LAST DEMO SORTA

severe pulmonary edema

Acute-onset dyspnea and cough productive of pink, frothy sputum indicate severe pulmonary edema, likely a complication from myocardial infarction. Pink sputum results from ruptured bronchial veins due to high back pressure. The mix of blood and airway fluids creates the pink tinge. On assessment, crackles can be heard at the lung bases. (Option 1) Bronchial breath sounds are normally heard over the trachea. These are harsh and high-pitched; inspiration and expiration are of similar duration. The presence of these on lung periphery indicates pneumonia (consolidation). (Option 2) Clear vesicular breath sounds (normal breath sounds) are not expected in pulmonary edema. (Option 4) Stridor is consistent with a laryngospasm or edema of the upper airway. Educational objective:Acute-onset dyspnea and cough with frothy, pink-tinged sputum indicate pulmonary edema. Auscultation reveals crackles at the lung bases.

Instructions for proper NTG administration include:

Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months (Option 1). Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS) should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment (Option 3). Avoid fatal drug interactions: Concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers (terazosin, tamsulosin) is contraindicated due to potentially fatal hypotension (Option 2). Headache may occur: Headache and flushing are common side effects of NTG due to systemic vasodilation and do not warrant medication discontinuation (Option 4). Educational objective:The nurse should instruct the client who is taking sublingual NTG to keep the tablets in a tightly capped, dark bottle away from heat and light. The client should be taught to take 1 tablet every 5 minutes (up to 3 tablets), but notify EMS if the pain does not improve or worsens 5 minutes after the first pill has been taken. These instructions should be reinforced at each appointment.

The practical nurse is performing a cardiac assessment in collaboration with the registered nurse. Where does the nurse expect to feel the client's point of maximal impulse?

The point of maximal impulse (PMI) is also called the apical pulse. It reflects the pulsation of the apex of the heart and should be felt medial to the midclavicular line at the 4th or 5th intercostal space. When the PMI is below the 5th intercostal space or left of the midclavicular line, the heart may be enlarged. Educational objective:The nurse should palpate the point of maximal impulse (PMI) medial to the midclavicular line at the 4th or 5th intercostal space. Palpation of the PMI below the 5th intercostal space or to the left of the midclavicular line may indicate cardiac enlargement.

Radiation therapy

to the head and neck can decrease a client's oral intake due to the development of mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth). These adverse side effects affect speech, taste, and ability to swallow and can have a significant impact on the client's nutritional status. The nurse teaches the client to: Avoid irritants such as spicy, acidic, dry, or crumbly foods; coffee; and alcohol (Option 1). Consume supplemental nutritional drinks (eg, Ensure), which are often easier to swallow (Option 3). Use artificial saliva to manage xerostomia and the production of thick saliva due to altered salivary gland function (Option 5). Sipping water throughout the day is equally effective and less expensive. (Option 2) Topical anesthetics (eg, lidocaine) have been found to increase comfort and improve oral intake in clients with mucositis due to radiation therapy. (Option 4) Clients on radiation therapy need to maintain more frequent (eg, before and after meals, at bedtime) oral hygiene (eg, using soft toothbrush, rinsing with baking soda solution) due to the drying effects of mucositis. Educational objective:Radiation therapy to the head and neck can cause mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth), leading to decreased nutrition. Care includes avoiding irritants, consuming supplements, using artificial saliva or sipping water, and performing frequent oral hygiene.

Individuals with obsessive-compulsive personality disorder

typically self-willed and obstinate, punctual, pay attention to rules and regulations, and need to control both internal and external experiences. These traits are very extreme and result in rigidity and inflexibility. In this scenario, a change has been made in the client's schedule for the day and is outside of the client's control. This could cause significant distress and impaired functioning so that the client feels emotionally paralyzed. (Option 1) This response is characteristic of a client with narcissistic personality disorder, who may behave in grandiose, demanding, and entitled ways and needs to have his/her own way. (Option 2) This response could be attributed to a client with dependent personality disorder, who tends to be passive and submissive and wants to please others. (Option 4) This response would be more characteristic of an individual with paranoid personality disorder, who may feel slighted or is overly sensitive. Educational objective:An individual with obsessive-compulsive personality disorder is typically rigid and inflexible and has a need to control both internal and external experiences. A change in a schedule that is outside of the client's control could cause significant distress.

