnosis. It addresses the most basic physiologic need—oxygen. Clients will not survive without adequate oxygenation. (Options 1, 2, and 3) Activity intolerance, acute pain, and anxiety elicit autonomic responses (exertional discomfort, dyspnea, tachycardia) and are all appropriate nursing diagnoses. However, none are the highest priority or pose the greatest threat to survival. Educational objective: Activity intolerance, anxiety, acute pain, and impaired gas exchange are all appropriate nursing diagnoses to include in the plan of care for a client with PE. The highest priority nursing diagnosis is the one that poses the greatest threat to the client's survival. Additional Information Management of Care NCSBN Client Need
The nurse is caring for a client with chronic pain who just had surgery and is receiving patient-controlled analgesia (PCA) morphine. The client is in severe pain, with a rating of 10/10, despite receiving the maximum ordered dose. The nurse calls the health care provider, saying that the client is still having pain and recommending a higher PCA dose. Which nursing role is being implemented in this situation? 1. Advocate 2. Caregiver 3. Educator 4. Manager
The role of the nurse as advocate is to protect the rights of the client, including the right to adequate pain control. The nurse acting as advocate speaks up for clients when they cannot easily speak for themselves. (Option 2) In the role of caregiver, the nurse promotes healing and well-being by helping the client and family set and achieve goals through the nursing process. (Option 3) In the role of educator, the nurse helps the client and family learn about topics relevant to their health. (Option 4) In the role of manager, the nurse coordinates the care of the client among different members of the interdisciplinary team and across care settings. Educational objective: An important nursing role is client advocacy, which involves speaking up for clients to protect their rights and improve their health outcomes and experiences.
The clinic nurse reviews teaching provided to the parent of a child being considered for growth hormone replacement therapy at home. Which statement by the parent indicates that teaching has been effective? 1. "Treatment will be considered a success when my child grows at a rate equal to peers." 2. "Treatment will be required throughout my child's life." 3. "Treatment will begin when my child becomes an adolescent." 4. "Treatment will require a daily injection under my child's skin."
A child who demonstrates a slow growth pattern will undergo diagnostic evaluation to determine the cause. If the cause is found to be growth hormone deficiency, the child may undergo growth hormone replacement therapy. The biosynthetic hormone is administered via subcutaneous injection on a daily basis. Despite replacement therapy, the child may still have a final height less than "normal." Treatment is most successful when diagnosis and replacement therapy begin early in the child's life. When to stop therapy is decided by the client, family, and provider. However, growth less than 1 inch (2.5 cm) per year and bone age of 14 years in girls and 16 years in boys are the criteria often used to stop therapy. (Option 1) Growth hormone replacement does not guarantee that a child will grow at a rate equal to peers. Treated children often remain shorter than their peers. (Option 2) Replacement therapy is not continued throughout a child's life. It is stopped when bone growth begins to cease or when the child, parents, and provider make the decision. (Option 3) Replacement therapy is most successful when treatment begins early, as soon as growth delays are noted. Educational objective: Growth hormone replacement is an option for children who are not growing according to accepted standards. The treatment should begin as soon as delays are noted and continue until bone growth begins to cease despite replacement therapy. Replacement is administered via subcutaneous injections.
The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first? 1. Auscultate lung sounds bilaterally 2. Hyper-oxygenate with 100% oxygen 3. Manually ventilate with bag valve mask 4. Suction the endotracheal tube
A drop in oxygen saturation signifies a problem with ventilation. When an artificial airway is present, the nurse should assess the client to determine the cause of hypoventilation. Auscultating lung sounds is the first step and quickest intervention to confirm proper tube placement. It is not uncommon for the tube to become displaced in the hypopharynx, which would not allow proper ventilation. Another important complication is pneumothorax, which can cause hypotension and a drop in oxygen saturation. Lung auscultation would help diagnose this as well. (Option 2) Hyper-oxygenating would not increase ventilation if the tube is not in proper position or if the client has a pneumothorax. (Option 3) The first step is to confirm tube placement. Manually ventilating through a displaced tube would produce no better results than use of the ventilator. (Option 4) Mucus plugs are a common cause of decreased oxygen saturation in the intubated client. There are, however, specific symptoms associated with this problem, including secretions backing up in the tube and high-pressure ventilator alarms. Although this client may still need suctioning even if these symptoms are not present, auscultating lung sounds is necessary to confirm tube placement before suctioning. Suctioning via a displaced tube could cause additional damage to the client's airway. Educational objective: Proper placement of the endotracheal tube is essential for adequate ventilation in intubated clients. If the tube becomes displaced in the hypopharynx, hypoxemia can result. Confirming the presence of equal breath sounds bilaterally via auscultation is an important initial nursing intervention.
After receiving the shift report, the nurse should assess which infant first? 1. An infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min 2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL (2.2 mmol/L) 3. An infant with bilateral crackles who was delivered vaginally 30 minutes ago 4. An infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C)
A normal blood glucose range for an infant is 40-60 mg/dL (2.2-3.3 mmol/L) within the first 24 hours after delivery. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline-low glucose level is symptomatic and should be assessed first. (Option 1) A normal respiratory rate for an infant is 30-60/min. This infant is currently stable. (Option 3) It is normal to auscultate crackles in an infant during the first hour of life. This is because fluid is still being pushed out of and absorbed by the lungs. This infant is currently stable. (Option 4) A normal temperature range for an infant is 97.7-99.7 F (36.5-37.6 C). This infant is currently stable. Educational objective: The nurse should monitor infants for hypoglycemia by assessing for symptoms and monitoring the blood glucose level. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia and should be treated immediately by feeding or administering a glucose bolus. Additional Information Management of Care NCSBN Client Need
The nurse conducts a program about strategies for preventing community-acquired pneumonia at a center for senior citizens. Which statement made by a participant indicates the need for further instruction? 1. "I got the flu vaccine, and it can help to prevent pneumonia." 2. "I got the one-time pneumonia shot, so I won't need it again." 3. "I stopped smoking a year ago, so that should help me a lot." 4. "I try to avoid going to the mall during the winter months."
