July 13th

A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply. 1. Contact the HCP if any hot areas or foul odors develop in the cast 2. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet 3. Elevate the affected extremity above the heart level for the first 48 hours 4. Expect some numbness and tingling of the fingers during the first week 5. Use only soft, padded objects to scratch the skin under the cast

1, 2, & 3 Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. Instructions for cast care include: Report foul odors or hot areas (hot spots) in the cast, which may indicate infection (Option 1). Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection (Option 2). Elevate the affected extremity above heart level for the first 48 hours to reduce edema (Option 3). Regularly perform isometric and range of motion exercises to prevent muscle atrophy. (Option 4) The client should also be instructed to contact the health care provider about symptoms of impaired circulation in the affected extremity, including numbness or tingling, pallor, coolness, loss of pulse distal to the cast, or pain that is unrelieved by ice, elevation, and pain medication. Swelling within the cast may result in compartment syndrome, a condition that involves limb-threatening tissue ischemia due to compression of blood vessels and nerves within the extremity's internal compartments. (Option 5) The client should never insert objects inside the cast due to the risk of tissue injury and infection. Directing air inside the cast with a hair dryer on the cool setting may help relieve itching. Educational objective: Cast care instructions include reporting foul odors or hot areas in the cast; preventing the cast from getting wet; elevating the affected extremity above heart level for the first 48 hours; regularly exercising the affected extremity; and reporting symptoms of impaired circulation (eg, numbness, tingling, pallor, coolness). Clients should never insert objects inside the cast.

The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply. 1. Encourage the parents to leave the child's favorite toy 2. Establish a daily schedule similar to the child's home routine 3. Give the child time to calm down alone when visibly upset 4. Provide frequent opportunities for play and activity 5. Remove visual reminders of the parents from the room

1, 2, & 4 Some of the first stressors faced by children from infancy through the preschool years are related to illness and hospitalization. Separation anxiety, also known as anaclitic depression, particularly affects children age 6-30 months. There are 3 stages of separation anxiety: protest, when the child refuses attention from others, screams for the parent to return, and cries inconsolably; despair, when the child is withdrawn, quiet, uninterested in activities or meals, and displays younger behavior (eg, use of pacifier, wetting the bed); and detachment, when the child suddenly appears happy and interested in building relationships. Nursing care of hospitalized clients experiencing separation anxiety focuses on maintaining a calm environment and a supportive demeanor to build trust between the nurse and the child, and encouraging connection with family and familiar environments, even when they are absent. Key interventions include: Encouraging the parents to leave favorite toys, books, and pictures from home Establishing a daily schedule that is similar to the child's home routine Maintaining a close, calming presence when the child is visibly upset Facilitating phone or video calls when parents are available Providing opportunities for the child to play and participate in activities (Option 3) When the child is visibly upset, it is important to provide a calming presence and implement strategies to reduce the child's anxiety. Leaving the child alone at such times can further increase stress. (Option 5) Providing pictures of the child's family is actually beneficial, as it reminds the child of something familiar and safe. Educational objective: Toddlers and preschool-age children experience separation anxiety in response to the stress of illness and hospitalization. Key nursing interventions to alleviate separation anxiety include encouraging the presence of favorite items, establishing a daily routine, providing opportunities for play, facilitating phone calls with the parents, and providing support when the child is upset.

A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which interventions can the nurse suggest to help mobilize secretions and improve sleep? Select all that apply. 1. Increase the fluids to at least 8 glasses of water a day 2. Sleep with a cool mist humidifier 3. Take prescribed guuaifenesin medicine before bedtime 4. Use abdominal breathing and the huff cough technique at bedtime 5. Use pursed lip breathing during the night

1, 2, 3, & 4 Chronic bronchitis is characterized by excessive mucus production, chronic cough, and recurrent respiratory tract infections. Interventions to help reduce viscosity of mucus, facilitate secretion removal, and promote comfort include the following: Increasing oral fluids to 2-3 L/day if not contraindicated prevents dehydration and keeps secretions thin Cool mist humidifier increases room humidity of inspired air Guaifenesin (Robitussin) is an expectorant that reduces the viscosity of thick secretions by increasing respiratory tract fluid; drinking a full glass of water after taking the medication is recommended. Abdominal breathing with the huff, a forced expiratory cough technique, is effective in mobilizing secretions into the large airways so that they can be expectorated Chest physiotherapy (postural drainage, percussion, vibration) Airway clearance handheld devices, which use the principle of positive expiratory pressure to help loosen secretions when the client exhales through the mouthpiece (Option 5) Pursed lip breathing prolongs exhalation, reduces air trapping in the lungs, and decreases dyspnea. It does not help to thin secretions. Educational objective: Interventions to help reduce viscosity of mucus, facilitate secretion removal, and promote comfort in clients with chronic bronchitis include the following: Increasing oral fluids to 2-3 L/day if not contraindicated Cool mist humidifier to increase room humidity Guaifenesin (Robitussin), an expectorant, to reduce viscosity of secretions Huff coughing

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply. 1. Age>50 2. Family history of skin cancer 3. High number of moles 4. History of severe adolescent acnr 5, Immunosuppresant medication use 6. Outdoor occupation

1, 2, 3, 5, & 6 Skin cancers are most often linked to damage of skin cells' DNA by overexposure to ultraviolet radiation (eg, sunlight, tanning beds). The three most common types of skin cancer are squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanomas grow rapidly and are highly metastatic, making them the most deadly form of skin cancer. Basal cell and squamous cell carcinomas generally have a much lower risk of metastasis. Risk factors for skin cancer include: Celtic ancestry traits (eg, light-colored skin, red or blonde hair, blue or green eyes, many freckles) Age >50 (Option 1) Family or personal history of skin cancer (Option 2) Atypical or high number of moles, as some skin cancers develop from preexisting moles (Option 3) Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations (Option 5) Ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation, tanning bed use, history of severe sunburns) (Option 6) Clients should be taught to avoid overexposure to sunlight, perform monthly skin checks with the ABCDE assessment, and immediately report any abnormal findings to their health care provider. Early detection and treatment of skin cancer significantly improves the client's outcome. (Option 4) Acne is not a known risk factor for skin cancer. Educational objective: Risk factors for skin cancer include Celtic ancestry traits (eg, light-colored skin, blue eyes), age >50, family or personal history of skin cancer, high number of moles, immunosuppression, and ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation).

The nurse assesses a client with fever and productive cough for the last 10 days. Which findings support the presence of pneumonia? Select all that apply. 1. Coarse crackles 2. Hyperresonance 3. Pleuritic chest pain 4. Shortness of breath 5. Trachea deviating from midline

1, 3, & 4 Pneumonia is an acute infection of the lungs. Findings in a client with pneumonia include: Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and small airways obstructed with mucus (Option 1) Fever, chills, productive cough, dyspnea, and pleuritic chest pain (Options 3 and 4) Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue. Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted through consolidated lung tissue, which are abnormal when heard in an area distant from where normally heard (ie, trachea); this finding can be an early sign of pneumonia. Unequal chest expansion - Decreased expansion of affected lung on palpation Dullness - Percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled space (eg, pleural effusion, a complication of pneumonia) (Option 2) Hyperresonance is percussed over a hyperinflated lung (eg, asthma, emphysema) or air in the pleural space (eg, pneumothorax). (Option 5) A trachea deviating from midline is not a symptom of pneumonia but instead indicates a tension pneumothorax where the trachea deviates away from the tension. Educational objective: Physical examination of a client with pneumonia can reveal crackles, increased vocal/tactile fremitus, unequal chest expansion, and bronchial breath sounds in peripheral areas. Clients often report fever, chills, productive cough, dyspnea, and pleuritic chest pain.

