*HURST REVIEW Qbank/Customize Quiz - Reduction Risk

The nurse is caring for a client who has a history of sleep apnea. The client is scheduled for a colon resection the following morning and asks if the sleep apnea machine should be brought to the hospital. What is the nurse's best response? 1. Yes, bring the sleep apnea machine. 2. No, do not bring the sleep apnea machine. 3. It is your choice. 4. Call your primary healthcare provider.

1. Correct: A client with sleep apnea is at risk for cardiac and respiratory complications post op due to decreasing oxygenation. So yes, the client needs to use the CPAP machine. Remember this client will also be receiving narcotics for pain and have a decreased activity level as well. All of these things can decrease oxygenation. 2. Incorrect: The client will need to have the machine after surgery. 3. Incorrect: Best response is for nurse to recommend that the client bring machine. 4. Incorrect: The nurse can answer this question.

A client admitted with somnolence has a history of chronic bronchitis and heart failure. Vital signs on admit are T 101.8ºF (38.8ºC), HR 106, R 26/shallow, BP 90/58. ABGs are pH 7.2, PCO2 75, HCO3 26. The nurse determines that this client has which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Correct: This client has a respiratory problem. Respiratory failure, COPD, and muscular weakness can lead to respiratory acidosis. Signs & symptoms: hypoventilation, sensorium changes, somnolence, semicomatose to comatose state. pH < 7.35, pCO2 > 45, HCO3 normal. 2. Incorrect: This is not alkalosis since the pH is 7.2 showing acidosis. 3. Incorrect: Not a metabolic related acid/base imbalance, because the HCO​2 is 26 and within the normal range. 4. Incorrect: Not a metabolic related acid/base imbalance, because the HCO​2​ is 26 and within the normal range.

A client with a history of alcoholism arrives at the clinic reporting severe abdominal pain with nausea and vomiting. What additional findings would make the nurse suspect the client may have pancreatitis? Select all that apply 1. Afebrile 2. Cullen's Sign 3. Pain relieved after eating 4. Positive Chvostek's sign 5. Tachycardia.

2 and 5. CORRECT: Whether the client is experiencing acute or chronic pancreatitis, symptoms are severe and distinct. Bruising around the umbilicus is referred to as "Cullen's Sign", indicating internal bleeding. Because of inflammation in the pancreas, the client generally becomes febrile and has pain. Both causing tachycardia. 1. INCORRECT: Because of inflammation in the pancreas, the client generally becomes febrile. 3. INCORRECT: Pain is worse with eating. 4. INCORRECT: A positive Chvostek's sign is an indication of low levels of calcium in hypocalcemia, occurring as a twitching occurs when the nurse taps the client's cheek. This sign does not relate to pancreatitis.

The nurse assesses a client post thyroidectomy for complications by performing which assessment? 1. Accucheck 2. Chvostek's 3. Ballottement 4. Ice water colonic

2. Correct: A positive Chvostek's and Trousseau's is indicative of tetany and low calcium. This can occur when a couple of parathyroids are accidently removed when the thyroid is removed. 1. Incorrect: Accucheck assesses for blood glucose levels, which is not the problem post thyroidectomy. 3. Incorrect: This assessment technique is used in examining the abdomen when ascites is present. It is done by palpating the abdomen to detect excessive amounts of fluid (ascites). 4. Incorrect: If you have never heard of it, no one else has either. The phrase implies using ice water to cleanse the colon and this would never be a good thing, especially for someone post thyroidectomy that would be intolerant to extremes in temperature.

A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? 1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Trace proteinurea

1. Correct: Facial and upper extremity edema can be a sign of preeclampsia, which can endanger both the mother and fetus. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. Even a slight rise in blood pressure may be a sign of preeclampsia. Left untreated, preeclampsia can lead to serious, even fatal, complications. Signs and symptoms of preeclampsia include hypertension and may include: Proteinuria; Severe headaches; Changes in vision; Upper abdominal pain; Nausea or vomiting; Decreased urine output; Thrombocytopenia; Impaired liver function; Shortness of breath; Sudden weight gain, and edema, particularly in face and hands. 2. Incorrect: Indigestion should be assessed for severity, but it is a common symptom in 3rd trimester of pregnancy. 3. Incorrect: Pedal edema should be assessed but is common in 3rd trimester of pregnancy. 4. Incorrect: Trace proteinuria is a benign sign in 3rd trimester of pregnancy.

The nurse is reviewing sequential lab results on a newly admitted client with multiple health issues. Critical changes in which body system require the nurse to immediately notify the primary healthcare provider? Exhibit Metabolic Profile: Date: 1/1, Sodium: 143 mEq/L (143 mmol/L), Potassium: 4.2 mEq/L (4.2 mmol/L), Chloride: 100 mEq (100 mmol/L), Glucose: 99 mg/dL (5.7 mmol/L), Blood Urea Nitrogen: 16 mg/dL (5.7 mmol/L), Creatinine: 1.3 mg/dL (99 mmol/L), Venous Carbon Dioxide: 24 mEq/L (24 mmol/L) Date: 1/2, Sodium: 138 mEq/L (138 mmol/L), Potassium: 4.6 mEq/L (4.6 mmol/L), Chloride: 102 mEq (102 mmol/L), Glucose: 102 mg/dL (5.6 mmol/L), Blood Urea Nitrogen: 19 mg/dL (6.8 mmol/L), Creatinine: 1.6 mg/dL (122 mmol/L), Venous Carbon Dioxide: 26 mEq/L (26 mmol/L) Date: 1/3, Sodium: 137 mEq/L (137 mmol/L), Potassium: 5.0 mEq/L (5.0 mmol/L), Chloride: 104 mEq (104 mmol/L), Glucose: 104 mg/dL (5.8 mmol/L), Blood Urea Nitrogen: 22 mg/dL (7.9 mmol/L), Creatinine: 2.0 mg/dL (153 mmol/L), Venous Carbon Dioxide: 27 mEq/L (27 mmol/L) 1. Renal 2. Endocrine 3. Pulmonary 4. Cardiovascular

1. Correct: All lab values are fluctuating, but those most significantly outside of normal range are the BUN and Creatinine levels, reflecting possible renal failure. The nurse would need to immediately notify the primary healthcare provider of possible complications in the client's renal system. The sodium, potassium, and glucose are within normal limits. 2. Incorrect: Several lab readings could relate to the endocrine system, but most specifically are glucose and chloride. Both these electrolytes have fluctuating levels but remain well within normal limits. Therefore, the endocrine system is not the nurse's concern at this time. 3. Incorrect: The carbon dioxide levels listed reflect venous, NOT arterial, blood. Norms for venous carbon dioxide are 23 to 29 mEq/L (milliequivalent units per liter of blood), indicating these results are all within normal levels. Although chloride could also reflect the pulmonary system, there are no irregular results in chloride levels. 4. Incorrect: Many of these elements could affect the cardiovascular system, but most specifically sodium and potassium. At present, these levels are all within normal limits, although the potassium has risen to the uppermost levels of normal. If those levels continue to climb, this could become a concern; however, this would not require a call to the primary healthcare provider at this time.