A once-in-a-lifetime pneumococcal vaccination is ineffective for preventing community-acquired pneumonia (CAP). The current guidelines for pneumococcal vaccination state that all adults age ≥65 should receive 2 pneumococcal vaccinations: PCV13, or 13-valent pneumococcal conjugate vaccine (Prevnar 13) followed by PPSV23, or 23-valent pneumococcal polysaccharide vaccine (Pneumovax 23) ≥1 year apart. In addition, pneumococcal pneumonia revaccination (PPSV23) is recommended after 5 years for clients who are immunocompromised, those with a splenectomy, and those who are ≥65 years old if the first dose was given before this age. (Option 1) CAP often follows a viral illness; therefore, an annual influenza vaccination is an effective prevention strategy for CAP. (Option 3) Smoking cessation is an effective prevention strategy for CAP. Smoking or exposure to secondhand smoke is a significant risk factor associated with pneumococcal infections, especially in individuals age ≥65. (Option 4) Effective prevention strategies for CAP include using proper cough etiquette, practicing respiratory and hand hygiene, and avoiding crowds and contact with individuals with viral respiratory illnesses. Educational objective: Effective prevention strategies for CAP include smoking cessation, vaccination for influenza and pneumococcal pneumonia, avoidance of contact with individuals with viral respiratory illnesses, respiratory and hand hygiene practices, and use of proper cough etiquette.
During a screening clinic, the nurse performs a health assessment on several adult clients. Which finding by the nurse is most important to report to the primary health care provider? 1. Body mass index (BMI) of 23 kg/m2 2. Brownish skin thickening on the neck 3. Fasting total cholesterol of 180 mg/dL (4.7 mmol/L) 4. Round 3x3 mm pale pink mole
Acanthosis nigricans is a skin disorder characterized by the presence of symmetric, hyperpigmented velvety plaques located in flexural and intertriginous regions of skin (axilla, neck). Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans. Both indicate insulin resistance (diabetic dermopathy). The client should be referred to the primary health care provider for evaluation of undiagnosed diabetes mellitus and/or metabolic syndrome. (Option 1) A BMI of 18.5 to 24.9 kg/m2 indicates a normal weight. (Option 3) A fasting total cholesterol <200 mg/dL (5.2 mmol/L) is normal. (Option 4) Although any change or growth of a mole should be reported, a pale or brown round mole <5 mm is typically a normal finding. Educational objective: Acanthosis nigricans is a velvety light brownish to black skin thickening seen in the axillae, neck, or flexures and is indicative of insulin resistance (diabetic dermopathy). Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans.
The nurse is caring for a 72-year-old client with a history of renal calculi and diabetes mellitus who was admitted for acute pyelonephritis. The nurse assesses shaking chills, temperature of 101.2 F (38.4 C), and flank pain. Which of the following is the priority nursing intervention? 1. Administer intravenous antibiotics 2. Check baseline serum creatinine level 3. Have the client strain all urine 4. Obtain blood and urine cultures
Acute pyelonephritis is an infection of the kidney usually caused by an extension of infection from the lower urinary tract (bladder). Chills and fever, vomiting, flank pain, and costovertebral tenderness are characteristic. Blood and urine cultures should be obtained prior to initiation of antibiotic therapy whenever possible to identify the causative microorganisms and determine the most effective antibiotics (Option 4). Given this client's age and underlying diabetes, sepsis can occur quickly. Therefore, antibiotics should be given immediately after cultures are obtained (Option 1). (Option 2) The nurse should check the client's baseline renal function and complete blood count tests to compare subsequent findings. This is not the priority nursing intervention. (Option 3) The client has a history of renal calculi. Straining all urine is not the priority nursing intervention. Educational objective: The priority of care for acute pyelonephritis is to obtain blood and urine cultures before initiating antibiotic therapy whenever possible.
A mother reports to the pediatric nurse that her 3-year-old child coughs at night and at times until he vomits. The symptoms have not improved over the past 2 months despite multiple over-the-counter cough medications. What should the nurse explore related to a possible etiology? 1. Ask about exposure to triggers such as pet dander 2. Assess for the presence of a butterfly rash 3. History of intolerance to wheat food products 4. Palpate for an abdominal mass from pyloric stenosis
Asthma is a chronic inflammatory disease of the lungs in genetically susceptible children. Frequent cough, especially at night, is the warning signal that the child's airway is very sensitive to stimuli; it may be the only sign in "silent" asthma. Common triggers include indoor contaminants (eg, tobacco smoke, pet dander, cockroach feces), outdoor contaminants (eg, air pollution), and allergic disease (eg, hay fever, food allergies). (Option 2) A red or pink butterfly rash across the cheeks and bridge of the nose is classic for systemic lupus erythematosus (SLE), an autoimmune disease that affects connective tissue. The child has no symptoms of SLE. Manifestations are acute (eg, nephritis, arthritis, vasculitis) or involve a gradual onset of nonspecific symptoms. (Option 3) Celiac, or gluten-sensitive, enteropathy is a chronic malabsorption syndrome. There is intolerance for gluten, a protein found in wheat, barley, rye, and oats. This condition affects absorption of nutrients; it does not cause nausea. (Option 4) Pyloric stenosis is a hypertrophy of the pylorus that results in stenosis of the passage between the stomach and the duodenum. Symptoms become evident 2-8 weeks after birth. It starts with occasional vomiting that eventually becomes forceful/projectile vomiting as the obstruction becomes complete. Dehydration and electrolyte imbalance result. The thickened pyloric muscle can sometimes be palpated and can be confirmed with ultrasound. This child is too old for this complication. Educational objective: Pediatric asthma can present as night coughing until the child vomits.
A pediatric client is diagnosed with an acute asthma attack. Which immediate-acting medications should the nurse prepare to administer to this client? Select all that apply. 1. Albuterol 2. Ibuprofen 3. Ipratropium 4. Montelukast 5. Tobramycin
Asthma is an inflammatory condition in which the smaller airways constrict and become filled with mucus. Breathing, especially on expiration, becomes more difficult. Pharmacologic treatment for acute asthma includes the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an effect. (Option 2) Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen, indomethacin) and aspirin can worsen asthma symptoms in some clients and are not indicated unless necessary. (Option 4) Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide) to provide long-term asthma control. (Option 5) Tobramycin is an aminoglycoside antibiotic. It is used in aerosolized form to treat cystic fibrosis exacerbation when Pseudomonas is the predominant organism causing lung infection. Educational objective: Inhaled corticosteroids and leukotriene inhibitors are typically used to achieve and maintain control of inflammation for long-term management of asthma. Quick-relief medications (eg, albuterol, ipratropium) are used to treat acute symptoms and exacerbations.