In the event of an accidental decannulation or another urgent need to change a tracheostomy tube

the most important action is to quickly replace the tube as it is the client's only means to ventilate. Clients should always carry two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is meeting resistance, the smaller tube should be used. (Option 2) Changing a tracheostomy tube is a high-risk procedure that should be done only if respiratory distress is noted and other interventions (eg, suctioning) have failed. Mucus plugs (ie, thickening and buildup of mucus due to dehydration) are one of the most common causes of respiratory distress. (Option 3) A tracheostomy should be suctioned frequently to maintain airway patency. However, deep suctioning should be reserved for clients in respiratory distress due to the risk of injury. Tracheostomy tubes should be suctioned to the specified depth using a measurement marked on the tube, to provide safe, effective suctioning. (Option 4) Humidification is crucial for clients with a tracheostomy as the upper airway, which provides natural humidity for inhaled air, is bypassed. Humidification helps keep secretions thin and reduces formation of mucus plugs. The humidifier should not be removed if the child develops more secretions as this is the intended effect. Educational objective:Clients with a tracheostomy should always carry two spare tubes, one the same size and one a size smaller, to ensure that the tube can be replaced quickly and effectively.

atrioventricular pacemaker

(also known as a sequential or dual chamber pacemaker) paces the right atrium and right ventricle in sequence. The ECG will have 2 pacer spikes, one before the P wave and one before the QRS complex. The P wave following the atrial pacer spike may be normal or abnormal appearing. The QRS complex following the ventricular pacer spike is typically wide and distorted. An atrioventricular pacemaker can improve synchrony between the atria and ventricles. It may be implanted in the client with bradycardia, heart block, or cardiomyopathy. (Option 1) An atrial paced rhythm would have a pacer spike before the P wave only. The P wave may appear normal or abnormal; the QRS complex will appear normal. (Option 3) Biventricular pacemakers (also known as sequential biventricular pacemakers) generate impulses in both ventricles. Two ventricular pacing spikes may be seen on the ECG, and one spike may appear after the beginning of the QRS complex. (Option 4) A ventricular paced rhythm would only have a pacer spike prior to a wide QRS complex. Impulses are generated in only one ventricle (typically the right ventricle). Educational objective:An atrioventricular pacemaker (also known as sequential or dual chamber) paces the right atrium and right ventricle in sequence. Two pacer spikes are visible on the ECG, one prior to the P wave and a second prior to the QRS complex. Atrioventricular pacemakers improve cardiac synchrony between the atria and ventricles.

tumor necrosis factor (TNF) inhibitor.

(eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies. Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these drugs. Otherwise, TB reactivation would occur (Option 4). (Option 1) CRP is a non-specific test used to detect acute or chronic inflammation in the body. CRP can be used to evaluate the effectiveness of medications that decrease inflammation. An elevation would be expected in clients with RA, especially during a flare, but it is not the most important test result to check before initiating therapy. (Options 2 and 3) LDL cholesterol and PT are unrelated to the administration of these medications. Educational objective:Major adverse effects of biologic disease-modifying TNF inhibitor drugs (eg, etanercept, infliximab, adalimumab) include severe infections and bone marrow suppression. TB reactivation is a major concern. Therefore, all clients must receive a TST to rule out latent TB.

Potassium-sparing diuretics

(eg, spironolactone, amiloride, triamterene eplerenone) are generally very weak diuretics and antihypertensives. However, they are useful when combined with thiazide diuretics to reduce potassium (K+) loss. Thiazide diuretics can cause hypokalemia when used as monotherapy. A potassium level of 4.2 mEq/L (4.2 mmol/L) falls in the normal range (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), which indicates that spironolactone has been effective in preventing hypokalemia in this client receiving a thiazide diuretic (eg, hydrochlorothiazide, chlorthalidone) (Option 2). (Option 1) Blood glucose levels can be increased by thiazide diuretics but are not affected by potassium-sparing diuretics. (Option 3) All diuretics, including spironolactone, have the potential to cause dizziness. The nurse should monitor the client for orthostatic hypotension and implement safety precautions. (Option 4) Potassium-sparing diuretics exchange sodium for potassium in the kidneys; potassium is saved but sodium is lost. Therefore, a normal sodium level (135-145 mEq/L [135-145 mmol/L]) is not the desired effect. Educational objective:Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene, eplerenone) are often combined with thiazide diuretics to reduce potassium loss.