A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 hours ago." The client's group B Streptococcus status is unknown. What intervention is a priority for this client? 1. Administration of prophylactic antibiotics 2. Assessment of uterine contraction frequency 3. Collection of clean catch urine specimen 4. Vaginal examination to assess cervical dilation

1. ADMINSTRATION OF PROPHYLACTIC ANTIBIOTICS Group B Streptococcus (GBS) may be present as part of normal vaginal flora in up to 30% of pregnant clients. Although colonization with GBS rarely poses harm to the client, it can be transmitted to the newborn during labor and birth, resulting in serious complications (eg, neonatal GBS sepsis, pneumonia). Pregnant clients are tested for GBS colonization at 35-37 weeks gestation and receive prophylactic antibiotics during labor if results are positive. If GBS status is unknown, antibiotics are typically indicated when membranes have been ruptured for ≥18 hours, maternal temperature is ≥100.4 F (38 C), or gestation is <37 weeks (Option 1). (Option 2) Part of the client's assessment includes evaluation of the uterine contraction pattern. However, the client and newborn are at risk for infection due to prolonged rupture of membranes and unknown GBS status, so antibiotic administration is the priority. (Option 3) A urine specimen is often collected to evaluate for proteinuria in clients with elevated blood pressure or to assess for urinary tract infection in symptomatic clients. Urine specimen collection is not the priority for this client. (Option 4) Vaginal examinations should be limited in the presence of ruptured membranes. Multiple vaginal examinations in such a client correlate with an increased risk for infection (eg, chorioamnionitis). Educational objective: Group B Streptococcus (GBS) infection can be transmitted to the newborn during labor and birth and cause serious complications. Indications for prophylactic antibiotics during labor include maternal GBS-positive status or unknown GBS status with fever ≥100.4 F (38 C), preterm gestation, and/or prolonged rupture of membranes.

A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H2O (11 mm Hg) positive end-expiratory pressure (PEEP). The nurse should assess for which complication associated with PEEP? 1. Barotrauma 2. Decreased oxygen saturation 3. Hypertension 4. Oxygen toxicity

1. BAROTRAUMA Positive end-expiratory pressure (PEEP) applies a given pressure at the end of expiration during mechanical ventilation. It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange. PEEP is usually kept at 5 cm H2O (3.7 mm Hg). However, a higher level of PEEP is an effective treatment strategy for acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type II surfactant-producing pneumocytes that then leads to atelectasis, noncompliant lungs, poor gas exchange, and refractory hypoxemia. High levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema. (Option 2) PEEP opens up collapsed alveoli and improves gas exchange at a lower fraction of inspired oxygen (FiO2), resulting in increased, not decreased, oxygen saturation. (Option 3) Hemodynamic effects of PEEP include increased intrathoracic pressure, which leads to reduced venous return, decreased preload and cardiac output, and hypotension, not hypertension. (Option 4) Keeping the alveoli open between breaths with PEEP improves gas exchange across the alveolar-capillary membrane, reduces hypoxemia, and allows for the use of a lower FiO2, which can reduce the risk for oxygen toxicity. Educational objective: High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension.

The nurse assesses a female client with a diagnosis of primary adrenal insufficiency (Addison disease). The nurse recognizes which finding associated with the disease? 1. Bronze pigmentation to the skin 2. Increased body or facial hair 3, Purple or red striae on the abdomen 4. Supracavicular fat pad

1. BRONZE PIGMENTATION OF SKIN Addison disease, or primary adrenocortical insufficiency, is also described as hypofunction of the adrenal cortex. The adrenal gland is responsible for secretion of glucocorticoids, androgens, and mineralocorticoids. Bronze hyperpigmentation of the skin in sun-exposed areas is caused by an increase in adrenocorticotropic hormone (ACTH) by the pituitary in response to low cortisol (ie, glucocorticoid) levels (Option 1). Clients with Addison disease may also have vitiligo, or patchy/blotchy skin, which is usually present when the etiology of the disease is an autoimmune problem. The immune cells are thought to destroy melanocytes which produce melanin (or brown pigment), resulting in a patchy appearance. Other common manifestations of Addison disease include the following: Slow, progressive onset of weakness and fatigue Anorexia and weight loss Orthostatic hypotension Hyponatremia and hyperkalemia Salt cravings Nausea and vomiting Depression and irritability (Options 2, 3, and 4) Purple striae, hirsutism (increased facial and body hair), and a supraclavicular fat pad (ie, buffalo hump) are characteristics of Cushing syndrome, a condition associated with excess corticosteroid production. In contrast, Addison disease is a condition of hyposecretion of glucocorticoids. Educational objective: Hyperpigmentation of the skin is a common characteristic of Addison disease, or primary adrenocortical insufficiency, which can also cause hypotension, hyponatremia, hyperkalemia, and vitiligo.

A child is brought to the school nurse after having a permanent tooth knocked out during gym class. Which action by the nurse is appropriate? 1. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity 2. Gently scrub the root of the tooth to remove any debris, and wrap it in sterile gauze 3. Place the tooth in water and transport the pt to the nearest emergency department 4. Wrap the tooth in sterile gauze and advise the parents to arrange for a dental appointment

1. GENTLY RINSE THE TOOTH WITH STERILE SALINEA ND REINSERT IT INTO THE GINIGIVAL CAVITY Dental avulsion (ie, tooth separated from the mouth) of a permanent tooth is a dental emergency. The priority nursing action is to rinse and reinsert the tooth into the gingival socket and hold it in place (eg, with a finger) until stabilized by a dentist (Option 1). Reimplantation within 15 minutes of injury re-establishes blood supply, increasing the probability of tooth survival. If the tooth cannot be reinserted it should be kept moist by submerging it in commercially prepared solution (eg, Hanks Balanced Salt Solution), cold milk, sterile saline, or as a last resort—due to bacteria—saliva (eg, holding it under the tongue). (Option 2) Scrubbing the root would damage it. The tooth should be gently rinsed with sterile saline or clean, running water. (Option 3) Placing the tooth in water (a hypotonic solution) would lyse the cells, killing the tooth. (Option 4) Wrapping the tooth in sterile gauze would dry it out. In addition, the nurse should arrange for immediate transfer to a dentist rather than advise the parent to schedule an appointment that might not be available for days. Educational objective: Dental avulsion is a dental emergency. The nurse should gently rinse off debris and reinsert the tooth into the gingival socket. If reimplantation is not possible, the tooth should be placed in a commercially prepared solution, cold milk, or sterile saline. The client should see a dentist immediately.

The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs further investigation? 1. I am taking an antibiotic for a urinary tract infection 2. I had a negative tuberculosis skin test 2 weeks ago 3. I just received my yearly flu shot a week ago 4. I will continue taking naproxen at night to help with pain

1. I AM TAKING AN ANTIBIOTIC FOR A URINARY TRACT INFECTION Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that suppress the inflammatory response in autoimmune diseases such as rheumatoid arthritis, Crohn disease, and psoriasis. Due to the immunosuppressive action of TNF inhibitors, clients taking these drugs are at increased risk for infection. A client with current, recent, or chronic infection should not take a TNF inhibitor (Option 1). (Option 2) The immunosuppressive action of TNF inhibitors can activate latent tuberculosis (TB). Therefore, a tuberculin skin test (TST) should be administered prior to beginning TNF inhibitor therapy, and clients who test positively for latent TB must also undergo treatment for TB before starting therapy. Clients should have a TST every year while receiving the drug. (Option 3) Clients taking immunosuppressive TNF inhibitors (eg, adalimumab) should receive an annual inactivated (injectable) influenza vaccine to reduce the risk of contracting the flu virus. Clients taking TNF inhibitors or other immunosuppressants are at risk for infection and therefore should not receive live attenuated vaccines. (Option 4) Many clients with rheumatoid arthritis use nonsteroidal anti-inflammatory medications (eg, celecoxib, naproxen) in conjunction with antirheumatic and/or targeted therapies (eg, methotrexate, adalimumab, etanercept) to effectively treat pain and minimize inflammation. Educational objective: Clients with infection should not take tumor necrosis factor (TNF) inhibitors (eg, infliximab, adalimumab, etanercept) as these suppress the immune response. Before starting drug therapy, clients should be tested for tuberculosis and receive the inactivated (injectable) influenza vaccine. Clients taking TNF inhibitors should avoid live vaccines.