The emergency nurse plans care for a female victim of sexual assault. Which of the following interventions should the nurse include in the care plan? Select all that apply. 1. Determine if the victim has douched or had a bath or shower since the incident 2. Educate the victim regarding the need for a pelvic examination 3. Obtain the date of the last menstrual period and current method of birth control 4. Perform head-to-toe assessment of injuries and document injury locations 5. Provide prescribed prophylactic antibiotic medications for sexually transmitted infection
Asthma is an inflammatory condition in which the smaller airways constrict and become filled with mucus. Breathing, especially on expiration, becomes more difficult. Pharmacologic treatment for acute asthma includes the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an effect. (Option 2) Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen, indomethacin) and aspirin can worsen asthma symptoms in some clients and are not indicated unless necessary. (Option 4) Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide) to provide long-term asthma control. (Option 5) Tobramycin is an aminoglycoside antibiotic. It is used in aerosolized form to treat cystic fibrosis exacerbation when Pseudomonas is the predominant organism causing lung infection. Educational objective: Inhaled corticosteroids and leukotriene inhibitors are typically used to achieve and maintain control of inflammation for long-term management of asthma. Quick-relief medications (eg, albuterol, ipratropium) are used to treat acute symptoms and exacerbations.
The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel? 1. Absent bowel sounds 2. Borborygmi sounds 3. High-pitched and gurgling sounds 4. Swishing or buzzing sounds
Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components. Bowel sounds are normally intermittent (every 5-15 seconds), high-pitched, gurgling sounds that can be auscultated with the diaphragm of the stethoscope in all 4 quadrants. Cardiovascular bruits (swishing, humming, buzzing) are rarely benign and usually indicate arterial narrowing or dilation. Procedures that require bowel manipulation cause a temporary halting of peristalsis (paralytic ileus) for the first 24-48 hours, resulting in absent bowel sounds (Option 1). For bowel sounds to be considered absent, the nurse must auscultate for 2-5 minutes in each quadrant. Peristalsis will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days. Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause absent bowel sounds. (Option 2) Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting in borborygmi include gastroenteritis, diarrhea, and the early phases of mechanical obstruction. (Option 3) High-pitched, gurgling sounds signify normal bowel sounds and are unlikely to be heard immediately following abdominal surgery. (Option 4) A swishing, humming, or buzzing sound (bruit) may be cardiovascular in origin; a bruit indicates turbulent blood flow as with artery dilation (aneurysm) or narrowing (obstruction). A bruit can best be auscultated with the bell of the stethoscope. Educational objective: Bowel sounds following abdominal manipulation may be absent for 24-48 hours. Any disease process that causes an increase in peristalsis may cause borborygmi (loud, gurgling sounds). Swishing and humming sounds heard best with the bell of the stethoscope may be indicative of turbulent blood flow.
The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? 1. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge 2. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device 3. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism 4. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine
Cellulitis is a common skin bacterial infection that is usually treated with IV antibiotics in clients with diabetes mellitus. Room 2 is the best assignment option for this client with cellulitis. The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to those in rooms 1, 3, and 4. (Option 1) The client who is 1 day postoperative laparoscopic cholecystectomy (surgical procedure with small incisions) is at increased risk for infection. The client with cellulitis should not be placed in room 1. (Option 3) Although this client has pulmonary embolism, the history of prior splenectomy leads to a very high lifelong risk of rapid sepsis. Splenectomy clients need vaccination against encapsulated organisms (eg, pneumococcus, meningococcus, and Haemophilus influenzae type B). Even a low-grade fever should be taken seriously in these clients. The client with cellulitis should not be placed in room 3. (Option 4) Lupus nephritis is a serious renal complication of systemic lupus erythematosus (SLE), an inflammatory autoimmune disease that can lead to end-stage kidney disease. The systemic disease and the immunosuppressant (azathioprine [Imuran]) prescribed to slow its progression increase infection risk. The client with cellulitis should not be placed in room 4. Educational objective: A client with an infection should not be assigned to a semi-private room with a client who had surgery or is immunocompromised and receiving immunosuppressants as these clients are highly susceptible to infection. Post-splenectomy clients are also at lifelong risk for rapid sepsis.
A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client? 1. Avoid consuming high-sodium foods 2. Change positions slowly to prevent dizziness 3. Don't stop taking this medication abruptly 4. Use an oral moisturizer to relieve dry mouth
Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation. Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death. (Option 1) Avoiding high-sodium foods is important for blood pressure control but is not the most important advice for this client as consumption of these is not immediately life-threatening. (Option 2) Dizziness is a side effect of clonidine. The nurse should teach the client to change positions slowly and sit for a few minutes before rising to prevent falls. Drowsiness is also quite common with clonidine. Clients should not use it with alcohol or central nervous system depressants. However, dizziness and drowsiness should diminish with continued use of the medication. (Option 4) Dry mouth is a side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may be helpful for clients with dry mouth. Educational objective: Clonidine is a very potent antihypertensive. Abrupt discontinuation can result in serious rebound hypertensive crisis. Other common side effects of clonidine include dizziness, drowsiness, and dry mouth (the 3 Ds). Beta blockers, another class of blood pressure medications, can result in withdrawal symptoms if discontinued suddenly.
A client presents to the emergency department with alcohol intoxication. Assessment shows nystagmus, ataxia, and confusion. The client's breath smells of alcohol. Which prescription from the health care provider should the nurse implement first? 1. Blood draw for liver function tests 2. D5 1/2 normal saline 3. Folic acid, IV 4. Thiamine, IV
Clients with alcoholism can have hypoglycemia. They can also have thiamine (vitamin B1) deficiency related to poor nutrient intake (a healthy diet contains enough thiamine) and alcohol-induced suppression of thiamine absorption. Thiamine deficiency can result in Wernicke encephalopathy (WE). Untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis). In the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the body; this can worsen thiamine deficiency, which in turn can precipitate the development of WE in a previously unaffected individual. Because the signs of alcohol intoxication and WE are similar, all intoxicated clients should be given IV thiamine before or with IV glucose (Options 2 and 4). (Option 1) A blood draw for liver functions tests to rule out alcoholic hepatitis is important but not a priority. (Option 3) Clients with alcoholism usually have additional nutritional deficiencies (eg, folic acid, magnesium). Magnesium and multiple vitamins should also be given to these clients. However, thiamine is the essential vitamin to administer before or with IV glucose in a client with suspected alcoholism. Educational objective: IV thiamine is given before or with IV glucose to a client with alcohol intoxication to prevent Wernicke encephalopathy. Clients with alcoholism often have thiamine deficiency.