The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time? 1. Warm the room. 2. Submerge the hand in warm water. 3. Order a K pad and apply to hand. 4. Have the client exercise the fingers to increase blood flow.

1. Correct: When caring for clients with skin grafts, we want good circulation, so warm that room up.2. Incorrect: This will not improve circulation and can lead to infection. 3. Incorrect: This will not improve circulation. Someone who has a skin graft doesn't have good sensation so there is risk of another burn to the graft with this. 4. Incorrect: Working those stiff, cold fingers will further imbalance the oxygen supply. This will not help, particularly if the environment remains cool.

The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? 1. Patency of endotracheal tube. 2. Adventitious breath sounds. 3. Fluid in the ventilator tubing. 4. Ventilator settings.

1. Correct: With restlessness, think hypoxia so the nurse should start assessment with airway first. Check for patency of the ET tube. If this is patent, then the other options would be next. 2. Incorrect: This is the next best answer, but hypoxia and airway comes first. 3. Incorrect: This is the third step. Rule out the other two before checking tubing for kinks or obstructions. 4. Incorrect: Start with the client first. Then move toward the ventilator. Always assess the client first.

The nurse is removing the client's peripheral IV line prior to discharge. The nurse completes the appropriate steps in what order? Stabilize cannula with one hand. Apply gauze and tape tightly. Wash hands and apply gloves. Loosen tape and tegaderm cover. Clamp IV line closed securely. Drag and Drop the items from one box to the other.

1. Wash hands and apply gloves. 2. Clamp IV line closed securely. 3. Stabilize cannula with one hand. 4. Loosen tape and tegaderm cover. 5. Apply gauze and tape lightly. When preparing to remove a peripheral IV line, the nurse begins by washing hands and applying non-sterile gloves. Next, the clamp is closed on the IV line or saline lock extension to prevent fluid or blood from leaking during process. Third, the nurse needs to stabilize the cannula with one hand to prevent trauma at the insertion site. Fourth, carefully begin to loosen all the tape on the site. The bottom dressing or tegaderm, is loosened last. Lastly, the nurse will place large, folded gauze square over the insertion site and gently pull the cannula out of the skin, while placing pressure on that gauze. After holding the gauze in place for a few moments, and checking for excess bleeding, the nurse will tightly tape that gauze square in place, providing pressure over the site. The client should be instructed to keep that dressing in place for at least one hour.

The nurse is preparing to educate a client diagnosed with essential hypertension on how to decrease the risk of developing complications. What topics should the nurse include? Select all that apply 1. Following the DASH dietary plan. 2. Use of blood pressure monitoring device. 3. Diaphragmatic breathing exercises. 4. Brisk walking for 30 minutes 3-4 times/week. 5. Reduce sodium intake to less than 2700 mg/day.

1., 2., 3., & 4. Correct: The DASH Eating Plan is recommended for clients who have hypertension. It is high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, beans, and nuts and is low in sweets, sugar-sweetened beverages, and red meats. Home blood pressure monitoring can help the client keep closer tabs on their blood pressure, show if medication is working, and even alert the client and primary healthcare provider to potential complications. However, home blood pressure monitoring isn't a substitute for follow-up visits. Reducing stress as much as possible helps to decrease blood pressure. Healthy coping techniques, such as muscle relaxation, deep breathing or meditation are good options. Getting regular physical activity and plenty of sleep can help, too. Regular physical activity can lower blood pressure, manage stress, reduce the risk of several health problems and keep weight under control. 5. Incorrect: A limit of 1500 mg of sodium per day is preferred on the low sodium DASH diet. On the standard DASH diet 2,300 mg of sodium are allowed each day.

A client is scheduled to have a Cardiac Positron Emission Tomography (PET). What pre-procedure information should the nurse provide to the client? Select all that apply 1. Avoid caffeinated food and drinks for 24 hours prior to test. 2. Do not eat for 4 to 6 hours before the test. 3. Do not wear jewelry. 4. Take calcium channel blocker prescription the day of the test. 5. Wear comfortable, loose-fitting clothing.

1., 2., 3., & 5 Correct: The client should avoid products containing caffeine for 24 hours prior to the stress test. Caffeine increases the heart rate and can affect the results of the test. Don't eat or drink anything except water for 4 hours before the test. The fullness from a meal makes it difficult to perform the stress test. Any jewelry or metal will show up on the scan and cause a false result. The client should dress in loose, comfortable clothing the day of the test because the stress test consists of intense exercise. 4. Incorrect: Clients are asked to hold beta-blockers, calcium channel blockers, and nitroglycerin medicines prior to a stress test. These medications either increase or slow down the heart rate, which can affect the test.

Which assessment findings would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? Select all that apply 1. Ecchymosis 2. Bleeding gums 3. Palpable spleen 4. Pain 5. Petechiae

1., 2., 3., & 5. Correct: The word thrombocytopenia means low platelets. Any client with low platelets is at risk for bleeding, which is indicated by ecchymosis (bruising), bleeding gums, and petechiae (red to purple dots on the skin, 1-3 mm in size). Spleen and liver are often slightly palpable. 4. Incorrect: Pain is not associated with ITP unless there are other associated problems. However, the stem of the question gave no indication that other problems exist.

A client is to be discharged following a left modified-radical mastectomy. When reviewing ADL's to be completed at home, the nurse anticipates the client will experience the most difficulty doing what tasks? Select all that apply 1. Cooking a meal. 2. Shampooing hair. 3. Doing the laundry. 4. Vacuuming carpets. 5. Changing bed linens.