The nurse is providing discharge teaching for a client who suffered full-thickness burns. Which statement by the client demonstrates a need for further instruction on the rehabilitation phase of a burn injury? 1. I should avoid using lotino to prevent infection 2. I should preform ROM exercises daily 3. I will avoid surect sun exposure for at least 3 months 4. I will wear pressure garments to minimize scars

1. I SHOULD AVOID USING LOTION TO PREVENT INFECTION The rehabilitation phase begins after the client's wounds have fully healed and lasts about 12 months. The initiation of this phase depends on the extent of the burns and the client's ability to care for themselves. Interventions in the rehabilitation phase are aimed at improving mobility and independence and minimizing the potential for long-term complications. These interventions include: Counseling or other psychosocial support Gentle massage with water-based lotion to alleviate itching and minimize scarring Planning for reconstructive surgery Pressure garments to prevent hypertrophic scars and promote circulation (Option 4) Range-of-motion exercises to prevent contractures (Option 2) Sunscreen and protective clothing to prevent sunburns and hyperpigmentation (Option 3) (Option 1) Daily application of water-based lotion is necessary to minimize scar formation and alleviate itching. Infection is not likely as the rehabilitation phase begins after the wounds are fully healed. Educational objective: The rehabilitation phase begins after the client's wounds are healed. The goals of this phase are to increase the client's ability to perform activities of daily living and prevent long-term complications.

The nurse is planning care for a client experiencing an acute attack of Meniere disease. Which action is a high priority to include in the plan of care? 1. Initiate fall precautions 2. Keep the emesis basin at bedside 3. Provide a quiet environment 4. Start IV fluids

1. INITIATE FALL PRECAUTIONS Meniere disease (endolymphatic hydrops) results from excess fluid accumulation inside the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and associated with nausea and vomiting. Clients report feelings of being pulled to the ground (drop attacks). During an attack, the client is treated with vestibular suppressants, including sedatives (eg, benzodiazepines such as diazepam), antihistamines (eg, diphenhydramine, meclizine), anticholinergics (eg, scopolamine), and antiemetics. The nurse's priority is to plan for client safety with fall precautions given the severe vertigo and use of sedating medications. Fall precautions include adjusting the bed to a low position with side rails up and instructing the client to call for help before getting up. Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements. The client should reduce stimulation by not watching television or looking at flickering lights. The client's diet should be salt restricted to prevent fluid buildup in the ear. (Option 2) An emesis basin should be provided at the bedside, but fall precautions are the priority. (Option 3) A quiet environment can help minimize vertigo. However, it is a lower priority than the fall precautions. (Option 4) Most clients with Meniere disease require parenteral fluids given the nausea and vomiting. However, these are not the highest priority. Educational objective: Clients with Meniere disease (endolymphatic hydrops) can have severe vertigo, tinnitus, hearing loss, and aural fullness. It is a priority for the nurse to institute safety measures, such as fall precautions, for these clients. They will require a salt-restricted diet.

An elderly client visits the clinic for an annual examination, which includes updating the client's advance care plan. When assessing the client's advance care planning needs, which topics should the nurse discuss? Select all that apply. 1. Financial power of attorney 2. Health care proxy 3. Life insurance beneficiary 4. Living will 5. Safe deposit box

2 & 4 Advance care planning is an ongoing process that should be revisited yearly and after changes in condition. Legal documentation is needed to ensure that the client's advance care plan is carried out correctly. Advance care planning documents may include the following: A health care proxy (durable power of attorney for health care or medical power of attorney) is a person appointed by the client to make decisions on behalf of the client. The proxy document only goes into effect when the health care team determines that the client lacks the capacity to make decisions. This should be deactivated if the client regains decision-making capacity. A living will is an advanced directive describing the type of life-sustaining treatments (eg, cardiopulmonary resuscitation, intubation, mechanical ventilation, feeding tube) that the client wants initiated if unable to make decisions. (Option 1) The financial power of attorney form can help clients having difficulty managing financial affairs and needing someone to help; however, it is not part of the advance care planning process. (Option 3) The client must choose a beneficiary for life insurance policies; however, life insurance is not part of the advance care plan. (Option 5) A safe deposit box can be a good place to ensure that legal documents are stored safely. It is not part of the advance care planning process. Educational objective: Advance care planning allows the client to determine desired treatments (eg, cardiopulmonary resuscitation, intubation, mechanical ventilation) and decision makers in the event the client is unable to do so. Advanced directives are legal documents outlining these wishes and include living wills and health care proxies (durable powers of attorney for health care or medical power or attorney).

Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. 1. Black cohoch 2. Garlic 3. Ginger 4. Ginko biloba 5, Hawthorn

2, 3, & 4 Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to elective surgery, but they may not know that some herbal supplements can increase bleeding risk. The nurse should question the client specifically about the use of herbal supplements. Herbal supplements that can increase risk for bleeding include: Gingko biloba Garlic Ginseng Ginger Feverfew (Option 1) Black cohosh is used for treatment of menopausal symptoms. The main side effect is liver injury. (Option 5) Hawthorn extract is used to control hypertension and mild to moderate heart failure. Hawthorn use does not increase the risk of bleeding. Educational objective: Use of herbal supplements such as ginkgo biloba, garlic, ginseng, ginger, and feverfew should be reported to the health care provider before surgery as they may increase the risk of bleeding.

A nurse is preparing to perform postmortem care on a client who recently died from metastatic cancer. No family members were present at the time of death. What interventions can be delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Notifying the family of the pt;s death 2. Placing dentures in the pt's mouth 3. Positioning a pillow beneath the pt's head 4. Transporting the pt to the morgue 5. Washing the pt's body

2, 3, 4, & 5 It is appropriate to delegate postmortem care to unlicensed assistive personnel (UAP) if they have been trained and have sufficient experience in the procedures (5 rights of delegation). Postmortem care involves the following series of steps: Wash and straighten the body (Option 5), change the linens, and place a pad under the perineum to absorb stool and urine from relaxed sphincters. Place a pillow under the head (Option 3) to prevent blood from pooling and discoloring the face. Place dentures in the client's mouth before rigor mortis sets in (Option 2) and close the mouth. Gently close the eyes. Remove tubes, lines, and dressings per institutional policy unless an autopsy or organ donation is to be performed. After the family leaves, take the client to the morgue or notify the funeral home to arrange transportation (Option 4). (Option 1) Family members are usually notified by the health care provider. Most likely they will ask questions that the UAP would be unable to answer. This task would not be appropriate for delegation. Educational objective: Postmortem care can be delegated to unlicensed assistive personnel at the nurse's discretion (5 rights of delegation). It includes client preparation (eg, hygiene, positioning) and transportation of the body to the appropriate facility.