The nurse is caring for a client with a history of heroin abuse. Which clinical finding may indicate withdrawal? 1. Constipation 2. Constricted pupils 3. Drowsiness 4. Tachycardia
Clinical features of opioid withdrawal Clinical presentation Acute opioid cessation/dose reduction after prolonged use Gastrointestinal: nausea, vomiting, diarrhea, cramping, ↑ bowel sounds Cardiac:↑ pulse, ↑ blood pressure, diaphoresis Psychological: insomnia, yawning, dysphoric mood Other: myalgias, arthralgias, lacrimation, rhinorrhea, piloerection, mydriasis Management Opioid agonist: methadone (preferred) or buprenorphine Nonopioid: clonidine or adjunctive medications (antiemetics, antidiarrheals, benzodiazepines) Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone [Narcan]) is administered. Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity as the depressant effect of the opioid wanes (Option 4). Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given medications, such as methadone, to alleviate discomfort. The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or maintenance interventions. (Options 1, 2, and 3) Opioid use typically causes constipation, constricted pupils, and drowsiness due to its central nervous system depressant effects. Educational objective: Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped or dosage is reduced. Symptoms of opioid withdrawal (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity. Additional Information Psychosocial Integrity NCSBN Client Need
The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway? 1. Head-tilt chin-lift in the supine position on a backboard 2. Head-tilt chin-lift in the Trendelenburg position 3. Jaw-thrust maneuver in semi-Fowler's position 4. Jaw-thrust maneuver in the supine position on a backboard
Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma Life Support-qualified health care provider. Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column. (Option 1) Although use of the backboard is appropriate, the head-tilt chin-lift should not be used as it involves manipulation of the neck without proper stabilization. If the cervical vertebrae are fractured, the spinal cord could be badly damaged. (Option 2) The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing. (Option 3) The jaw-thrust maneuver is appropriate, but stabilization of the spine is best performed in the supine position, such as on the flat, hard surface of a backboard. Educational objective: If there is any suspicion of spinal injury, the jaw-thrust maneuver should be used for airway assessment to avoid any shifting of unstable vertebrae and subsequent spinal cord damage.
The nurse prepares to administer clozapine to a client with schizophrenia. Which client statement would require priority investigation before administering the medication? 1. "I have gained a few pounds since I started this medication." 2. "I have had a sore throat for 3 days and feel feverish today." 3. "I have noticed increased salivation and drooling." 4. "I often feel sleepy when I take this medication."
Clozapine (Clozaril) is an atypical antipsychotic medication used to manage schizophrenia in clients who have not improved with other antipsychotic medications. Clozapine is highly effective at controlling schizophrenia; however, it has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease (myocarditis), and seizures. Agranulocytosis (decreased neutrophils) increases the risk for infection. Clients require serial monitoring of white blood cell counts and frequent assessment for signs of infection (eg, sore throat, fever, flulike symptoms), which should be reported immediately to the health care provider (Option 2). (Option 1) Weight gain is a common side effect. Clients should be educated about weight management. (Option 3) Hypersalivation and drooling are common side effects. When excessive, they can occasionally pose risk for aspiration, especially while the client is sleeping. This is important but not an immediate priority. The side effect can be reduced by lowering the dose. The client should chew sugarless gum to promote swallowing and reduce drooling. (Option 4) Many clients experience significant sedation when the medication is started. Most will develop tolerance to this and eventually improve. Educational objective: Clozapine, an atypical antipsychotic, is used to manage schizophrenia in clients who have not improved with other medications. Clozapine may cause agranulocytosis, which increases the risk of life-threatening infection. Clients receiving clozapine should be monitored for signs of infection (eg, fever, flulike symptoms).
The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply. 1. History of angioedema with lisinopril 2. History of epilepsy 3. Known allergy to avocados and bananas 4. Known allergy to shellfish 5. Lip swelling when blowing up balloons
Latex allergy is an exaggerated immune-mediated reaction when one is exposed to products or dusts containing latex, a natural rubber used in many medical devices (eg, gloves, catheters, tape). Many people, particularly health care workers and individuals requiring chronic invasive procedures (eg, self-catheterization), develop latex allergy from repeated exposures. When assessing for potential latex allergies, the nurse should inquire about the client's reactions to common latex-containing objects and potentially cross-allergenic products. Balloons commonly contain latex, and reports of lip swelling, itching, or hives after contact indicate a high risk for anaphylactic reactions with continued exposure (Option 5). Many food allergies (eg, avocado, banana, tomato) also increase the risk for latex allergy because the food proteins are similar to those found in latex (Option 3). (Option 1) There is no documented cross-sensitivity reaction between ACE inhibitors (eg, lisinopril) and latex. (Option 2) Epilepsy is not associated with an increased risk for latex allergy. However, clients who have spina bifida or who have undergone multiple surgeries are at increased risk. (Option 4) Shellfish allergy was previously believed to be associated with allergy to iodine (CT contrast material), which has now been disproved. Shellfish allergy has no relationship to latex allergy. Educational objective: Latex allergy is an exaggerated immune reaction to exposure to latex-containing products (eg, gloves, catheters, tape). Risk factors include swelling, hives, or itching after exposure to common latex-containing products (eg, balloons); certain food allergies (eg, banana, avocado, tomato); and a history of multiple latex exposures (eg, self-catheterization, multiple surgeries).
The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? Select all that apply. 1. Helps prevent colorectal cancer 2. Improves glycemic control 3. Promotes weight loss 4. Reduces risk of vascular disease 5. Regulates bowel movements
Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet high in fiber-rich foods (eg, fruits, vegetables, legumes, whole grains) improves stool elimination, which helps prevent constipation and decreases the risk of colorectal cancer (Options 1 and 5). Fiber-rich foods tend to have a low glycemic load (less sugar per serving) and are nutrient dense, yet they have lower caloric density. Clients may also experience increased satiety as fiber absorbs water and produces fullness. This may help reduce caloric intake, improve blood glucose control, and promote weight loss (Options 2 and 3). Fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of dietary cholesterol that enters the bloodstream. Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis. A high intake of fiber-rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery disease and stroke (Option 4). Educational objective: Dietary fiber increases stool bulk and makes stool softer and easier to pass. A fiber-rich diet helps prevent constipation; decreases risk of colorectal cancer; promotes weight loss; improves blood glucose control; and decreases serum cholesterol levels, which reduces the risk of coronary artery disease and stroke.