2, 3, & 5. CORRECT: The modified-radical mastectomy is a surgical approach to cancer in which the breast tissue, nipple, and axillary lymph nodes are removed but the chest muscles remain intact. Following surgery, individuals usually experience pain and stiffness when resuming normal daily activities, particularly tasks which require stretching the arm above the head. Shampooing or drying hair would be challenging, as would moving loads of heavy laundry between washer and dryer. Also difficult is changing bed sheets because it involves lifting and stretching across the bed. 1. INCORRECT: The process of cooking food can be modified in such a way the client would not need to extend the surgical arm above the head or in a painful position. 4. INCORRECT: Vacuuming carpet does not require lifting or reaching if the client uses an upright sweeper. This task should not present difficult challenges and can be completed with the non-surgical arm.

Following a motor vehicle accident, a client is brought to the emergency room with shallow, labored respirations. The client is intubated and placed on a ventilator. What is the nurse's priority action immediately after the intubation? 1. Suction to clear all secretions 2. Listen for bilateral breath sounds 3. Secure the endotracheal tube 4. Obtain x-ray to verify tube placement

2. Correct: All actions are important but assessment is the nurse's immediate priority. Clear and equal bilateral breath sounds along with equal chest wall movement would confirm that the endotracheal tube has been correctly inserted into trachea. 1. Incorrect: Although suctioning after intubation is an appropriate action, the nursing process requires assessment first. Clearing secretions will be more effective if the endotracheal tube is actually in the correct location in the lungs. 3. Incorrect: Prior to securing the endo tube to the client's mouth/face, it is more important to verify that tube is in the correct location within the lungs. If the tube is not placed properly, the client will not be adequately ventilator, and the tape would have to be removed for reinsertion. 4. Incorrect: Follow up chest x-rays are needed to verify that the endotracheal tube has been properly placed in the lungs. However, this action is not an immediate priority for the nurse. Assessment is the nursing priority.

The nurse has just received a client from the special procedures lab for a liver biopsy. What is the position of choice for this client post procedure? 1. Fowler's 2. Right side 3. Left side 4. Prone

2. Correct: How do you stop bleeding from a puncture site? With pressure, right? Yes. So where is the liver? In the right upper abdomen under the rib cage. So position the client on the right side so that pressure is applied to the liver's puncture site. Then apply pressure with a sand bag or rolled up towel. This will help to stop bleeding. 1. Incorrect: This will not help control the bleeding. Pressure needs to be applied to the liver, so we want the liver coming forward toward the abdominal wall and pressure to be applied with a sand bag or rolled up towel. 3. Incorrect: The liver is on the right, not the left. Without the liver next to the abdominal wall, pressure cannot be exerted on the liver's puncture site. 4. Incorrect: We don't turn clients onto abdomen. You will not be able to assess for bleeding with the client in this position.

The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching? 1. I'll have to take a strong laxative the morning of the test. 2. I'll have to drink contrast while x-rays are taken. 3. I'll have a CT scan after I'm injected with a radiopaque contrast dye. 4. I'll have an instrument passed through my mouth to my stomach.

2. Correct: In an upper GI series (sometimes called a barium swallow test), the client swallows barium contrast while x-rays are taken. 1. Incorrect: Laxatives are taken the night before a colonoscopy to ensure stool is cleared from the colon. Waiting to take the laxative the morning of the test would be ineffective and uncomfortable for the client. 3. Incorrect: Radiopaque dye injected before a CT (computed tomography) scan is not part of a GI series. This would be a totally different diagnostic test from the upper GI. 4. Incorrect: In a gastroscopy (sometimes called a gastric endoscopy), a scope is passed through the mouth to the stomach to visualize the inner lining of the upper GI tract.

The nurse's assessment of a client post-op abdominoplasty reveals tachycardia, restlessness and shallow slow breaths. The client was medicated with morphine 2 mg IVP one hour ago. The primary healthcare provider prescribes arterial blood gases (ABG). Which ABG report is consistent with this clinical picture? 1. pH 7.30, PaCO2 40, HCO3 29 2. pH 7.33, PaCO2 48, HCO3 25 3. pH 7.47, PaCO2 35, HCO3 29 4. pH 7.50, PaCO2 33, HCO3 22

2. Correct: You may only know abdomino-abdomen. That's ok. Plasty; well some kind of plastic surgery on the abdomen. Focus on what you do know, look at the scenario. See the hints, abdominal surgery, restless, shallow breaths, requested pain med.... We already know that we SHOULD be watching for respiratory acidosis so what lab values are consistent with this imbalance. Low pH, high CO2. 1. Incorrect: The pH is acidosis, but it is not respiratory acidosis the pC02 is normal. 3. Incorrect: This client is in metabolic alkalosis. 4. Incorrect: This client is in respiratory alkalosis.

A pregnant client's initial blood work shows a negative rubella titer. The nurse is aware this result indicates what important course of action? 1. Client needs to be isolated until delivery. 2. Client is immune to rubella currently. 3. Client should be given rubella vaccine after delivery. 4. Client has never been exposed to rubella.

3. CORRECT: A negative titer indicates the client has no rubella antibodies present currently. But because the rubella vaccine contains a live virus, the client cannot be safely vaccinated until after delivery. 1. INCORRECT: Although the client may be cautioned about being around groups of children until after delivery, there is no need for total isolation for the duration of the pregnancy. 2. INCORRECT: If the client were immune to rubella, the titer would have been positive, indicating the presence of rubella antibodies. This client is not immune currently. 4. INCORRECT: Whether the client has ever been exposed to rubella cannot be determined from the information presented in this question.

Following surgery, a client has an indwelling urinary catheter attached to a collection bag. The nurse empties the collection bag at 0900. At the change of shift at 1500, the collection bag contains 100 mL of urine. The system has no obstructions to urinary flow. What would be the nurse's most appropriate initial response? 1. Elevate the head of the client's bed. 2. Start giving the client 8 ounces of oral fluid per hour. 3. Check circulation and take the vital signs of the client. 4. Continue monitoring, because this is an expected finding.

3. Correct: A urine output (U/O) of 100 mL over a 6 hour period is dangerously low. This client could be experiencing hypovolemic shock. In clients who are "shocky", the kidneys stop making urine to try to hold on to what little volume the body has left. The nurse is checking the vital signs for low BP and increased HR, indicators of hypovolemic shock. Also, when the urine output is this low, the client is at risk for renal failure. 1. Incorrect: Elevating the head of the client's bed is a good choice when the client is having difficulty breathing, but not here. Raising the HOB will cause the BP to drop lower. Clients in shock should be supine. 2. Incorrect: Normally, pushing fluids is a good choice if the urine output were low. 100 mL over six hours requires more aggressive treatment to combat shock. 4. Incorrect: This is not an expected finding. Urine output less than 240 mL in an eight hour time frame should alert the nurse to a serious problem such as shock.