The nurse is planning care for a premature infant who is about to receive a painful heel stick. Which of the following pain-reducing interventions should be included in the plan of care? Select all that apply. 1. Apply a cold pack to the heel to numb the area 2. Offer a pacifier to increase relaxation 3. Offer a sucrose solution to induce a calming effect 4. Place the infant skin to skin with a parent to reduce stress 5. Swaddle the infant to promote comfort

2, 3, 4, & 5 Nonpharmacological pain control methods block or dampen pain signals before they reach the brain, potentially reducing the amount of pharmacological interventions needed during painful procedures (eg, heel stick, immunizations). Nonpharmacological pain reduction methods for infants include: Nonnutritive sucking: Diminishes behavioral and hormonal responses to pain (Option 2) Concentrated sucrose: Administered before a painful procedure, sucrose stimulates the internal opioid system of infants age 6 months and younger, leading to decreased pain scores and duration of pain response (Option 3). Skin-to-skin contact with a parent (also known as "kangaroo care"): Significantly reduces infant pain scores (Option 4) Swaddling: Offers the infant a sense of comfort and security and reduces crying and heart rate (Option 5) (Option 1) Before administering a heel stick, a warm pack should be applied to help facilitate blood flow to the area. A cold pack will cause vasoconstriction and impede blood draw. Educational objective: During painful procedures, nonpharmacological pain management strategies for an infant include nonnutritive sucking, concentrated sucrose solutions, skin-to-skin contact with a parent, and swaddling.

The nurse is gathering data on a client with obstructive sleep apnea. Which findings are consistent with this client's diagnosis? Select all that apply. 1. Difficulty arousing from sleep 2. Excessive daytime sleepiness 3. Morning headaches 4. Postural collapse and falling 5. Snoring during sleep 6. Witnessed episodes of apnea

2, 3, 5 ,& 6 Obstructive sleep apnea (OSA) is the most common type of breathing disorder during sleep and is characterized by repeated periods of apnea (>10 seconds) and diminished airflow (hypopnea). A partial or complete obstruction occurs due to upper airway narrowing that results from relaxation of the pharyngeal muscles or from the tongue falling back on the posterior pharynx due to gravity. During periods of apnea, desaturation (hypoxemia) and hypercapnia occur; these stimulate the client to arouse and breathe momentarily to restore airflow. These cycles of apnea and restored airflow can occur several hundred times per night, resulting in restless and fragmented sleep. Partners of clients with OSA witness loud snoring, apnea episodes, and waking with gasping or a choking sensation (Options 5 and 6). During the day, clients experience morning headaches, irritability, and excessive sleepiness. Excessive daytime sleepiness can lead to poor work performance, motor vehicle crashes, and increased mortality (Options 2 and 3). (Option 1) Frequent (not difficult) arousal from sleep is associated with OSA. (Option 4) Cataplexy is a brief loss of skeletal muscle tone or weakness that can result in a client falling down. It is associated with narcolepsy, a chronic neurologic sleep disorder. Educational objective: At night, clients with obstructive sleep apnea experience repeated periods of apnea, loud snoring, and interrupted sleep. During the day, morning headaches, irritability, and excessive sleepiness are common.

A nurse is admitting a child and observes multiple irregular bruises. Which action should the nurse take next? 1. Ask the parents to leave the room during the admission process 2. Continue with a detailed interview and physical examination 3. Notify the charge nurse and the social worker 4. Promise not to tell anyone if the child reveals abuse

2. CONTINUE WITH A DETAILED INTERVIEW AND PHYSICAL EXAMINATIONS A nurse who suspects child abuse should conduct a detailed interview and physical examination to identify potential indicators of abuse (Option 2). In addition to obvious injuries, abused children may show extremes in behavior, including being overly shy, fearful, or even unusually affectionate. Parents should remain present during the admission process and the nurse should observe parent-child interactions for signs of abusive behavior (eg, refusal to comfort, blaming, belittling) (Option 1). Abusive parents may be hostile or uncooperative with the health care team. The nurse should also assess for inconsistencies between the parents' report and the actual findings. (Option 3) The nurse should report findings that indicate abuse to the charge nurse, social worker, and health care provider only after conducting a full history and physical examination. (Option 4) The nurse should not make promises of secrecy to the child or family if abuse is revealed. The child or family should be told that the nurse is required by law to report all abuse. Educational objective: If child abuse is suspected, the nurse should obtain a detailed history, perform a physical examination, and report signs of abuse. Parent-child interaction should be examined closely, and any inconsistencies between a parent's report and the actual findings should be documented.

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include? 1. Belief that the curent surroundings are a racetrack 2. GCS score was 11 one hour ago 3. Recent vital signs show BP of 120/0 and HR of 82 4. Reported allergy to penicillin and vancomycin

2. GCS SCORE OF 11 ONE HOUR AGO The GCS quantifies the level of consciousness in a client with acute brain injury by measuring eye opening (alertness), verbal response (orientation), and motor response (eg, obeying a command, frontal lobe function). The maximum score on the GCS is 15 and the lowest is 3. If a client is trending for deterioration, this should always be noted in neurological assessments. A numerical decline of a single number in 1 hour is significant. A criticism of the GCS score is that it is not that precise. (Option 1) Orientation to place is part of the GCS score (under best verbal). The total score and the negative trend are more indicative of the client's condition than any individual GCS component. (Option 3) This client's vital signs are within normal limits and are not significant. It would be more important to communicate if there is absence of Cushing's triad (bradycardia, bradypnea/Cheyne-Stokes, and widening pulse pressure) or to give a brief summary of overall vital signs (eg, "normal"); exact readings are accessible and can be recited if the oncoming nurse needs to know them. However, reporting the negative neurological trend in the GCS score is the priority. (Option 4) Although it is important to be aware of allergies, the oncoming nurse can find that information on the chart if these medications are ordered. The main concern is blunt head trauma and not infection; therefore, it is unlikely that the oncoming nurse will be required to know this information and need to administer antibiotics. Educational objective: It is a priority to report a negative neurological trend as evidenced by GCS score in a client with blunt head trauma.

The registered nurse is teaching the parent of a 6-year-old about behavioral strategies for treating fecal incontinence due to functional constipation. Which statement by the parent indicates a need for further teaching? 1. I will give mt chikd a picture boo kto look at during toilet time 2. I will give my child a reward for each bowel movement while sitting on the toilet 3. I will keep a log of my child's bowel movements, laxative use, and episodes of soiling 4. I will schedule regular toilet time for my child

2. I WILL GIVE MY CHILD A REWARD FOR EACH BOWEL MOVEMENT WHILE SITTING ON THE TOILET Fecal incontinence (ie, encopresis, soiling) refers to the repeated passage of stool in inappropriate places by children age ≥4 years. In more than 80% of cases, it is due to functional constipation (retentive type); in about 20% of cases, it may be caused by psychosocial triggers (nonretentive type). Management of fecal incontinence/constipation primarily includes 3 components: Disimpaction followed by prolonged laxative therapy, dietary changes (increased fiber and fluid intake), and behavior modification. Behavioral strategies are used to promote and restore regular toileting habits and to gain the child's cooperation and participation in the treatment program. Behavioral interventions include the following: Regularly schedule toilet sitting times 5-10 minutes after meals for 10-15 minutes (Option 4) Provide a quiet activity for the child during toilet sitting, which will help pass the time and make the experience more "enjoyable" (Option 1) Initiate a reward system to boost the child's participation in the treatment program; the reward would be given for effort, not for success of evacuation in the toilet (children with retentive encopresis have dysfunctional anal sphincters and little control over bowel movements; giving a reward for something the child has no control over would not be effective) (Option 2) Keep a diary or log of toilet sitting times, stooling, medications, and episodes of soiling to evaluate the success of the treatment (Option 3) Educational objective: A reward system is one of the behavioral strategies used in the treatment of functional incontinence (due to constipation). The reward is given to encourage the child's involvement in the treatment to restore normal bowel function. Rewards are given for the child's effort and participation, not for having bowel movements while sitting on the toilet.