Naloxone (Narcan), an opioid antagonist, will temporarily reverse the effects of any opioid medications.

A client in the postoperative period who is unresponsive to painful stimuli is likely still under the effects of opioid medications used during anesthesia. Naloxone (Narcan), an opioid antagonist, will temporarily reverse the effects of any opioid medications. However, the half-life of naloxone is shorter than that of most opioid medications (ie, the effect typically wears off in 1-2 hours), and a second dose may be required. The nurse should make frequent observations of the client's respiratory rate and administer prescribed oxygen for respiratory support (Options 1 and 5). The registered nurse should be notified to fully assess the client and to administer a second dose of naloxone as prescribed (either a one-time dose or continuous drip) (Option 2). (Option 3) A postoperative client will likely still need pain medication due to the trauma from surgery. Pain should be managed with nonopioids (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) if needed. (Option 4) An overly sedated client is not an indication for a rapid response team. Although this intervention is unlikely to cause harm to the client, it is not necessary and may result in overuse of personnel resources. Educational objective:Naloxone is usually prescribed as needed in postoperative clients for over-sedation related to opioid use. The nurse should monitor clients who are given naloxone with the understanding that the opioid antagonist has a shorter half-life than that of most of the opioids it is meant to counteract. As a result, a second dose of naloxone may be necessary.

Acne vulgaris

Acne vulgaris is a skin disorder characterized by obstructed sebaceous glands, which form comedones (ie, blackheads, whiteheads). Bacteria consume and metabolize the obstructed sebum, and the metabolic products cause inflammation, pustules, papules, and nodules. Acne usually develops during puberty, and multiple factors influence its development (eg, overgrowth of normal bacteria, heredity, stress, hormones). Treatment includes topical and oral medications such as tretinoin (Retin-A), benzoyl peroxide, isotretinoin (Accutane), and oral contraceptives. Antibacterial soaps are harsh and ineffective, increase the pH of the skin, and can dry the skin (Option 1). The client should instead gently wash the face with a mild facial cleanser. Additional self-care measures include: Using noncomedogenic skin care products (ie, products that do not clog pores) to avoid creating new lesions (Option 2) Maintaining a healthy lifestyle (eg, moderate exercise, balanced diet, adequate sleep) to reduce stress and promote healing (Option 3) Refraining from squeezing, picking, and vigorously scrubbing lesions to prevent additional inflammation and worsening the acne (Option 4) Educational objective:Acne vulgaris is a skin disorder that usually develops during puberty and is characterized by obstructed sebaceous glands; inflammation; and pustules, papules, and nodules. Antibacterial soaps dry the skin and are ineffective. The client should gently wash the face with a mild facial cleanser.

The following are important principles to teach clients with celiac disease:

All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. Rice, corn, and potatoes are gluten free and are allowed on the diet. Deficient vitamins (mainly fat-soluble vitamins), iron, and folic acid should be replaced. Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk of nutritional deficiencies and intestinal cancer (lymphoma). Eating even small amounts of gluten will damage the intestinal villi although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet (Option 3). Educational objective:All sources of gluten must be eliminated from the diet of a client with celiac disease; consuming small amounts, even in the absence of clinical symptoms, will increase the risk of damage to the intestinal villi. Clients can have foods containing rice, corn, and potatoes. They should read food labels and follow the diet for the rest of their lives.

MRI. Absolute contraindications include the following:

Cardiac pacemaker (Option 1) Implantable cardioverter defibrillator Cochlear implant Retained metallic foreign body, especially in organs such as the eye (Option 3) Relative contraindications include the following: Prosthetic heart valve Metal plate, pins, brain aneurysm clip, or joint prosthesis (Option 4) Select devices; those composed of nonferrous MRI-safe materials should be verified first Implanted device (eg, insulin pump, medication port) Other factors that can affect the client's eligibility include inability to remain supine for 30-60 minutes and claustrophobia; sedation can be prescribed or an open MRI machine can be used in such cases. (Option 2) Colostomy is not a contraindication for MRI. (Option 5) Transdermal metal-containing medication patches (clonidine, nicotine, scopolamine, testosterone, and fentanyl) are not a contraindication for MRI. However, these must be removed before and replaced after testing. Educational objective:Absolute contraindications for MRI include metallic implants (eg, pacemaker, implantable cardioverter defibrillator, plates, pins, brain aneurysm clips), implanted devices (eg, insulin pumps, medication ports), and prostheses (eg, joints, heart valves). Some of these devices are manufactured with MRI-safe materials that should be verified prior to testing.