A nurse is giving medications to a client who is being evaluated for a brain malignancy. The health care provider (HCP) has ordered a computed tomography (CT) scan with intravenous (IV) iodinated contrast for the next morning. Which medication should the nurse plan to withhold from this client? 1. Amlodipine 2. Gabapentin 3. Metformin 4. Phenytoin
IV iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury (contrast-induced nephropathy). The side effect of metformin (Glucophage) is lactic acidosis. If the client takes metformin and develops kidney injury from contrast, then the lactic acidosis will worsen. As a result, most HCPs discontinue metformin on the day of IV iodine contrast exposure (regardless of baseline creatinine) and restart the drug at least 48 hours later, after stable renal function has been documented. (Options 1, 2, and 4) Amlodipine (Norvasc) is a calcium channel blocker commonly used to treat hypertension. Gabapentin (Neurontin) is commonly used for neuropathic pain. Phenytoin (Dilantin) is an antiseizure medication. None of these medications interact with the iodinated contrast or worsen kidney injury. Therefore, these can be safely administered. Educational objective: Iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury. Metformin (Glucophage) can worsen lactic acidosis in the presence of kidney injury. Metformin should be withheld prior to the contrast exposure and can be resumed when kidney function is within normal limits.
A nurse on the antepartum unit is caring for a pregnant client at 30 weeks gestation who was admitted with reports of vaginal bleeding. A diagnosis of placenta previa was confirmed by ultrasound. What should the nurse tell the client to anticipate? Select all that apply. 1. Additional ultrasound around 36 weeks gestation 2. Clearance for sexual activity if bleeding stops 3. Discharge home if bleeding stops and fetal status is reassuring 4. Scheduled cesarean birth before onset of labor 5. Weekly vaginal examinations to assess for cervical change
In placenta previa, the placenta is implanted over or very near the cervix. This causes placental blood vessels to be disrupted during cervical dilation and effacement, which may result in massive blood loss and maternal/fetal compromise. Because of the increased risk of hemorrhage if contractions result in cervical change, a cesarean birth is planned for after 36 weeks gestation and prior to the onset of labor (Option 4). A stable client with no active bleeding and reassuring fetal status may be discharged home and managed in an outpatient setting (Option 3). However, the client must be closely monitored and instructed to return to the hospital immediately if bleeding recurs. As pregnancy progresses, the placenta grows in size and can potentially migrate away from the cervical opening, resulting in complete resolution of the previa. Therefore, an additional ultrasound is usually performed around 36 weeks gestation to assess placental location (Option 1). (Options 2 and 5) Clients with placenta previa should be instructed to remain on pelvic rest. Vaginal examinations, douching, and vaginal intercourse are contraindicated due to the risk of disruption of the placental vessels and subsequent hemorrhage. Modified bed rest (ie, decreasing any physical activity that could cause contractions) is also recommended. Educational objective: Clients with placenta previa are at risk for hemorrhage. Vaginal examinations are contraindicated, and pelvic rest is recommended to prevent disruption of placental vessels. A cesarean birth is planned prior to onset of labor.
The community health nurse prepares a teaching plan for a client with latent tuberculosis who is prescribed oral isoniazid (INH). Which instructions should the nurse include? Select all that apply. 1. Avoid drinking alcohol 2. Expect body fluids to change color to red 3. Report yellowing of skin or sclera 4. Report numbness and tingling of extremities 5. Take with aluminum hydroxide to prevent gastric irritation
Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy. A teaching plan for a client prescribed INH includes the following: Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity (Option 1) Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH Report changes in vision (eg, blurred vision, vision loss) Report signs/symptoms of severe adverse effects such as: Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) (Option 3) Peripheral neuropathy (eg, numbness, tingling of extremities) (Options 4) (Option 2) Rifampin, another antitubercular drug, often causes a red-orange discoloration of body fluids (ie, urine, sweat, saliva, tears). However, this effect is not associated with INH use. (Option 5) Concurrent use of antacids containing aluminum decreases INH absorption. The medication may be taken with food if gastric irritation is a concern. Educational objective: Common potential side effects of INH include hepatotoxicity (eg, jaundice, vomiting, dark urine, fatigue) and peripheral neuropathy (eg, numbness, tingling of extremities). Clients should avoid alcohol use and aluminum-containing antacids, and report any experienced side effects to the health care provider immediately.
An adolescent client with a sore throat is diagnosed with infectious mononucleosis. Which comment by the caregiver would alert the nurse that additional instruction is necessary? 1. "I need to go to the pharmacy to pick up an antibiotic prescription." 2. "It is acceptable for my child to have ibuprofen for discomfort or fever." 3. "My child will be on bed rest with few activities for the next 2 weeks." 4. "Participation in soccer practice will not be allowed for the next month."
Mononucleosis is caused by the Epstein-Barr virus. It is typically seen in adolescence from the sharing of drinks, kissing, or other direct exposure to saliva. Symptoms may include fatigue, fever, sore throat, splenomegaly, hepatomegaly, and swollen lymph nodes. Antibiotic treatment is inappropriate for a viral infection. Inadvertent intake of antibiotics (amoxicillin) can cause a rash. Treatment for mononucleosis is management of symptoms and includes hydration, rest, control of pain, and reducing fever as necessary. Sore throat is treated with saline gargles or anesthetic troches. Complications include airway obstruction (eg, stridor, difficult breathing) from swollen lymph nodes around the neck and severe abdominal pain (splenic rupture). These should be reported to the health care provider (HCP) immediately. (Option 2) Ibuprofen or acetaminophen is appropriate treatment to control pain and manage fever in the child with mononucleosis. Aspirin should be avoided in children due to the risk of Reye syndrome. (Option 3) Fatigue is a symptom of mononucleosis. Rest is very important in the care of a client with mononucleosis. (Option 4) Mononucleosis may cause splenomegaly or hepatomegaly. Contact sports such as soccer should be avoided to prevent injury to the spleen or liver. Educational objective: Treatment for mononucleosis is largely symptomatic. It includes rest, hydration, pain control for sore throat, and fever reduction. Clients should avoid contact sports such as soccer to prevent injury to the spleen or liver. Breathing difficulty or abdominal pain should be reported to the HCP.