A concerned mother is asking the nurse about activities that would be best for her child who has been diagnosed with asthma. In order to minimize the risk of exercise induced asthma, which activity would be best for the nurse to suggest? 1. Track 2. Basketball 3. Baseball 4. Soccer

3. Correct: Baseball is an activity that is considered "asthma friendly". It requires short, intermittent periods of exertion and is therefore tolerated better by children with asthma. 1. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. 2. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. 4. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma.

When planning post procedure care for a client who is having a barium enema, what must the nurse include? 1. Cardiac monitoring for potential arrhythmias 2. Monitoring urinary output 3. Administration of a laxative or enema after the procedure 4. Reordering the client's diet

3. Correct: The client must expel the barium post procedure. If the barium is not eliminated, it can harden in the colon and cause an obstruction. 1. Incorrect: It is not standard practice to place clients on a cardiac monitor after a barium enema. 2. Incorrect: Monitoring urine output has nothing to do with this procedure and does not answer the specific question related to this diagnostic procedure. 4. Incorrect: Reordering the client's diet is important but is not as life-threatening as a bowel obstruction.

The nurse is reviewing morning laboratory results on four clients. Which lab finding should the nurse report to the primary healthcare provider immediately? Exhibit Client Lab Values: Client diagnosed with deep vein thrombosis who is receiving a heparin infusion - aPTT 85 sec. Client diagnosed with possible appendicitis - WBC 18,000 per mm3 Client diagnosed with rheumatoid arthritis - Sed rate 100 mm/hr Client diagnosed with congestive heart failure receiving furosemide - K + 2.9 mEq/L 1. aPTT 2. WBC 3. Sed rate 4. K+

4. CORRECT: Notice that all laboratory results are abnormal, based on the disease process of each client. However, the potassium level for the cardiac client is way below normal, most likely secondary to the furosemide. Levels that low can result in premature ventricular contractions (PVCs) or other arrhythmias, placing the client at risk for sudden onset of CHF. 1. INCORRECT: The client is on the heparin infusion for a diagnosed deep vein thrombosis (DVT). While normal aPTT levels should be between 20 - 36 seconds, the therapeutic levels of heparin are usually 2 ½ to 3 times normal to keep the blood thin. This result is expected and not alarming at this point. 2. INCORRECT: Appendicitis is a serious infection that is treated with either antibiotics or surgery to remove the organ. While normal WBC values are 5,000 to 10,000, this elevated result is not unexpected for an infection. 3. INCORRECT: A Sed rate or sedimentation rate, reveals inflammatory activity in the body and can be used to diagnose or monitor the status of an inflammatory disease process. The blood cells affected (erythrocytes) will settle to the bottom of a blood tube and that speed indicates the severity of the inflammatory process in the body. This is not an unexpected result in clients with rheumatoid arthritis.

The parents of a child hospitalized with cystic fibrosis have been given discharge instructions. The nurse knows that teaching has been successful when the parents make what statement? 1. "Our child will need to have a gluten free diet." 2. "The enzymes should be given at bedtime daily." 3. "Salt needs to be decreased in our child's diet." 4. "We need to prepare high calorie, high fat meals."

4. Correct: Cystic fibrosis is an inherited disorder in which abnormally viscous secretions affect the respiratory and digestive systems. Because the client is unable to absorb nutrients, several dietary adaptations are crucial, including frequent small meals along with digestive enzymes to help the client process food. The meals should be high calorie, high fat with increased amounts of sodium to help stabilize fluids. 1. Incorrect: A gluten free diet is not associated with cystic fibrosis. This special diet is generally required for clients with Celiac disease and certain food allergies, although clients with either of these diseases will need the addition of fat soluble vitamins A, D, E and K. This statement by the parents indicates the need for further teaching. 2. Incorrect: Pancreatic digestive enzymes, such as Creon or Pancreaze, must be given with every meal or snack in order to help the digestive system absorb nutrients properly. Because clients with cystic fibrosis need frequent small meals throughout the day, digestive enzymes must also be provided throughout the day with any food. 3. Incorrect: Clients with cystic fibrosis lose abnormally large amounts of salt in sweat, and the glands are unable to reabsorb needed sodium into the body system. Rapid dehydration is common due to decreased sodium levels, which are exacerbated during exercise or hot weather. These clients are encouraged to increase salt intake.

A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is receiving a continuous bladder irrigation of normal saline infusing at 1000 mL/hr. The client's urine output for the past two hours is 410 mL. What is the nurse's first action? 1. Inspect the catheter tubing for obstruction. 2. Irrigate the catheter with a large piston syringe. 3. Notify the primary healthcare provider. 4. Stop the irrigation flow.

4. Correct: The catheter output should be at least the volume of irrigation input plus the client's actual urine. A severe decrease in output indicates obstruction in the drainage system. The first action is to stop the irrigation flow to prevent further bladder distention. Bladder distention is one of the main causes of hemorrhage in the fresh post op period. 1. Incorrect: The next action is to check the external system for kinks or obstruction to assess if this is the cause of the decreased urine output. Obstruction of the catheter tubing can also cause bladder distention. 2. Incorrect: After the external system is checked for kinks or obstruction, and the client's urine output doesn't change, then the catheter is irrigated with 30 to 50 mL of normal saline using a large piston syringe. However, irrigating a new post-op client is not the safest or first action for the nurse. 3. Incorrect: Of the options listed here, this is the last intervention. If the obstruction is not resolved after irrigating the system, the primary healthcare provider must be notified.

A client arrives by ambulance after being thrown from a horse. The client is pale, clammy and tachycardic with bruising over left upper abdominal quadrant. The nurse is aware what prescription by the primary healthcare provider takes priority? 1. Obtain blood for type and crossmatch. 2. Administer hydromorphone IV for pain. 3. Increase Lactated Ringers to 150 mL/hour. 4. Send client to radiology for stat CAT scan.

1. CORRECT: The signs and symptoms displayed by the client suggest a ruptured spleen and shock. The greatest concern in this situation is internal bleeding and possible emergency surgery. The client will need blood; therefore, the nurse should immediately obtain blood for type and crossmatch. 2. INCORRECT: There is no indication in the scenario the client has pain. Pain medication should never be administered while the client is still being assessed or is in shock. 3. INCORRECT: Fluids are crucial for clients in shock and increasing the Lactated Ringers to 150 mL/hr. is important to help maintain blood pressure. However, this is not the nurse's priority action. 4. INCORRECT: A CAT scan is often prescribed prior to surgery to verify the extent of splenic injury and the amount of blood in the abdominal cavity. Though the order is written as 'stat', this is not the nurse's priority. Transporting an unstable client to another department requires preparation.

Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm.

1. Correct: This client has developed signs of cardiogenic shock, one of the complications post CABG. Cardiac output is decreased, so the client needs more oxygen for the circulating blood volume. 2. Incorrect: Lowering the HOB will not help in cardiogenic shock but will actually make it harder for the heart to pump. 3. Incorrect: Poor kidney perfusion is the reason for the decreased UOP. The kidneys are trying to conserve what little volume the body has to maintain vital organ perfusion as long as possible. 4. Incorrect: Rechecking the BP will not help the problem. With the other symptoms, this BP is most likely accurate. This would only delay treatment and would not fix the problem.

A client is admitted to the LDR from the emergency department at 34 weeks gestation with profuse, painless, bright red vaginal bleeding. The priority action by the nurse is to prepare for which procedure? 1. Sterile vaginal exam 2. Ultrasound exam 3. Amniocentesis 4. Contraction stress test

2. Correct: Painless, bright red vaginal bleeding is a sign of a placenta previa. Ultrasound can confirm this diagnosis with minimal risk to the mother and her fetus. This is the safest action for this client and best for fixing the problem. 1. Incorrect: If the placenta is over the cervix, a finger can go right through the placenta and cause hemorrhage and fetal death so vaginal exams would be absolutely contraindicated. 3. Incorrect: Amniocentesis is done for genetic analysis or to determine fetal lung maturity when delivery is likely. It is preferable to delay delivery until the fetus is term. It would not be safe to puncture the abdomen of a client that is already hemorrhaging. 4. Incorrect: Contractions can cause further detachment of the placenta from the cervix, which would also cause hemorrhage.

A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? Exhibit Lab Values: Na+ 147 mEq/L (147 mmol/L) Specific Gravity 1.030 Hct 55% 1. Provide foods high in iron 2. Increase fluid intake 3. Obtain a urine for culture 4. Measure intake and output

2. Correct: We already know that the question is about what life threatening complication? A pulmonary embolism. And these lab values say that the client is what? Dehydrated! So the only thing that is going to fix that is....... Increasing fluids. 1. Incorrect: This will not prevent pulmonary embolism. The problem is dehydration. Do something to fix the problem. Foods high in iron will not fix the problem. 3. Incorrect: This will not prevent pulmonary embolism. How will obtaining a urine sample for culture fix dehydration? It won't. This client needs to increase fluid intake. 4. Incorrect: We do want to monitor intake and output to see how the client is doing, however, this will not fix the problem. Hydrating the client will help the problem.

A client has just had a bone marrow biopsy. What is the nurse's priority intervention post procedure? 1. Apply ice pack to needle site. 2. Hold pressure on needle site for at least 5 minutes. 3. Observe needle insertion site every 2 hours. 4. Advise client to avoid activities that may result in trauma to the site for 48 hours.

2. Correct: When you see the word priority, you need to think: "What is the MOST important thing I can do for my client?" If you can only pick one answer, pick the life threatening answer or the answer that will decrease the risk for harm to the client. Here, that answer is hold pressure on the site to prevent bleeding. 1. Incorrect: There is nothing wrong with applying ice to decrease swelling, however, it is not the priority. Bleeding takes priority over swelling. 3. Incorrect: Yes, you want to monitor the client's needle insertion site at least every 2 hours, but you better make sure the bleeding stops immediately after the procedure first. 4. Incorrect: Nurses must teach about potential complications and ways to avoid them, but that is not the priority here.

What should the nurse teach the client following a right knee arthroscopy? Select all that apply 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.

2., 3., 4. & 5. Correct: Elevating the joint for several days will reduce swelling and pain. Tingling to the extremity could mean nerves have been damaged. Exercise is gradually started to strengthen muscles surrounding the joint and prevent scarring of surrounding soft tissues. The client needs to keep the site as clean and dry as possible. 1. Incorrect: Continuous ice can cause tissue damage.

The nurse is planning care for the prevention of skin breakdown in a client diagnosed with a stroke. What intervention is important for the nurse to include? Select all that apply 1. Massage reddened skin areas located over bony prominences. 2. Place pillows under lower extremities to raise heels off the bed. 3. Position client on paralyzed side for one hour. 4. Apply emollients to dry skin. 5. Place a gel seat cushion on the wheelchair seat. 6. Shift client weight every two hours while sitting in a wheelchair.

2., 4., & 5. Correct: These interventions will decrease the risk of skin breakdown by eliminating sustained pressure to areas at greatest risk of breakdown. 1. Incorrect: Do not massage the damaged area because this may cause additional damage. 3. Incorrect: This is way too long. The client should only be on their paralyzed side for 30 minutes. 6. Incorrect: This is way too long. Skin breakdown can result within this period of time. The client's weight should be shifted within the wheelchair every 15-20 minutes.

A client arrives at the emergency room with active gastrointestinal bleeding. What is the most important nursing action? 1. Treat the cause of the bleeding. 2. Record the amount of blood loss. 3. Initiate an intravenous access line. 4. Prepare client for stat endoscopy.

3. CORRECT: The client has active gastrointestinal bleeding, which can quickly lead to hypovolemic shock. Active bleeding would be treated with fluids, and in certain cases, blood products. Establishing an IV site allows for immediate initiation of treatment before veins vasoconstrict and become too difficult to access secondary to shock. 1. INCORRECT: While it is crucial to find and treat the cause of the bleeding, diagnosing is the responsibility of the primary healthcare provider. Because this client is experiencing internal bleeding, further tests may be needed to determine the source of the hemorrhage. 2. INCORRECT: Gastrointestinal bleeding is very difficult to measure since there is no effective way to collect the fluid. The primary healthcare provider could order a hemoglobin and hematocrit but that does not precisely measure the actual amount of blood loss. 4. INCORRECT: An endoscopy is an internal examination of a portion of the gastric system. However, proper preparation requires the client to be NPO for hours in order to properly visualize that system. This is not the most important nursing action.