A health-related belief of Jehovah's Witnesses

Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma) (Options 2, 3, and 5). Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered safely to clients who refuse blood products (Option 4). Recombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah's Witnesses. These medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and hemoglobin levels (Option 1). Educational objective:Jehovah's Witnesses believe that transfusion of blood and blood products is not acceptable. Acceptable blood product alternatives include non-blood volume expanders (eg, saline, lactated Ringer's, dextran, hetastarch) and albumin-free erythropoietin. Unacceptable treatments are transfusions of whole blood, red cells, white cells, platelets, and plasma.

Clients with chronic kidney disease (CKD) have decreased glomerular filtration, resulting in retention of fluid, potassium, and phosphorus.

Fluid retention is initially treated with sodium restriction and diuretic therapy. Dietary adjustments should also be made to reduce serum potassium and phosphorus. Laboratory values are key to determining allowable foods. Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products also contain high phosphorus levels. Examples of allowable foods for CKD clients include apples, pears, grapes, pineapple, blackberries, blueberries, and plums. (Option 2) Avocados are high in potassium; the chips may be high in sodium. (Options 3 and 4) Pudding and yogurt contain dairy products and are high in phosphorous and potassium. Oranges are high in potassium. Educational objective:The diet for a client with chronic kidney disease may need to be restricted in fluids, sodium, potassium, and phosphorus. Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products are also high in phosphorus.

A child who demonstrates a slow growth pattern will undergo diagnostic evaluation to determine the cause

If the cause is found to be growth hormone deficiency, the child may undergo growth hormone replacement therapy. The biosynthetic hormone is administered via subcutaneous injection on a daily basis. Despite replacement therapy, the child may still have a final height less than "normal." Treatment is most successful when diagnosis and replacement therapy begin early in the child's life. When to stop therapy is decided by the client, family, and provider. However, growth less than 1 inch (2.5 cm) per year and bone age of 14 years in girls and 16 years in boys are the criteria often used to stop therapy. (Option 1) Growth hormone replacement does not guarantee that a child will grow at a rate equal to peers. Treated children often remain shorter than their peers. (Option 2) Replacement therapy is not continued throughout a child's life. It is stopped when bone growth begins to cease or when the child, parents, and provider make the decision. (Option 3) Replacement therapy is most successful when treatment begins early, as soon as growth delays are noted. Educational objective:Growth hormone replacement is an option for children who are not growing according to accepted standards. The treatment should begin as soon as delays are noted and continue until bone growth begins to cease despite replacement therapy. Replacement is administered via subcutaneous injections.

This client has chronic kidney disease with an elevated serum creatinine level.

Ketorolac (Toradol) is a highly potent nonsteroidal anti-inflammatory drug (NSAID) often used for pain and available in intravenous form. However, NSAIDs (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. Also, the client should not be given 2 types of NSAIDs simultaneously (eg, naproxen plus ibuprofen) as they can be toxic to the stomach and kidneys. (Option 1) Prescribing acetaminophen as needed is appropriate to treat fever. (Option 2) Clients with chronic kidney disease often have anemia due to erythropoietin deficiency. Recombinant erythropoietin injections are often prescribed to treat anemia. (Option 4) Levofloxacin is an appropriate antibiotic to use for treating pneumonia. Educational objective:Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. In addition, clients taking a NSAID medication should not take a different NSAID medication at the same time.

Nurses assisting a client to collect sputum should instruct the client to:

Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora (Option 1) Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin (Option 2) Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume (Option 3) Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection (Option 5) (Option 4) Sputum specimens should be collected early in the morning after awakening, which improves the quality of the sample because secretions accumulate overnight due to cough inhibition. A nebulizer treatment may be prescribed to help mobilize thick secretions.

This client is experiencing acute pulmonary edema

Sitting upright (high Fowler's position) at the edge of the bed with the legs dangling is the appropriate position. This position will reduce the venous return to the heart and congestion to the lung, promote lung expansion, and immediately alleviate the client's symptoms and respiratory effort. (Options 2, 3, and 4) Left Sims', supine, and modified Trendelenburg positions will increase the venous return, augment pulmonary congestion, and worsen the client's condition. Modified Trendelenburg is an optimal position for a client in hypovolemic shock. Educational objective:The proper positioning for acute pulmonary edema is high Fowler's with the legs dangling.