The nurse cares for a 4-year-old who is on long-term, strict bed rest. Which toy is most appropriate to provide diversion and minimize developmental delays? 1. Board games 2. Puppets 3. Soap bubbles 4. Stacking and nesting toys

2. PUPPETS Play is an integral part of a child's mastery of emotional, social, and physical development. When a child is hospitalized, play can also serve as a diversion and a way to express stress and anxiety. Preschoolers enjoy play that enables them to imitate others and be dramatic. They have rich imaginations and enjoy make-believe. Their play often centers on imitating adult behaviors by playing dress up and using housekeeping toys, telephones, medical kits, dolls, and puppets. Quiet play appropriate for the preschooler includes finger paints, crayons, illustrated books, puzzles with large pieces, and clay. Through playing with objects such as dolls or puppets, preschoolers can often process fears and anxieties that are difficult for them to express. (Option 1) Board games are appropriate for children of school age, when play becomes more complex and competitive. (Option 3) Soap bubbles are appropriate for toddlers, who learn from tactile play and environmental exploration. (Option 4) Stacking and nesting toys are appropriate for toddlers who are developing fine motor skills. Educational objective: Play serves as an important part of children's emotional, social, and physical development. It is important that they be provided with toys that can help them achieve developmental tasks. Appropriate toys for preschoolers are those that encourage imitation of adults, such as dolls, puppets, imaginative toys, dress-up clothing, medical kits, cars, and planes.

The nurse is caring for an alert client with jaundice, scleral icterus, and a bilirubin level of 12.3 mg/dL (210 µmol/L). Which instruction would be most important to include when delegating the client's morning hygiene tasks to unlicensed assistive personnel? 1. Do not leave the pt alone in the shower 2. Use cool water in the shower 3. Use hot water in the shower 4. Wash pt with antibacterial soap

2. USE COOL WATER IN THE SHOWER Jaundice is associated with elevated bilirubin levels and yellowing of the sclera (icterus). It often causes intense itching that can be exacerbated by the use of hot water and strong soaps. Therefore, when delegating hygiene tasks, the registered nurse should instruct the unlicensed assistive personnel to use cool water and the minimum necessary amount of mild soap (Options 2, 3, and 4). (Option 1) The client with jaundice due to liver disease may be at risk for falls and requires supervision during a shower. However, unsteadiness and confusion is not evident in this scenario; therefore, this is not the best answer. Educational objective: For clients with jaundice, the use of hot water and strong soaps can exacerbate itching and dryness and should be minimized. Mild soaps for sensitive skin should be used instead.

The health care provider orders 2 mEq/kg (2 mmol/kg) of 8.4% sodium bicarbonate IV to be administered over the next 4 hours. The client weighs 150 lb and the pharmacy supplies the following IV solution: 8.4% sodium bicarbonate in 1000 mL D5W with 150 mEq (150 mmol) sodium bicarbonate. At what rate should the nurse set the infusion pump? Record your answer using a whole number.

227 Explanation: 150 lb ÷ 2.2 kg = 68.1818 kg Dosage calculation: 2 mEq (2 mmol) X 68.1818 kg = 136.3636 mEq (136.3636 mmol) in 4 hours 136.3636 mEq (136.3636 mmol) ÷ 4hr = 34.0909 mEq/hr (34.0909 mmol/hr) Concentration: 150 mEq (150 mmol) ÷ 1000 mL = 0.15 mEq/mL (0.15 mmol/mL) To calculate pump setting in mL/hr if specific dose is ordered: dosage ÷ concentration = pump setting 34.0909 mEq/hr (34.0909 mmol/hr) ÷ 0.15 mEq/mL (0.15 mmol/mL) = 227.2727 mL/hr Answer: Set infusion pump at 227 mL/hr Educational objective: Sodium bicarbonate is an electrolyte replenisher and is administered intravenously to correct moderate to severe metabolic acidosis (pH <7.2).

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply. 1. I can mix the medication in a bowl of my child's favorite cereal 2. I should give another dose if my childs vomits after taking ht emedication 3. I should measure liquid medications using an oral syringe 4. I will encourage my child to help me as I prepare the medications 5. I will place my child in time out if the medication is refused

3 & 4 For pediatric clients, liquid medications should be measured with oral syringes, which have small, well-defined increments and provide accuracy for small doses (Option 3). Household measuring devices (eg, teaspoon) are inaccurate due to variability of size and differences in measuring methods. Pediatric clients may refuse medication due to a fear of an unpleasant taste. Preschool children (age 3-6) typically start to take initiative and affirm power over the environment (Erickson's initiative vs. guilt). Encouraging participation (eg, allowing the child to depress the syringe plunger) promotes initiative and cooperation by giving the child a sense of control (Option 4). (Option 1) The child may not finish eating food mixed with medication and would receive only a partial dose. In addition, some medications cannot be given with food. (Option 2) Parents should notify the health care provider if the child vomits after oral medication administration; additional medication may cause an overdose, as some of the medication may have been absorbed. (Option 5) Preschool children respond best to positive reinforcement and rewards (eg, stickers) as incentives for desired behavior. A time-out is more effective in interrupting undesired behavior. Educational objective: For pediatric clients, liquid medication should be measured with an oral syringe for accuracy. To prevent inaccurate dosing, parents should not mix medications with meals or give additional medication if vomiting occurs. To promote initiative and cooperation from preschool children (age 3-6), parents should provide positive reinforcement (eg, stickers) and allow children to participate in self-administration.

A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply. 1. I don't plan on eating any more frozen meals 2. I plan to take my diuretic pill in the morning 3. I will weigh myself at least every other day 4. I am going to look into joining a cardiac rehabilitation program 5. Ibuprofen works best for me when I have pain

3 & 5 Client and family education is important for those with heart failure to prevent/minimize exacerbations, decrease symptoms, prevent target organ damage, and improve quality of life. The use of any nonsteroidal anti-inflammatory drugs (NSAIDS) is contraindicated as they contribute to sodium retention, and therefore fluid retention (Option 5). To monitor fluid status, clients are instructed to weigh themselves daily, at the same time, with the same amount of clothing, and on the same scale (Option 3). Weights should be recorded to allow for day-to-day comparisons to help identify early signs of fluid retention. (Option 1) Frozen meals are often high in sodium. Most heart failure clients are instructed to limit sodium intake. All foods high in sodium (>400 mg/serving) should be avoided. (Option 2) Diuretic medications cause clients to urinate more. Morning is the appropriate time to take this type of medication. Evening administration would cause nocturia and interrupted sleep. (Option 4) Exercise training, such as cardiac rehabilitation, improves symptoms of chronic heart failure. It has been found to be safe and improves the client's overall sense of well-being. It has also been correlated with reduction in mortality. Educational objective: Discharge education for the client with chronic heart failure should include daily weights, drug regimens, diet, and exercise plans. The use of any NSAIDS is contraindicated in heart failure as these contribute to sodium retention, and therefore fluid retention.

A client is scheduled for allergy skin testing to identify asthmatic triggers. Which medications should the nurse instruct the client to withhold before the test to ensure accurate results? Select all that apply. 1. Acetaminophen 2. Albuterol 3. Diphenhydramine 4. Enalapril 5. Loratidine

3 & 5 Allergy skin testing involves introducing common environmental and food allergens (ie, antigens) into the skin surface and then observing the site for an allergic reaction (eg, formation of a wheal, erythema). Several different antigens, as well as positive and negative controls, are usually tested at the same time for accuracy. To ensure an accurate result, the client should avoid antihistamines (eg, diphenhydramine [Benadryl], loratadine [Claritin], promethazine [Phenergan]) for up to 2 weeks prior to the test (Options 3 and 5). Antihistamines block mast cell release of histamines that are responsible for allergic symptoms. Systemic corticosteroids, used to treat the inflammatory component of asthma, may also affect the accuracy of allergy skin testing; therefore, the use of these medications is assessed by the health care provider. (Option 1) Acetaminophen does not have antihistamine properties and will not interfere with allergy skin testing. (Option 2) Albuterol, an inhaled short-acting beta adrenergic agonist, will not interfere with allergy skin testing results and should not be discontinued, as it is necessary to ensure client safety during acute asthma exacerbations. (Option 4) Enalapril, an ACE inhibitor, is used to treat high blood pressure and heart failure and will not impact the results of allergy skin testing. Educational objective: Allergy skin testing involves introducing common allergens (ie, antigens) into the skin surface and then observing the site for an allergic reaction (eg, formation of a wheal, erythema). Clients should avoid antihistamines as these drugs can prevent accurate results.