The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first? 1. Ask the UAP to take a set of vital signs 2. Assess the symptoms reported by the UAP 3. Hold the prescribed diuretic medications 4. Instruct the UAP to assist the client to bed
Paracentesis is a procedure that involves removal of excess fluid from the peritoneal cavity (ascites) and is performed to relieve dyspnea and discomfort related to increased intra-abdominal pressure and fluid volume. Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure and also to high volume peritoneal fluid removal (>5 L). The nurse should first validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for manifestations of hypovolemia (eg, orthostatic hypotension, tachycardia, reduced pulse volume, decreased urine output), as decreased circulating volume can lead to hemodynamic instability. (Option 1) Post-paracentesis vital signs are frequently monitored for the first 4 hours to assess for complications (eg, hypotension, bleeding). The nurse can ask the UAP to take another set of vital signs, but this should not be the nurse's first intervention. (Option 3) Diuretics (eg, spironolactone, furosemide) are prescribed for clients with ascites. If the client is hypotensive or hypovolemic, the nurse can hold the prescribed diuretics, but this should not be the nurse's first intervention. (Option 4) The nurse can instruct the UAP to assist the client back to bed if this is an appropriate action after assessing the client, but this should not be the nurse's first intervention. Educational objective: A client who is experiencing lightheadedness and unsteady gait following paracentesis requires immediate assessment because these manifestations can signal hypovolemia with hypotension, which can lead to hemodynamic instability and hypovolemic shock.
The nurse is assessing a client with a possible diagnosis of peripheral artery disease. Which client statement is consistent with the diagnosis? 1. "At the end of the day, my shoes and socks are tight." 2. "I have a slow-healing sore right above my ankle." 3. "My legs ache when I stand for extended periods." 4. "When I sit down to rest and elevate my legs, the pain increases."
Peripheral artery disease (PAD [previously called peripheral vascular disease]) refers to arteries that have thickened, have lost elasticity due to calcification of the artery walls, and are narrowed by atherosclerotic plaques (made up of fat and fibrin). Pain due to decreased blood flow is the most common symptom of PAD. Cramping pain in the muscles of the legs during exercise, known as intermittent claudication, is usually relieved with rest. However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that is worsened by elevating the legs and improved when the legs are dependent. Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen). Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. Clients should be advised that a progressive walking program will aid the development of collateral circulation. (Options 1, 2, and 3) Chronic venous insufficiency refers to inadequate venous blood return to the heart. Too much venous blood remains in the lower legs, and venous pressure increases. This increased venous pressure inhibits arterial blood flow to the area, resulting in inadequate supply of oxygen and nutrients to area cells and the development of stasis ulcers, which are typically found around the medial side of the ankle. By the end of the day or after prolonged standing, the legs become edematous with dull pain due to venous engorgement. The skin of the lower leg becomes thick with a brown pigmentation. Educational objective: The pain of peripheral artery disease is arterial in nature and results from decreased blood flow to the legs. It is made worse with leg elevation. Arterial ulcers are formed at the most distal end of the body. Venous ulcers form over the medial malleolus, and compression bandaging is needed to reduce the pressure.
The pediatric nurse is performing an assessment on a 4-week-old client in the clinic. During the assessment, the newborn's mother starts to cry and states, "I am the worst mother in the world." What should the nurse ask next? 1. "Do you have a support system to help process your feelings?" 2. "Do you have any questions about how to care for your newborn?" 3. "Have you experienced difficulty falling asleep or getting rest?" 4. "Have you felt depressed or hopeless over the last 2 weeks?"
Postpartum depression (PPD) is a perinatal mood disorder that affects women following childbirth. Symptoms may include crying, irritability, difficulty sleeping (or sleeping more than usual), anxiety, and feelings of guilt. Symptoms typically arise within 4 weeks of delivery and can affect the mother's ability to care for herself and the newborn. The nurse should ask specific questions about depression or hopelessness to assess for PPD (Option 4). It is also important to ask about thoughts of self-harm or harm to the newborn. (Option 1) Women who do not have strong support systems are at a higher risk for PPD. However, it is most important to assess for the presence of PPD. (Option 2) Mothers may have feelings of inadequacy or guilt as they experience challenges in caring for their infant (eg, breastfeeding difficulties, infant colic). The nurse should assess the need for client teaching, which can help to alleviate anxiety and improve outcomes; however, this is not the priority. (Option 3) Sleep disturbances are common when caring for a newborn and may worsen depression or anxiety. However, it is most important to directly ask the client about depression. Educational objective: Postpartum depression (PPD) is a perinatal mood disorder characterized by crying, irritability, sleep disturbances, anxiety, or feelings of guilt. Nurses should assess for PPD by asking specific questions about feelings of depression and hopelessness as well as thoughts about self-harm or harm to the newborn.
The nurse is caring for a hospitalized client with an acute exacerbation of heart failure. The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCl) 20 mEq PO twice daily. The client's child reports that the client has trouble swallowing the large KCl pill. The client's potassium level is 3.7 mEq/L (3.7 mmol/L). What action should the nurse take first? 1. Consult with the pharmacist to see if other oral forms of KCl are available 2. Crush the pill and mix it with applesauce or pudding 3. Hold the KCl until the health care provider makes rounds 4. Instruct the client to tuck the chin to the chest when swallowing the pill
Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia. Oral KCl is available in extended-release tablets, capsules, dissolvable packets, and effervescent tablets, and as an oral liquid. If a client has difficulty swallowing large pills, the nurse should consult the pharmacist to see if other forms of KCl are currently available and to determine if the medication is safe to crush. If a more appropriate form (eg, liquid) is available, the nurse would then discuss that change in route with the health care provider and obtain an updated prescription. (Option 2) Some pills or capsules are sustained-release formulations, and crushing may alter the release of the drug and cause an overdose of the medication. The nurse should consult the pharmacist before altering the form of the drug. (Option 3) The use of a loop diuretic, such as furosemide, is a common cause of potassium depletion. Holding the KCl dose may cause the client's potassium level to fall below normal (<3.5 mEq/L [3.5 mmol/L]), which can potentiate digoxin toxicity (eg, cardiac dysrhythmias, gastrointestinal upset). (Option 4) Tucking the chin to the chest during swallowing is a technique used to prevent aspiration. This most likely will not help the client swallow the large pill. Educational objective: Oral potassium chloride comes in multiple forms: tablet or capsule, oral liquid, dissolving packets, and effervescent tablets. If a client has difficulty swallowing large pills, the pharmacist can determine availability of other medication forms, which can then be prescribed by the health care provider.
The parents of a hospitalized 3-month-old have to leave the infant while they work. One parent fears that the baby will cry as soon as they walk out. The nurse teaches both parents about separation anxiety. Which statement by the parent indicates that the teaching has been effective? 1. "At this age, my baby will not cry because we are leaving." 2. "I know my baby will feel abandoned when we leave." 3. "My baby is too young to sense my anxiety about leaving." 4. "My baby understands that we will return later in the day."