Discharge teaching for a client who had deep venous thrombosis (DVT) emphasizes minimization of risk factors and interventions to promote blood flow and venous return and prevent reoccurrence.

Teaching points include the following: Drink plenty of fluids and limit caffeine and alcohol intake to avoid dehydration, which predisposes to blood hypercoagulability and venous thromboembolism (Option 2). Elevate legs when sitting, and dorsiflex the feet often to reduce venous hypertension and edema and to promote venous return (Option 3). Begin or resume a walking/swimming exercise program as soon as possible to promote venous return through contraction of the calf and thigh muscles (Option 4). Change position frequently to promote venous return and circulation and prevent venous stasis. Stop smoking to prevent endothelial damage and vasoconstriction as this promotes clotting. Avoid wearing restrictive clothing (eg, Spanx, tight jeans) that interferes with circulation and promotes clotting. The nurse would suggest consultation with a nutritionist or enrollment in a weight-loss program to overweight/obese clients as excess weight contributes to venous insufficiency and hypertension by compressing large pelvic vessels. (Option 1) Traveling does not need to be avoided. During extended travel periods (>4 hours), clients are instructed to use preventive measures (eg, wear knee-high compression stockings, exercise calf and foot muscles every 30 minutes, take frequent breaks and walk briefly every hour, recline in their seats, remove objects around the feet and legs to allow maximal movement, drink ample fluids to avoid dehydration). (Option 5) Clients should avoid sitting in any cross-legged position and should never cross the legs at the knees or ankles as this compresses the veins and limits venous return.

cold injury

The clinical indications of a cold injury include redness and swelling of the skin (chilblains or pernio) and blanched skin with hardness of the affected area (frostbite). For any cold injury, it is important to re-warm the area as soon as possible to restore blood flow and reduce the risk of permanent tissue damage. The recommendation for re-warming is immersion of the affected area in warm water (104 F [40 C]) for about 30 minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of warm facecloths (Option 4). Once re-warming has been effective, the child should be seen by an HCP as soon as possible (Option 1). (Option 2) Giving the child something warm to drink is an appropriate intervention; however, re-warming the child's feet in warm water is the priority action. (Option 3) Massaging a body part that has sustained a cold injury is contraindicated due to the risk of tissue injury. Educational objective:The most important treatment for suspected chilblains/pernio or frostbite is re-warming of the affected area by immersion in warm (104 F [40 C]) water. The individual can also be given a warm liquid to drink and should be seen by an HCP as soon as possible.

With procedural moderate sedation at the bedside, the nurse takes on the role of an anesthetist.

The nurse's role is to monitor the client's condition while the health care provider focuses on performing the procedure. The nurse should never leave the client during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of the client next door. (Option 1) This action would place the UAP in the role of assessing and prioritizing, which is beyond the scope of the UAP's practice. In addition, the nurse must stay in the room and cannot meet the other client's need as a result. (Option 2) Taking on the role of assessing/monitoring (related to anesthesia) and/or administering additional intravenous drugs during the procedure is beyond the scope of the UAP's practice. (Option 3) The UAP has already communicated that the client's need is urgent. The client should not be kept waiting without further assessment to evaluate the situation. Educational objective:The nurse takes on the role of anesthetist when assisting with bedside procedural moderate sedation and cannot leave the client during the procedure.

Additional ways to deal with hallucinations include the following:

The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence. Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory (taste).

Uterine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the fetus.

Uterine contraction duration should not exceed 90 seconds. During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity. (Option 2) Uterine frequency should be 2-5 contractions every 10 minutes. If contractions occur less than 2 minutes apart, fetal distress can occur as a result of uteroplacental insufficiency. (Option 3) In the first stage of labor, the intensity of uterine contractions should be 25-50 mm Hg. Intrauterine pressure of more than 80 mm Hg is a sign of hypertonicity of the uterus. (Option 4) Uterine resting tone of 20 mm Hg or less is considered acceptable. Uterine resting tone allows blood flow to the placenta and therefore the fetus, ensuring a well-oxygenated fetus. Educational objective:Uterine contractions during labor dilate and efface the cervix and cause descent of the fetus. The contraction duration should not exceed 90 seconds or occur less than 2 minutes apart. Excess resting tone, contraction duration, and frequency result in uteroplacental insufficiency.