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms

3. Correct: The irrigation is regulated so that the urine is free of clots and slightly pink tinged. When it becomes clear after surgery, the fluid is going too fast and not clearing any blood clots effectively. 1. Incorrect: The irrigation should be increased if you see clots in order to keep the catheter patent. 2. Incorrect: Bladder pressure may mean that the indwelling urinary catheter is obstructed. Either increase flow or manually irrigate catheter to ensure patency and no retention of fluid in the bladder. 4. Incorrect: Bladder spasms occur with clots so you do not want to slow the irrigation if this happens. This would indicate the need for increasing the irrigation fluid rate.

While preparing an IV in the med room, you observe a new nurse drawing up a dose of insulin in a tuberculin syringe. What is your priority action? 1. Report the incident immediately to the charge nurse. 2. Tell new nurse you will prepare and give the insulin dose. 3. Discuss procedure to prepare insulin with the new nurse. 4. Draw up insulin but let new nurse administer the injection.

3. Correct: This situation is dangerous since the new nurse obviously does not know the proper process or even the correct syringe with which to draw up insulin. This lack of knowledge could lead to serious or even fatal consequences for a client. It is vital the new nurse be properly instructed and then supervised on how to prepare insulin. Additional measures to ensure client safety can then be pursued. 1. Incorrect: Client safety is always priority, and therefore the new nurse must be stopped immediately before going any further with this procedure. Informing the charge nurse of the situation can wait until steps to ensure client safety are completed. 2. Incorrect: Completing the task personally may keep this client safe at the moment; however, it does not ensure the error will not be repeated with another client. 4. Incorrect: Completing part of insulin administration process for the new nurse does not guarantee the error will not be repeated. In fact, there is no way to be sure the new nurse understands the specifics of injections either. This individual needs to be instructed, supervised and evaluated on all parts of the insulin administration process, including injections. There may be more errors in the process that need addressed.

The nurse is discharging a client post right radial percutaneous transluminal coronary angioplasty (PTCA) with stent insertion. Which instructions should the nurse give the client to reduce the risk of complications? Select all that apply 1. Do not use the wrist to lift more than 5 pounds (2.27 kg) for 24 hours. 2. Stop taking aspirin in one week. 3. Drink at least 8 glasses of water a day. 4. Wear loose fitting sleeves. 5. Do not shower or soak in a tub for one week. 6. Take short walks around your house.

3., 4., & 6. Correct: Drink eight to ten glasses of water to flush the contrast material from the client's system. The client should wear loose sleeves. We do not want any constriction to the surgical site. In general, the client will need to take it easy for the first two days after getting home. The client can expect to feel tired and weak the day after the procedure, but it is important to take walks around the house. This will help prevent blood clots. 1. Incorrect: The client should limit the use of the wrist. It is important to allow the artery to heal. So, no straining of the wrist. Do not use the wrist used in the procedure to lift more than 2 pounds (0.9 kg) for 24 hours. 2. Incorrect: Clients are maintained on aspirin indefinitely after percutaneous coronary intervention to prevent future thrombotic events. 5. Incorrect: The client can shower after the pressure dressing is removed (usually the day after surgery). The client should keep the area clean and dry when not showering.

A client returns from post anesthesia care unit (PACU) following a mastectomy with a Jackson-Pratt drain in place. What action by the nurse is important? 1. Empty drain every eight hours. 2. Irrigate drain with NS every shift. 3. Drape tubing above breast incision. 4. Empty and compress bulb when 2/3 full.

4. CORRECT: A Jackson-Pratt drain is not connected to wall suction, but instead uses gravity and compression to create suction. For maximum efficiency, the bulb must be emptied at only 2/3 capacity. If the bulb becomes filled, suction fails, and fluid will build up in the tissues, possibly leading to wound dehiscence. 1. INCORRECT: The purpose of a surgical drain is to prevent the buildup of fluid under the incision, thus decreasing the chance of dehiscence. Emptying the drain is based on the amount of fluid in the bulb, not timed by shift. 2. INCORRECT: A drainage device connected to the body is meant to pull liquid from inside the body, and therefore is never irrigated. Doing so would increase the chance of infection, even if using sterile normal saline. Pushing fluid into a drain could damage the incision, or even lead to dehiscence. 3. INCORRECT: Any drain or tubing inserted into the body should always be draped below that area or system of the body to improve gravity drainage. The tubing of the Jackson-Pratt drain must hang below the level of the incision.

A client with a history of angina has returned to the unit following a cardiac catheterization. What nursing action has the highest priority? 1. Obtain vital signs every thirty minutes. 2. Assess pedal pulses every ten minutes. 3. Place the call bell within client's reach. 4. Keep affected extremity immobilized for 6 hours.

4. CORRECT: The greatest risk following a cardiac catheterization is the potential for hemorrhage, most often from the insertion site. Therefore, the affected extremity must remain straight and immobilized for 4-6 hours after the procedure. 1. INCORRECT: The frequency of vital signs is determined by facility protocol, but generally vital signs are obtained every ten minutes for the first half hour, then every fifteen minutes for another half hour. While vital signs provide valuable information to compare to baseline, another action is more important. 2. INCORRECT: It is vital to assess pedal pulses in order to verify circulation following a catherization. The frequency is based on facility protocol. However, this action is not the highest priority. 3. INCORRECT: Because the client is on bed rest, it is crucial for the client to be able to summon staff when needed. Despite the importance of this action, there is an even more important action.

A client is admitted to the unit from the ED department. What acid base imbalance do the lab values indicate to the nurse? Exhibit ABGs: pH 7.48 PaCO2 38 HCO3 30 1. Metabolic alkalosis 2. Compensated metabolic alkalosis 3. Respiratory alkalosis 4. Compensated respiratory alkalosis

1. Correct: The pH is 7.48 which is alkalosis. PaCO2 is 38, which is normal.​HCO3 is 30, which is high (alkaline). The problem is a metabolic problem, making this Metabolic Alkalosis. 2. Incorrect: The pH is 7.48 which is alkalosis. PaCO2 is 38, which is normal. HCO3 is 30, which is high (alkaline). The problem is a metabolic problem, making this Metabolic Alkalosis. 3. Incorrect: The pH is 7.48 which is alkalosis. PaCO2 is 38, which is normal. HCO3 is 30, which is high (alkaline). The problem is a metabolic problem, making this Metabolic Alkalosis. 4. Incorrect: The pH is 7.48 which is alkalosis. PaCO2 is 38, which is normal. HCO3 is 30, which is high (alkaline). The problem is a metabolic problem, making this Metabolic Alkalosis.