Separation or stranger anxiety occurs when the primary caregivers leave the child in the care of others who are not familiar to the child. This behavior starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. Separation anxiety produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. However, this reaction is normal and resolves as the child approaches age 3 years. A 3-month-old can be soothed by any comforting voice (Option 1). (Option 2) A 3-month-old is not developmentally capable of fearing abandonment. (Option 3) A 3-month-old might sense a parent's anxiety but is cognitively unable to process it. (Option 4) A 3-month-old cannot tell time and would not understand the concept of returning later in the day. Educational objective: Separation anxiety starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. It produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. However, separation anxiety is normal and resolves by age 3 years.
A nurse working at a mental health clinic is reviewing four messages from clients requesting a same-day appointment. Which client does the nurse prioritize to call back first? 1. A client who experienced a panic attack for the first time in 6 months after a minor car accident yesterday and is requesting a refill for alprazolam 2. A client who is experiencing a fever and diarrhea 2 days after the health care provider increased the sertraline dose 3. A client taking phenelzine who is concerned about food-medication interactions and is requesting a list of foods to avoid 4. A client who has attention-deficit hyperactivity disorder and is experiencing insomnia and irritability 2 days after starting methylphenidate
Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (eg, St. John's wort), placing clients at risk for serotonin syndrome. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). The nurse should call this client back to investigate the symptoms further. (Option 1) Panic attacks can be frightening but typically last less than 10 minutes. A panic attack following a stressful event does not pose an immediate risk; the request for a refill of alprazolam (benzodiazepine for acute anxiety relief) can wait. (Option 3) Phenelzine is a monoamine oxidase inhibitor that has multiple food interactions (eg, foods containing tyramine), which can cause hypertensive crisis. This client needs further education to prevent this condition, but is asymptomatic and not in immediate danger. (Option 4) Stimulants (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are commonly used for attention-deficit hyperactivity disorder (in both children and adults) and are commonly associated with insomnia, irritability, diminished appetite, weight loss, and headaches. Educational objective: Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (eg, St. John's wort), placing clients at risk for serotonin syndrome. Additional Information Management of Care NCSBN Client Need
The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client? 1. Room A: Client with multiple myeloma who is being treated with corticosteroids 2. Room B: Client with diabetes mellitus and osteomyelitis receiving IV antibiotics 3. Room C: Client with a gastrointestinal bleed who has a nasogastric tube 4. Room D: Client with influenza with a high fever who is receiving oseltamivir
Surgical debridement of an unstageable pressure injury involves using a scalpel to remove necrotic (eschar) or infected tissue from the wound to promote healing. The most appropriate room assignment for this client is Room C, as the client with a gastrointestinal bleed and nasogastric tube is the least susceptible to infection compared with the clients in Rooms A and B (Option 3). (Option 1) Multiple myeloma is a cancer that involves proliferation of malignant plasma cells (monoclonal antibodies), which are ineffective in providing protection against infection and suppress normal bone marrow cell production (eg, erythrocytes, platelets, leukocytes). This client in Room A is especially vulnerable to infection due to immunosuppression related to the disease process and to drug therapy with corticosteroids. (Option 2) The postoperative client should not be assigned to Room B with a client who has osteomyelitis, an infection of bone. (Option 4) The client with influenza requires droplet precautions and would likely require a private room (Room D). Clients with severe disease (ie, requiring hospitalization) should receive antiviral medication (eg, zanamivir, oseltamivir) as they are at high risk for complications. Educational objective: A client undergoing an extensive surgical debridement for an infected pressure injury should not be assigned to a room with a client who is vulnerable to infection (eg, immunocompromised) or who has an active infection.
Which of the following tasks would the charge nurse on a surgical unit assign to the experienced unlicensed assistive personnel (UAP)? 1. Assisting a client in ambulating to the bathroom for the first time following surgery 2. Explaining why using the incentive spirometer is important to a client with postoperative pneumonia 3. Feeding a client with dementia who has a blood sugar of 70 mg/dL (3.9 mmol/L) 4. Taking vital signs every 15 minutes on a client who was just transferred from the post- anesthesia recovery unit
The charge nurse must know the UAP's level of knowledge and competency in relation to the task and be familiar with institutional policy and procedures before delegating the task. Routine tasks, such as taking vital signs, supervising ambulation, bed making, assisting with hygiene, and activities of daily living, can be delegated to an experienced UAP. The charge nurse appropriately delegates the routine task of feeding to the UAP. The general procedure and safety principles associated with feeding (positioning, observations about swallowing, recording intake) do not change because of the client's diagnosis of dementia. Normal fasting blood glucose levels are 70-110 mg/dL (3.9-6.1 mmol/L). (Option 1) It is not appropriate for the UAP to independently assist a client in ambulating for the first time following surgery as it requires assessment of potential postoperative complications and evaluation of ability to ambulate. (Option 2) Initial teaching/explaining about the use of incentive spirometer is the sole responsibility of the registered nurse (RN). (Option 4) Taking vital signs in an unstable newly postoperative client requires assessment of potential postoperative complications and is not appropriate to delegate to the UAP. Educational objective: The RN can delegate routine tasks such as taking vital signs, supervising ambulation, making beds, assisting with hygiene, and activities of daily living to the experienced UAP. Assessment, analysis of data, planning, teaching, and evaluation are the responsibilities of the RN.
A client's arterial blood gases (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs? Click on the exhibit button for additional information. Laboratory results PH 7.25 PO2 79 mm Hg (10.5 kPa) PaCO2 35 mm Hg (4.66 kPa) HCO3- 12 mEq/L (12 mmol/L) 1. Decrease in bicarbonate reabsorption 2. Decrease in respiratory rate 3. Increase in bicarbonate reabsorption 4. Increase in respiratory rate
The client's ABGs have low pH consistent with acidosis. If it is a primary respiratory acidosis, pCO2 would be higher. If it is metabolic acidosis, bicarbonate would be lower. Because this client has low pH coupled with low bicarbonate, the most likely diagnosis is primary metabolic acidosis. Respiratory alkalosis is the body's natural compensation for metabolic acidosis. Respiratory alkalosis is achieved by blowing more CO2 off from the system through rapid breathing. (Option 1) Decreased bicarbonate reabsorption would produce metabolic acidosis; this would occur as a compensation for primary respiratory alkalosis (decreased pCO2 and high pH). (Option 2) When the respiratory rate is decreased, pCO2 would increase, creating a respiratory acidosis; this would occur in response to a primary metabolic alkalosis. (Option 3) Increased bicarbonate reabsorption would produce metabolic alkalosis; this would occur as a compensation for primary respiratory acidosis (increased pCO2 and low pH). Educational objective: Respiratory alkalosis is the body's natural compensation for metabolic acidosis. It is achieved by blowing more CO2 off from the system through rapid breathing.