The nurse is planning care for a client with suspected stroke who has just arrived at the emergency department with slurred speech, facial drooping, and right arm weakness that began 1 hour ago. Which of the following interventions should the nurse anticipate including in the initial plan of care? Select all that apply. 1. Arrange for a speech pathologist consult 2. Discuss community resources with family 3. Obtain a STAT ct scan of the head 4. Perform a baseline neurologic assessment 5. Prepare to initiate altepase within the next 3 hours

3, 4, & 5 Strokes may be either ischemic or hemorrhagic. Ischemic stroke occurs when circulation to parts of the brain is interrupted by occlusion of cerebral blood vessels by a thrombosis or embolus. Hemorrhagic stroke occurs when a cerebral blood vessel ruptures and bleeds into the cranial vault. Both types of stroke result in brain tissue death without prompt treatment. A client with stroke symptoms must have an immediate CT scan or MRI of the head to determine the type and location of the stroke (Option 3). Determining exactly when symptoms began is essential for diagnosis and planning treatment. Thrombolytic therapy (eg, alteplase, tissue plasminogen activator [tPA]) is used to dissolve blood clots and restore perfusion to brain tissue in clients with an ischemic stroke unless contraindicated (eg, active bleeding, uncontrolled hypertension, aneurysm). It must be administered within 4.5 hours from onset of symptoms (Option 5). A baseline neurologic assessment is essential for tracking ongoing neurologic symptoms that indicate improvement or complications which guide later treatments (Option 4). (Options 1 and 2) Consultation with a speech pathologist and providing the family with information about community resources are important later but not during the initial (acute) phase of stroke management. Educational objective: The initial plan of care for a client with an acute stroke should include performing baseline neurologic assessment to begin monitoring neurologic status trend, obtaining an immediate CT scan of the head to determine stroke type, and anticipating administration of thrombolytics (if indicated) within 4.5 hours of symptom onset.

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention does the nurse anticipate? 1. Administering PRN antiemetic prior to the infusion 2. Administering via an infusion pump over at least 30 minutes 3. .Drawing a trough level just prior to administration of the vancomycin 4. Starting a new IV line before administration

3. DRAWING A TROUGH LEVEL JUST PRIOR TO ADMINISTRATION OF THE VANVOMYCIN Vancomycin is a very potent antibiotic that can cause nephrotoxicity and ototoxicity. Measuring for serum concentrations is a way to monitor for risk of nephrotoxicity as well as for therapeutic response. Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A trough should be obtained just prior (about 15-30 minutes) to administration of the next dose. (Option 1) Unlike some chemotherapy medications, vancomycin does not commonly cause nausea or vomiting. Premedication with antiemetics is not required. However, premedication with antihistamines (diphenhydramine) is recommended if the client had developed red man syndrome, also known as red neck syndrome, with prior vancomycin infusion. This syndrome is characterized by red blotching of the face, neck, and chest due to too rapid administration. (Option 2) Vancomycin should be administered over a minimum of 60 minutes. Too rapid administration can cause red man syndrome, considered a toxic effect rather than an allergic reaction. (Option 4) The nurse would want to verify patency of the IV line prior to administration as thrombophlebitis is a possibility with vancomycin; however, a new IV line is not necessarily required. Educational objective: To measure for efficacy and risk of nephrotoxicity with vancomycin, the nurse should draw periodic trough levels just prior to administration of the next IV dose.

A pregnant client provides the following obstetric history to the nurse at the first prenatal visit: Elective abortion at age 17; a 5-year-old daughter born at 40 weeks gestation; and 3-year-old twin boys born at 34 weeks gestation. Using the GTPAL system, which option is correct? 1. G3, T1, P1, A1, L3 2 .G3, T1, P2, A1, L3 3. G4, T1, P1, A1, L3 4. G4, T1, P2, A1, L3

3. G4, T1, P1, A1, L3 The GTPAL system is a shorthand system of documenting a client's obstetric history. Under this system, twins, triplets, or other multiple births count as one in the term (T) or preterm (P) category but are counted separately (as 2, 3, or more) in the living child (L) category. A current pregnancy (not yet delivered), as in this client, counts in the gravida (G) category as this category includes all pregnancies, past and present. In this scenario, the client is a G4 T1 P1 A1 L3. She is gravida (G) 4 as she has a history of 4 pregnancies (which includes the present pregnancy) (Option 3). The client delivered a child at 40 weeks gestation (counts 1 in the term [T] category). She delivered twins at 34 weeks gestation, reflected as a single birth (1 pregnancy) in the preterm (P) category and as 2 living children in the living child (L) category. She had an elective abortion, reflected as 1 in the abortion (A) category. She has a total of 3 living children (1 term and 2 preterm children), reflected in the living child (L) category. Educational objective: Under the GTPAL system, G - gravida indicates the number of pregnancies, delivered or undelivered; T - term deliveries are from 37 wk 0 days and beyond; P - preterm deliveries are from 20 wk 0 days to 36 wk 6 days gestation; A - abortions (spontaneous or elective) occur prior to 20 wk 0 days gestation; and L - living children are counted individually regardless of multiple birth status.

A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? Select all that apply. 1. Identify the number "8" traced on the palm 2. Shrug the shoulder against resistane 3. Swallow water 4. Touch each finger of one hand to the hands thumn 5. Walk heel-to-toe

4 & 5 The cerebellum is involved in 2 major functions: coordination of voluntary movements and maintenance of balance and posture. Maintenance of balance is assessed with gait testing and includes watching the client's normal gait first and then the gait on heel-to-toe (tandem), on toes, and on heels (Option 5). Coordination testing involves the following: Finger tapping - ability to touch each finger of one hand to the hand's thumb (Option 4). Rapid alternating movements - rapid supination and pronation Finger-to-nose testing - clients touch the clinician's finger and then their own nose as the clinician's finger varies in location Heel-to-shin testing - client runs each heel down each shin while in a supine position (Option 1) This is a test of sensory function, specifically fine touch (graphesthesia). Other tests for this include identifying an object in the hand (stereognosis) and two-point discrimination. (Option 2) Shrugging the shoulders against resistance (as well as turning the head against resistance) is a test for cranial nerve (CN) XI (spinal accessory). (Option 3) In a client who has an intact gag reflex, the ability to swallow water helps to assess CN IX (glossopharyngeal) and CN X (vagus). The nurse can also observe for a symmetrical rise of the soft palate and uvula by asking the client to say "ah." Educational objective: The cerebellum is involved in coordination of voluntary movements and maintenance of balance and posture. Balance is assessed with heel-to-toe gait testing. Coordination is assessed with finger tapping, rapid alternating movements, finger-to-nose testing, and heel-to-shin testing.