The cervical cap

a barrier method of contraception used with spermicide (eg, nonoxynol-9). The reusable, cup-shaped cap is placed over the cervix before intercourse to block sperm from the uterus. To allow time for sperm to die, the cap should remain in place for ≥6 hours after intercourse but should not remain for more than 48 hours (Option 3). The cap may remain in place for multiple acts of intercourse, but clients should confirm correct placement and insert additional spermicide into the vagina each time. (Option 1) Prior to insertion, spermicide is applied to the cervical cap to maximize contraceptive effectiveness. Spermicide should be applied inside the cap, along the rim of the cap, and in the groove on the underside of the cap. (Option 2) Use of cervical caps during menses (or during the postpartum period in clients with lochia discharge) increases the risk of toxic shock syndrome; an alternate contraceptive method should be used during this time. (Option 4) Inserting the cervical cap several hours before intercourse is acceptable and may improve correct use. Before each use, the client should inspect the cap for holes, cracks, or tears to ensure its effectiveness for blocking sperm. Educational objective:The cervical cap is a barrier method of contraception used with spermicide. It can be inserted several hours before intercourse and should be left in place for at least 6 hours after. Its use during menses increases the risk of toxic shock syndrome.

Sulfamethoxazole/trimethoprim (Bactrim, sulfa)

a common cause of allergic reactions that often present as delayed cutaneous reactions. Allergic reactions frequently begin with fever, followed by a flat, red rash (looks like measles) and itching. The priority is to identify the allergy and take appropriate measures. (Option 1) Frequent urination, more than 8 times in 24 hours or more often than every 2 hours, is an expected symptom of urinary tract infection (UTI). In addition, if the client is forcing fluids as recommended for this diagnosis, increased voiding could result. The UTI is already being treated with the antibiotic, and this symptom is not a priority. (Option 2) Dysuria, painful urination, is an expected symptom of UTI and does not require urgent intervention. The nurse could advocate for phenazopyridine hydrochloride (Pyridium), a urinary tract analgesic, for comfort, but stopping the drug to which the client is allergic is a priority. (Option 3) Blood or sediment (making the urine cloudy) can be present with a UTI. Treatment has been started, and identifying the allergy and taking appropriate measures are the priority. Educational object:Sulfa is a common cause of drug allergy that manifests as fever, rash, and itching. Identifying and treating a potential rash are the priority over management of expected symptoms for a known diagnosis.

Irritable bowel syndrome (IBS)

a common, chronic bowel condition caused by altered intestinal motility. Peristaltic action is affected, causing diarrhea, constipation, or a combination of both. Management focuses on reducing diarrhea or constipation, abdominal pain, and stress. Clients can manage symptoms with diet, medications, exercise, and stress management. To manage IBS, clients should restrict gas-producing foods (eg, bananas, cabbage, onions); caffeine; alcohol; fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) (eg, honey, high-fructose corn syrup, wheat); and other gastrointestinal (GI) irritants (eg, spices, hot/cold food or drink, dairy products, fatty foods). Clients should gradually increase fiber intake (eg, whole grains, legumes, nuts, fruits, vegetables) as tolerated. Foods that are generally well tolerated include proteins, breads, and bland foods (Option 4). (Option 1) Although they are a great source of fiber, beans are gas-producing and should be avoided. Most dairy products are GI irritants; however, yogurt is often better tolerated and may be included in the diet. (Option 2) Gas-producing cruciferous vegetables (eg, broccoli, cabbage) should be avoided. Alcohol exacerbates IBS symptoms. (Option 3) Hot beverages and caffeine (eg, coffee) irritate the GI tract. Bagels are gas-producing. Educational objective:Irritable bowel syndrome is a chronic condition characterized by altered intestinal motility, causing abdominal discomfort with diarrhea and/or constipation. Clients can manage symptoms by avoiding gas-producing foods (eg, broccoli), caffeine, alcohol, and gastrointestinal irritants (eg, high-fructose corn syrup, spices, dairy products) and by increasing fiber.