A client with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria and hematuria. The primary healthcare provider prescribes corticosteroids. During the acute phase of the client's illness, what is most important for the nurse to do? 1. Monitor intake and output and daily weight. 2. Allow for frequent, uninterrupted rest periods. 3. Institute seizure precautions. 4. Protect client from injury that may cause bleeding.

1. Correct: Look at the clues in the stem. Proteinuria and hematuria. When you see proteinuria what do you need to worry about? The kidneys! Protein is a great big molecule. The only way for protein to be seen in the urine is if there are holes in the glomerulus. So the kidneys are being damaged. Thus, the nurse knows that the biggest problem to "worry" about here is renal failure. The best methods for monitoring fluid status and renal status for a client are to monitor I and O and daily weights. (Also, remember that one weight doesn't mean anything. The hematuria indicates that there has already been glomerular damage). 2. Incorrect: Systemic lupus erythematosus (SLE) is an autoimmune disease. In this disease, the body's immune system mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs. Fatigue is a major symptom so allowing for frequent, uninterrupted rest periods is important for this client but monitoring for renal failure is more acute. 3. Incorrect: Seizures are a potential problem with SLE, but the ACTUAL problem depicted in the stem of the question, renal failure, takes priority. Look for the option that relates to the renal system. 4. Incorrect: Hemolytic problems can occur with SLE, but this is not the ACTUAL problem depicted in the stem of the question. The stem is indicating a renal problem, so look for a renal answer.

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which finding would indicate the need to increase the irrigation rate? 1. Clots in urine 2. Unable to palpate bladder 3. Slightly pink tinged urine 4. No report of bladder spasms

1. Correct: The irrigation should be increased if you see clots in order to keep the catheter patent. 2. Incorrect: If you are unable to palpate the bladder, then it is not distended. That is good. Bladder pressure would mean that the indwelling urinary catheter is obstructed. Then you would either increase flow or manually irrigate catheter to ensure patency and no retention of fluid in the bladder. 3. Incorrect: The irrigation is regulated so that the urine is free of clots and slightly pink tinged. This is an indication that the irrigation rate is appropriate. 4. Incorrect: Absence of bladder spasms means there are no clots occluding the catheter.

The nurse is discharging the client after removing sutures from an abdominal wound. Which instructions should the nurse give the client at the time of discharge to reduce the risk of complications? 1. inspect the wound daily for any changes 2. Resume normal activities when you go home. 3. Keep the incision covered at all times. 4. Follow up with primary healthcare provider when scheduled.

1. Correct: The wound should be inspected daily for any signs of infection once the client goes home. Healing has only just begun by discharge. Signs of wound infection include: Increased pain, swelling, redness, or warmth around the affected area; Red streaks extending from the affected area; Drainage of pus from the area; Fever. 2. Incorrect: The client may be restricted in some activities, such as lifting, that would place undue strain on the suture line. 3. Incorrect: It is likely that the incision can be uncovered, but the primary healthcare provider prescription would apply here. Look for words like "all" which generally make the option wrong. Things are not that definite. 4. Incorrect: This is true; however, the signs and symptoms of infection should be given to the client. If signs/symptoms develop, the primary healthcare provider should be notified prior to the next appointment.

Which nursing intervention should the nurse implement when administering a medication through a nasogastric (NG) tube? 1. Place the client in a high-Fowler's position for medication administration. 2. Flush the tubing between administering medications 3. Turn the client onto their left side after medication administration. 4. Mix the medication directly into the tube feeding

2. Correct: The NG tube should be flushed with appropriate facility approved amount of fluid between medications. The amount of the flushing solution should be added to the intake amount. 1. Incorrect: Semi-Fowler's position is the position of choice for administering tube feedings. This position helps prevent aspiration and promotes digestion. The volume of fluid administered with medication administration is usually much smaller than with tube feedings, so high-Fowler's is not required. 3. Incorrect: The left side position slows gastric emptying, which could lead to aspiration. The right side is the position that best promotes gastric emptying. 4. Incorrect: Do not mix medications in the enteral feeding solution. The tube feeding rate may be prescribed at different rates or the tube feeding can be held for a designated time. The proper administration of the medication could not be determined.

After a thoracotomy, which interventions will the nurse initiate to reduce the risk of acute respiratory distress? Select all that apply 1. Allow 4 hours of rest between deep breathing and coughing exercises. 2. Splint the incision during deep breathing and coughing exercises. 3. Have the client drink a glass of water before coughing. 4. Perform percussion and vibration every 2 hours. 5. Promote incentive spirometer use several times per hour while awake.

2., & 5. Correct: Splinting helps with the ability to control pain and produce an effective cough. Incentive spirometry encourages deep inspiratory efforts, which are more effective in re-expanding alveoli than forceful expiratory efforts. 1. Incorrect: They need to cough more often than every 4 hours. It is the best when this is done every 2 hours. 3. Incorrect: It takes longer than a few minutes to liquefy secretions and, if the stomach is full, vomiting may occur which would put the client at risk for aspiration. 4. Incorrect: After the surgery, we do not want to percuss and vibrate the incision. Besides being extremely painful, this could potentially disrupt the suture line.

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the parents, what information is most important for the nurse to include? 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water the day. 4. Apply heating pad to bruised areas of the skin.

2. Correct:The greatest risk to clients following a transplant is the chance of infection from any source since the client is severely immunocompromised for an extended period of time. There are numerous precautions necessary to avoid bacteria, but one area of concern is food storage, preparation, and consumption. Raw fruits with no skin to peel, such as strawberries, and raw vegetables like broccoli and cauliflower, present a serious risk for bacterial contamination and should not be consumed by new transplant clients. 1. Incorrect: Precise mouth care is vital following a bone marrow transplant; however, rinsing a toothbrush in alcohol is unsafe. Any residual alcohol would cause irritation and trauma to gum tissue, placing the client at risk for mouth inflammation and infection. Clients are instructed to brush teeth twice daily with a soft bristle brush, using a fluoride toothpaste. Some clients are instructed to soak the toothbrush once weekly in a special bleach solution, then rinse in hot water, while others need to replace the toothbrush weekly, based on lab test results. 3. Incorrect: Standing water of any type quickly builds up bacteria, including flower vases and vaporizers. Although bottled water may seem a safe choice, after that bottle is opened, bacteria begins to quickly build up, even if the bottle is recapped. Any water standing more than 15 minutes is considered old and must be thrown out. 4. Incorrect: With bone marrow transplant clients, it will be months before the body begins to stabilize and produce normal blood cells. Bruising and low platelet counts are to be expected for a period of time. When clients develop bruising, the approved treatment is cold compresses or ice packs applied for 15 minutes a couple times per day, and never a heating pad. Additionally, the healthcare provider should be notified so that a current platelet count can be obtained.