A diabetic woman has a precipitous delivery in the emergency department. Which initial neonate assessment finding is the priority and requires a nursing response? 1. Apgar score at 1 minute 2. APical heart rate of 160 3. Circumoral duskiness 4. Jitteriness

4. JITTERINESS Infants of diabetic mothers are at risk of hypoglycemia and hypocalcemia. The transitional time (the first 6 hours after birth) is especially high risk for hypoglycemia as the fetus produced high levels of insulin in response to the high levels of circulating maternal glucose. The insulin level for a diabetic mother's neonate remains higher than normal in the first few hours of extrauterine life, making the neonate at risk for hypoglycemia. Hypoglycemia in a newborn is considered a blood glucose level <40 mg/dL (2.2 mmol/L). Symptoms of hypoglycemia include jitteriness, irritability, hypotonia, apnea, lethargy, and temperature instability. (Option 1) An Apgar score of 7-10 indicates a stable status. Apgar assessment is normally performed at 1 minute and 5 minutes after birth. If the 5 minute score is <7, additional scores should be assigned every 5 minutes up to 20 minutes. (Option 2) Normal neonatal heart rate is 110-160/min. The rate can increase to 180/min with crying and fall as low as 100/min during sleep. Sustained tachycardia (>160/min) for >10 minutes indicates possible sepsis, respiratory distress, or congenital heart abnormality. Bradycardia indicates possible sepsis, increased intracranial pressure, or hypoxia. The neonate's heart rate should be assessed by taking an apical rate for a full minute (noting the rate and rhythm). (Option 3) Circumoral cyanosis is a benign, localized, transient cyanosis around the mouth during the transition period. If it persists, it may be related to a cardiac anomaly. Educational objective: Infants of diabetic mothers are at high risk for hypoglycemia, especially in the transition period. A common symptom of hypoglycemia in a newborn is jitteriness.

A 24-year-old female client has been prescribed isotretinoin for severe nodulocystic acne that has been resistant to other therapies. Which instruction is most important for the nurse to reinforce with this client? 1. Apply lubricating eye drops when wearing contacts 2. Swallow capsules whole 3. Use sunscreen routinely 4. Use 2 forms of contraception

4. USE TWO FORMS OF CONTRACEPTION Isotretinoin (Accutane) decreases sebum secretion and is prescribed for severe, disfiguring nodular acne that has been unresponsive to other therapies, including antibiotics. It is a pregnancy category X drug and is known to cause serious birth defects if taken during pregnancy. Females prescribed isotretinoin must have 2 negative pregnancy tests before taking the medication. Also, 2 forms of contraception must have been in place for at least 1 month prior to starting isotretinoin, and these must be continued both during treatment and for 1 month after the medication is discontinued. Before refills can be obtained, enrollment in a risk management program is required to verify that pregnancy tests are negative and 2 forms of contraception are being used. Blood donation is also discouraged while on therapy and for 1 month afterward to ensure that pregnant women do not receive any donated blood. (Option 1) Dryness of the eyes, mouth, and skin are common side effects. Lubricating eye drops may be needed to wear contacts. Some clients are unable to wear contacts while taking this medication. Good oral hygiene and skin care are needed. (Option 2) Capsules should be swallowed whole with at least 8 oz of water or other fluid. Capsules should not be broken, crushed, or chewed as contents of opened capsules could irritate esophagus. (Option 3) This medication causes photosensitivity. The nurse should teach the client to use sunscreen routinely. Educational objective: Isotretinoin is a pregnancy category X drug and will cause birth defects if taken during pregnancy. The client must use 2 forms of birth control for 1 month prior to taking the medication as well as during treatment and 1 month afterward. The client must also be enrolled in a risk management program prior to receiving refills.

A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.... I can get out of anything. There could be trouble now." Which of the following is the best response to this client? 1. How are you feeling now 2. How did you manage to get out of the restraints 3. Say nothing but signal to other staff that assistance is needed 4. What kind of trouble are you thinking about

4. WHAT KIND OF TROUBLE ARE YOU THINKING ABOUT? In this situation, the priority nursing action is to quickly and calmly assess this client's present risk for violence before implementing an intervention. This client's statement, "There could be trouble now," has multiple possible meanings (eg, Is the nurse "in trouble" as the restraints may not have been applied properly? Are the other clients in the unit "in trouble" as this client is out of restraints? Is this client "in trouble" due to thoughts of self-harm?). Seeking clarification of this client's statement is a therapeutic communication technique that will help the nurse determine the next steps in providing care. Mechanical restraints may be necessary only as a last resort for a client at high risk for violence, self-directed or other-directed. Clients placed in restraints must be observed and monitored frequently for: Assisting with hydration, elimination, and positioning Ensuring that circulation is not compromised Determining readiness for removal of restraints (Option 1) It is important to ask this client about current feelings. However, in this situation, the priority is to clarify this client's statement. (Option 2) This statement is immaterial; it is important to assess this client's current status. (Option 3) Assistance from another staff member may be necessary if this client is still at high risk for violence; this client needs to be assessed first. Educational objective: A client at high risk for violence, self-directed or other-directed, may need to be placed in restraints as a last resort. Frequent monitoring and assessment through observation and use of therapeutic communication techniques will help determine if a client is ready to have restraints removed.

The nurse is providing discharge instructions on the proper use of prescribed short-acting beta agonist and inhaled corticosteroid metered-dose inhalers to a client with newly diagnosed asthma. Which instructions should the nurse include? Select all that apply. 1. Omit the beclomethasone if the albuterol is effective 2. Rinse your mouth well after using the beclomethasone inhaler and do not swallow the water 3. Take the albuterol inhaler apart and wash after every use 4. Use the albuterol inhaler first if needed, then the beclomethasone inhaler 5. Use the beclomethasone inhaler first, then the albuterol, if needed

2 & 4 Asthma is a disorder of the lungs characterized by reversible airway hyper-reactivity and chronic inflammation of the airways. Albuterol (Proventil) is a short-acting beta agonist (SABA) administered as a quick-relief, rescue drug to relieve symptoms (eg, wheezing, breathlessness, chest tightness) associated with intermittent or persistent asthma. Beclomethasone (Beconase) is an inhaled corticosteroid (ICS) normally used as a long-term, first-line drug to control chronic airway inflammation. When using an ICS metered-dose inhaler (MDI), small particles of the medication are deposited and can impact the tongue and mouth. Rinsing the mouth and throat well after using the MDI and not swallowing the water are recommended to help prevent a Candida infection (thrush) (white spots on tongue, buccal mucosa, and throat), a common side effect of ICSs. The use of a spacer with the inhaler can also decrease the risk of developing thrush (Option 2). When both MDIs are to be taken at the same time, clients are instructed to take the SABA first to open the airways and then the ICS to provide better delivery of the medication. It is important for the nurse to clarify indications and sequencing as the SABA is a rescue drug taken on an as-needed basis and is not always taken with the ICS (Options 4 and 5). (Option 1) Inhaled corticosteroids (eg, fluticasone, beclomethasone) are not rescue drugs. They are prescribed to be taken on a regular schedule (eg, morning, bedtime) on a long-term basis to prevent exacerbations and should not be omitted even if the SABA is effective. (Option 3) Taking the albuterol (Proventil) inhaler apart, washing the mouthpiece (not canister) under warm running water, and letting it air dry at least 1-2 times a week is recommended. Medication particles can deposit in the mouthpiece and prevent a full dose of medication from being dispensed. Taking the ICS inhaler apart and cleaning it every day is recommended. Educational objective: Proper use of the short-acting beta agonist (SABA) inhaler includes taking it apart and rinsing the mouthpiece with warm water 1-2 times a week. Proper use of the inhaled corticosteroid (ICS) inhaler includes taking it apart and rinsing the mouthpiece with warm water daily and rinsing the mouth and throat after each use to prevent a Candida infection (thrush). When these medications are administered together, the sequence is SABA first to open the airways and ICS second.

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used.