The parent of a 2-year-old tells the nurse at the well-child clinic, "I am concerned because my child does not like to be cuddled, does not respond when called by name, and does not make eye contact when being fed." What is the priority question for the nurse to ask when completing the health history? 1. "How many words can your child say?" 2. "Is your child potty trained?" 3. "What are your child's favorite foods?" 4. "What kind of toys does your child like to play with?"
The concerns presented by this child's parent are suggestive of a developmental delay and very possibly autism spectrum disorder (ASD). ASD is a complex neurodevelopmental disorder characterized by the onset of abnormal functioning before age 3. The 2 core symptoms of ASD are abnormalities in social interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. Social skills, especially communication, are delayed more significantly than other developmental functioning and are the focus during client assessment. The vast majority of children diagnosed with ASD lack the acquisition of communication skills during the first 2 years of life. A healthy 2-year-old should have a vocabulary of about 300 words and should be able to string 2 or more words together in a meaningful phrase. Assessing this child's language abilities would be the priority. (Option 2) Assessing any 2-year-old's progress in toilet training is appropriate. However, it is not the priority assessment given the parent's concerns. (Option 3) A nutrition assessment is part of every well-child visit, but it is not the priority in this situation. (Option 4) Although not the priority assessment, it would be important to ask the parent about the child's play activities. Children with ASD often have a restricted interest in and preoccupation with a single toy, exhibit repetitive behaviors when playing with the toy, and insist on the same play routine. Educational objective: The 2 core symptoms of autism spectrum disorder are abnormalities in social interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. Social skills, especially communication, are delayed more significantly than other developmental functioning.
A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response? 1. The nurse has encouraged exploration of the client's situation 2. The nurse has shown interest in the client's concerns 3. The response conveys empathy toward the client and promotes self-confidence 4. The response devalues the client's feelings and gives false reassurance
The nurse has used a nontherapeutic communication technique known as "giving reassurance" or "giving false reassurance." A nurse who does not acknowledge a client's feelings and gives the impression that there is nothing to worry about has devalued the client's concerns. This technique serves to block a therapeutic conversation as the client may feel that the verbalization of additional concerns or feelings will also be devalued. (Option 1) The nurse has not encouraged exploration of this client's feelings and options. This could have been done by using any one of several therapeutic communication techniques (eg, reflecting, focusing, exploring). An appropriate response by the nurse, such as stating, "Tell me what concerns you have," would have facilitated communication with the client. (Option 2) The nurse has shown no interest in the client's concerns; instead, the nurse should show interest, be available, and have a conversation with the client (eg, "I will stay and listen to your concerns"). (Option 3) The nurse has not conveyed empathy (attempting to understand and share the feelings behind a client's actions and words). An empathetic nurse might say, "This must be hard for you," or, "I understand you are upset." Educational objective: The nurse must learn to use effective therapeutic communication skills to enhance the development of a trusting and therapeutic nurse-client relationship.
The nurse is caring for a client with a pulmonary contusion. Assessment reveals restlessness, chest pain on inspiration, diminished breath sounds, and oxygen saturation of 86%. Which acid-base imbalance does the nurse correctly identify? Click on the exhibit button for more information. Laboratory results pH 7.31 PaO2 76 mm Hg (10.11 kPa) PaCO2 54 mm Hg (7.18 kPa) HCO3⁻ 24 mEq/L (24 mmol/L) 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
This client's arterial blood gas analysis reveals respiratory acidosis, with a low pH (<7.35), low PaO2, and high PaCO2 (>45 mm Hg [>5.98 kPa]). Any condition that causes a decrease in respiratory rate or tidal volume (eg, chronic obstructive pulmonary disease, chest trauma, over-sedation, sleep apnea) increases the risk of developing respiratory acidosis. This client's breathing is likely shallow due to pain, impairing gas exchange and leading to buildup of acidic carbon dioxide in the blood. (Option 1) In metabolic acidosis, pH would be decreased (<7.35) and HCO3- would be decreased (<22 mEq/L [<22 mmol/L]). (Option 2) In metabolic alkalosis, pH would be increased (>7.45) and HCO3- would be increased (>26 mEq/L [>26 mmol/L]). (Option 4) In respiratory alkalosis, pH would be increased (>7.45) and PaCO2 would be decreased (<35 mm Hg [<4.7 kPa]). Educational objective: Buildup of acidic carbon dioxide from hypoventilation causes a decrease in pH, creating a state of respiratory acidosis.
The clinic nurse is assessing the client's understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication? 1. "A capsule holds the powdered medication that I have to put in a special inhaler." 2. "I do not need to rinse my mouth with water after taking tiotropium." 3. "I have been taking tiotropium every time I have difficulty breathing." 4. "Tiotropium helps control my COPD by reducing inflammation in my airway."
Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic, inhaled medication used to control chronic obstructive pulmonary disease (COPD). It is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client proper administration prior to the first dose, emphasizing that the capsule should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future appointments, the nurse should assess/reassess the client's ability to use this medication correctly. (Option 2) Clients should rinse the mouth after using tiotropium and inhaled steroids (eg, beclomethasone, budesonide, fluticasone) to remove any medication remaining in the mouth, which decreases the risk of developing thrush. (Option 3) Tiotropium is a controller medication for COPD with a peak effect of approximately 1 week; therefore, it should not be used as a rescue medication. Instead, short-acting bronchodilators (eg, albuterol and/or ipratropium) should be used for symptom rescue. Clients must discontinue ipratropium before taking tiotropium as both are anticholinergic. (Option 4) Anticholinergic inhaled medications (eg, ipratropium, tiotropium, umeclidinium) do not reduce inflammation in the airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help dry up airway secretions. Educational objective: Tiotropium and umeclidinium are long-acting, 24-hour, anticholinergic medications. Ipratropium is a short-acting anticholinergic used as a rescue medication for COPD and asthma. Tiotropium is typically administered as a powder via a special inhaler. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need