Which signs/symptoms should the nurse assess for when caring for a client diagnosed with bulimia nervosa? Select all that apply 1. Increased thirst 2. Muscle cramps 3. Blurred vision 4. Tingling of lips 5. Constipation

2., 4., 5. Correct: The typical abnormalities associated with bulimia are hypokalemia and metabolic alkalosis because of the binging and purging process. This leads to muscle cramps, weakness, fatigue, constipation, and arrhythmias are all symptoms of this electrolyte and acid-base imbalance. Hypokalemia leads to metabolic alkalosis. 1. Incorrect: Increased thirst is a sign of hyperglycemia and would not be the concern with someone that is purging. This client would be more likely to be hypoglycemic instead. 3. Incorrect: Blurred vision is a sign of hyperglycemia because of the effect of too much glucose in the small vessels of the eye. Microvascular damage is one of the biggest concerns with hyperglycemia; the bulimic client would be hypoglycemic.

A nurse is caring for a client on the second day after a thoracotomy. The client reports incisional pain. The nurse assesses the client and evaluates the vital signs. Based on the data documented in the chart, what action should the nurse take first? Exhibit Nursing Notes: Client reports incisional pain as 8/10. WOund is clean and dry, without redness, edema, or drainage. Shallow respirations noted at 24/min. Adventitious lung sounds noted in bilateral bases. Vital Signs: Oral temperature 100º F/37.8ºC Heart rate 92/min and regular BP 130/80 Respirations 24/min 1. Have client cough and deep breathe. 2. Administer acetaminophen for fever 3. Administer the prescribed analgesic 4. Assist the client to ambulate.

3. Correct: The client described in this question is post thoracotomy. With ANY post-op client, the number one concern, especially as a brand new nurse, is preventing pneumonia. A thoracotomy is very painful and the client is unlikely to breathe deep unless the pain is relieved. Temperature of 100º F/37.8ºC, HR 92, respirations 24, bilateral crackles (indicating atelectasis) all reveal this client is heading for pneumonia. 1. Incorrect: Coughing and deep breathing exercises are exactly what the client needs, but the client will not cough and deep breathe if it hurts. Give pain medication first. 2. Incorrect: Acetaminophen is not potent enough to relieve pain. The goal is to "fix the problem". The problem is that the client is not properly deep breathing due to pain. 4. Incorrect: Assisting the client to ambulate is a good idea, but the nurse has to fix the problem, and the problem is that the client is not deep breathing.

Which immediate action should a nurse take if a client's chest tube is accidentally disconnected from the disposable water-seal system? 1. Have client hold breath 2. Administer oxygen 3. Place the tubing coming from the client into sterile water 4. Raise the head of the bed

3. Correct: The nurse should immediately place the tubing coming from the client into at least 2 cm of sterile water. A disconnected chest tube can allow air to travel into the client's chest cavity and create a life-threatening tension pneumothorax. By putting the end of the disconnected tube into sterile water, a water seal is recreated that will prevent air from entering but will still allow air to escape. 1. Incorrect: For how long? No, a water seal needs to be created. 2. Incorrect: Oxygen is not always the first thing the nurse should do. Re-establish the water seal. 4. Incorrect: Elevating the HOB will not fix the problem. Re-establish the water seal.

A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent skin breakdown.

3. Correct: The postoperative client with a total hip replacement is at risk for thromboembolism and fat emboli which can travel to the lungs and cause respiratory distress. Without proper turning, coughing, and deep breathing, pneumonia and atelectasis may occur. So preventing respiratory complications is high on the priority list. Remember the ABCs - airway, breathing, then circulation. Preventing respiratory complications is the highest priority because of the possibility of sudden death from the complications of deep vein thrombosis and pulmonary embolism. 1. Incorrect: This client is at risk for hemorrhage and/or hematoma formation related to surgical trauma to blood vessels (the hip is a very vascular area) and use of anticoagulants or antiplatelet agents before and after surgery. So the nurse will need to monitor for shock caused by loss of volume. The nurse should monitor drains, wound dressings, and intake and output. But remember, Airway and Breathing take priority. 2. Incorrect: Dislocation of the prosthesis is another complication to worry about. It will cause pain and possible deformity and is very important, but airway is the priority. Dislocation of the hip prosthesis is related to weakness of the hip muscles, improper positioning or movement of the operative extremity, and/or noncompliance with weight-bearing limitations. 4. Incorrect: The client is at risk for skin breakdown if not turned and repositioned properly or ambulated as soon as prescribed. However, Airway is still the priority for this client.

Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what action takes priority? 1. Remove any exudate around eyes with warm water. 2. Instill exact number of drops into lower conjunctival sac. 3. Instruct client to look upward when drops are instilled. 4. Avoid dropping the medication directly on the cornea.

4. CORRECT: The most important safety consideration when instilling eye drops is to avoid dropping the medication directly onto the cornea. The extreme sensitivity of the cornea before, and after, eye surgery could cause serious eye problems if meds were dropped onto the cornea. 1. INCORRECT: It is important to clean away any exudate prior to instilling eye drops to maintain aseptic technique and decrease chance of infection. Though this is an important action, there is another task which takes priority. 2. INCORRECT: Instilling the exact number of drops is appropriate when implementing written prescriptions from the primary healthcare provider. This is an important nursing action but not the priority. 3. INCORRECT: Instructing the client to look upward helps prevent drops from running out of the eye but there is another issue more important.

A nurse is triaging a 2 year old child in the pediatric emergency department. The nurse notes that the child will not lie down and is consistently drooling. A croaking sound is heard on inspiration. What is the priority nursing intervention? 1. Examine the oral pharynx using a tongue depressor. 2. Administer a sedative so the child can be examined. 3. Have a second nurse hold the child down for the assessment. 4. Notify the primary healthcare provider immediately.

4. Correct: This is the safest answer. The child could suddenly obstruct the airway upon examination of throat. 1. Incorrect: If it looks like epiglottitis, do not examine as this could cause sudden airway obstruction which could be fatal. 2. Incorrect: The client is having trouble breathing, so do not sedate the client. Sedatives would depress the respirations more and potentially cause the client to go into respiratory arrest. Remember, the NCLEX® lady does not want you to be a killer nurse. 3. Incorrect: This will cause more respiratory and emotional distress to the child. This is an unsafe answer.