-Hand hygiene -Gown -Mask or respirator -Goggles or face shield -Gloves

Which are appropriate examples of cost-effective care? Select all that apply. 1. Considering the inside of sterile gloves wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a pt's dressing 3. Returning unopened, unused supplies from a pt's room to the central supply room 4. Reusing a tourniquet for multiple pts unless it is visibly soiled 5. Using remaining sterile saline in abottle opened 48 hours ago before discarding

1 & 2 Removing a dressing that has been on the client's skin is not a sterile procedure (unlike applying a new dressing, when sterile technique is commonly used). The gloves need to be removed and changed prior to application of a new dressing. There is no need to use the more expensive sterile gloves. The sterile glove wrapper is inside a paper package and is sterile. It can be used as a small sterile field if properly opened, with the other aspects of asepsis/sterile field observed (eg, do not get it wet, do not reach over it). (Option 3) Once supplies have been in a client's room, they are "contaminated" and cannot be returned to a central source or used on other clients. They can be sent home with the client for the client's own use. (Option 4) Tourniquets should be for single client use. They should not be shared as there is a risk of cross-infection, even if contamination is not visible. (Option 5) Pour bottles and IV bags with sterile solutions have no preservative and must be changed every 24 hours after being accessed. After 24 hours following opening a bottle of sterile saline, the solution is considered contaminated and must be discarded, even if there is still unused solution in the container. Educational objective: Use clean, rather than sterile, gloves when removing contaminated dressings. The inside of a sterile glove wrapper is sterile. Do not return items in clients' rooms to central supplies, discard sterile solution after 24 hours, and do not reuse tourniquets between clients.

A nurse is caring for a client who is breastfeeding and has been diagnosed with mastitis of the right breast. Which instructions should be included in the teaching? Select all that apply. 1. Increase oral fluid intake 2. Cease breastfeeding from the right breast 3. Reduce frequency of feeds to every 8 hours in right breast 4. Take ibuprofen as needed for pain 5. Use underwire bra for 24 hours a day for support

1 & 4 Mastitis is a common infection in postpartum women due to multiple risk factors leading to inadequate milk duct drainage (eg, poor latch). Bacteria are transmitted from the infant's nasopharynx or the mother's skin through the nipple and multiply in stagnant milk. Staphylococcus aureus is the most common offending organism. Symptoms of mastitis include fever, breast pain, and focal inflammation (redness, edema). In addition to antistaphylococcal antibiotics (dicloxacillin or cephalexin) and analgesics (eg, ibuprofen), treatment of lactational mastitis requires effective and frequent milk drainage. Milk ducts are most efficiently drained by direct breastfeeding. The correct position for optimal milk intake involves the infant forming a tight seal around most of the areola. However, a common cause of severe pain during latching occurs when the infant only suckles on the nipple. This improper position can cause nipple blistering. Adequate rest and increase of oral fluid intake is also recommended. (Options 2 and 3) Breastfeeding should be continued every 2-3 hours to relieve milk duct obstruction. Mothers should be reassured that the infant can safely feed from the infected breast as the newborn is already colonized with the mother's skin flora. (Option 5) Underwire bras (tight bras) are not recommended with breastfeeding or mastitis as milk flow is impeded, worsening engorgement. Soft cup bras are recommended for support and to encourage milk flow. Educational objective: Treatment of lactational mastitis includes antibiotic therapy, breast support, adequate hydration, analgesics, and frequent continued breastfeeding (every 2-3 hours).

The nurse educates a 30-year-old female client who is being evaluated for hyperthyroidism with a radioactive iodine uptake (RAIU) test. Which instruction(s) should the nurse include in the teaching plan? Select all that apply. 1. A pregnancy test must be obtained prior to RAIU test administration 2. All jewelry around the neck area should be removed before th RAIU test 3. Antithyroid medications should be held for 5-7 days before the RAIU test 4. Concious sedation will be used to help with relaxation during the RAIU test 5. It is important to refrain from eating ot drinking for at least 12 hours before the RAIU test

1, 2, & 3 A RAIU test involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease). Important nursing considerations: Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results. Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also alter results. All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the development of the fetal thyroid gland. Important aspects of client education: Maintain nothing by mouth (NPO) status for 2-4 hours prior to the procedure (Option 5). Eating may resume 1-2 hours after swallowing the iodine; a normal diet can be restarted when the test ends. Remove dentures and jewelry/metal around the neck to allow clear visualization during the scan. Drink plenty of fluids after the procedure to clear RAI from the system. Notify the PHCP if you are allergic to any medications (eg, iodine). However, a RAIU test is generally safe (even in the presence of an iodine allergy) due to the diminutive amount of iodine used. You will be awake during the procedure but there should be no discomfort (Option 4). Do not breastfeed immediately after this procedure, and ask your PHCP when breastfeeding may resume. Educational objective: RAIU measures the metabolic activity in the thyroid gland in order to differentiate between the many types of thyroid disorders. For an accurate measurement, medications affecting the thyroid should be held 7 days prior to the test date and clients are NPO for 4 hours prior to iodine administration. Premenopausal women must take a pregnancy test. Dentures, metal, and jewelry should be removed.

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to <20 mL/hr over the past 2 hours. The postoperative hematocrit is 36% (0.36), and the hemoglobin is 12 g/dL (120 g/L). Which action should the nurse carry out first? 1. Assess vital signs 2. Increase the IV rate to 125 3. Notify the HCP 4. Perform bladder scan

1. ASSESS VITAL SIGNS Third-spacing of fluids can occur 24-72 hours after extensive abdominal surgery as a result of increased capillary permeability due to tissue trauma. It occurs when too much fluid moves from the intravascular into the interstitial or third space, a place between cells where fluid does not normally collect (ie, injured site, peritoneal cavity). This fluid serves no physiologic purpose, cannot be measured, and leads to decreased circulating volume (hypovolemia) and cardiac output. The priority intervention is to assess vital signs as the manifestations associated with third-spacing include weight gain, decreased urinary output, and signs of hypovolemia, such as tachycardia and hypotension. If third-spacing is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and hypovolemic shock (Option 1). (Option 2) Increasing the IV flow rate of the isotonic solution may be an appropriate intervention once the nurse has assessed the client, including taking a full set of vital signs. The nurse should intervene only after assessing to rule out other problems for which an increase in IV fluid intake would not be an appropriate solution (eg, Foley catheter obstruction). (Option 3) The nurse will notify the health care provider to report oliguria (<0.5 mL/kg/hr) after collecting all of the data necessary (ie, vital signs). This is not the nurse's first action. (Option 4) Urinary retention is possible following surgery due to the adverse effects of anesthesia, opioids, anticholinergic drugs, and immobility. However, a bladder scan is not an appropriate action in this situation as the client has a Foley catheter. Irrigating the catheter is the appropriate intervention if the nurse questions its patency. Educational objective: Third-spacing can occur following extensive abdominal surgery and can lead to hypovolemia, decreased cardiac output, hypotension and tachycardia, and decreased urine output. Monitoring vital signs and urine output, and maintaining IV fluids are appropriate interventions to prevent prerenal failure and hypovolemic shock.

The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? 1. I will ask the HCP to expllain the consequences of your procedure 2. This is a common complication that will require you to have a hearing test ev ery year 3. This is a common complication; your HCP will order a consult for the speech pathologist 4. This is the reason you are using a special swallwoing technique when you eat and drink

4. THIS IS THE REASON YOU ARE USING A SCPECIAL STRAT TO ORDER A SPEECH PATHOLOGIDT Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to: Inhale deeply Hold breath tightly to close the vocal cords Place food in mouth and swallow while continuing to hold breath Cough to dispel remaining food from vocal cords Swallow a second time before breathing (Option 1) This would be considered "passing the buck." The nurse should try to address the client's concerns before calling the health care provider. (Option 2) Cranial nerve VIII (vestibulocochlear) affects hearing and equilibrium, not swallowing. (Option 3) The speech pathologist conducts a swallowing assessment early on to evaluate a client's ability to swallow safely. This consult is not done at discharge. Educational objective: Clients who undergo a partial laryngectomy are at increased risk for aspiration. As a result, they are taught a swallowing technique (supraglottic swallow) to decrease this risk.