Disulfiram (Antabuse)

a form of aversion therapy that promotes abstinence from alcohol. If the client consumes alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can be fatal. Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist (Options 1 and 2). Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of hidden alcohol (Option 3). Teaching includes: Avoid hidden alcohol in:liquid cold and cough medicationsaftershave lotions, colognes, and mouthwashesfoods such as sauces, vinegars, and flavor extracts Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur Wear a bracelet alerting others of being on disulfiram therapy (Option 4) Educational objective:Disulfiram is a medication that promotes abstinence from alcohol by causing uncomfortable, potentially fatal reactions when alcohol is consumed. Clients must avoid sources of hidden alcohol (eg, liquid cough medicine, aftershave, mouthwash). Effects of the drug can last 2 weeks after the last dose.

Acute angle-closure glaucoma

a form of glaucoma that requires immediate medical intervention. Glaucoma disorders are characterized by increased intraocular pressure (IOP) due to decreased outflow of the aqueous humor, resulting in compression of the optic nerve that can lead to permanent blindness. In acute angle-closure glaucoma, IOP increases rapidly and drastically, which can lead to the following manifestations: Sudden onset of severe eye pain Reduced central vision Blurred vision Ocular redness Report of seeing halos around lights (Options 1 and 3) Gradual loss of peripheral vision and difficulty adjusting to different lighting are manifestations of chronic open-angle glaucoma. Although further evaluation and treatment are necessary, this condition develops slowly and is not considered an emergency situation. (Option 4) Opaque lenses are characteristic of cataracts , which are not a medical emergency. Educational objective:Manifestations of acute angle-closure glaucoma include sudden onset of severe eye pain, reduced central vision, blurred vision, ocular redness, and report of seeing halos around lights. This condition requires immediate medical intervention to reduce increased intraocular pressure and prevent permanent blindness.

Hemophilia

a hereditary bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including: Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties (Option 4). Avoid intramuscular injections; subcutaneous injections are preferred. Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging, tennis) and use of protective equipment (eg, helmets, padding) are encouraged (Option 5). Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used. MedicAlert bracelets should be worn at all times (Option 3). (Option 1) Malnutrition is not commonly associated with hemophilia; a regular diet is indicated. Clients with cystic fibrosis are at risk for malnutrition and need a high-calorie diet. (Option 2) Dehydration is not commonly associated with hemophilia. Avoiding dehydration is important for those with sickle cell anemia. Educational objective:Parents of a child with hemophilia should encourage noncontact sports, avoid giving medications that inhibit platelet aggregation, know how to control bleeding when it occurs, and ensure that the child wears a MedicAlert bracelet at all times.

Measles (rubeola)

a highly contagious viral illness that affects people of all ages. Measles spreads when infected individuals cough or sneeze, sending the virus into the air, where it remains suspended for up to 2 hours. In the United States, widespread use of the measles, mumps, and rubella (MMR) vaccine has reduced measles incidence by 99%. However, increased frequency of international travel and number of unvaccinated children have caused a resurgence of the disease. For hospitalized clients with measles, interventions should include the following: Recommendation of postexposure prophylaxis (eg, MMR vaccine) for eligible, susceptible (eg, unvaccinated) family members within 72 hours of exposure to decrease the severity and duration of symptoms should they contract the disease (Option 1) Implementation of airborne precautions, including a negative-pressure isolation room and use of an N95 respirator mask, during contact with the client by health care staff (Options 4 and 5) Administration of vitamin A supplements to prevent severe, measles-induced vitamin A deficiency, which can cause blindness, particularly in clients in low-resource areas (Option 2) An erythematous, maculopapular, morbilliform rash is characteristic of measles, but it is not typically pruritic. Calamine lotion is effective for soothing pruritic rash (eg, varicella [chickenpox]). (Option 3) A tracheostomy tray is not required for this client with measles because respiratory paralysis or emergency intubation is not expected. Educational objective:Clients with measles are highly contagious, and susceptible family members should receive postexposure prophylaxis (eg, measles, mumps, and rubella vaccine). Hospitalized clients require airborne precautions (eg, negative-pressure isolation room, N95 respirator mask).

Shock

a life-threatening syndrome characterized by decreased perfusion and impaired cellular metabolism. A lack of perfusion at both the tissue and cellular level (anaerobic metabolism) occurs due to decreased cardiac output, ineffective blood flow, and inability to meet the body's demand for increased oxygen. Sustained hypoperfusion activates compensatory mechanisms (eg, neural, hormonal, biochemical) to maintain homeostasis and reverse the consequences of anaerobic metabolism. Shock will progress through 4 stages (initial, compensatory, progressive, irreversible). Early identification and intervention help to prevent stage progression. Adequacy of tissue perfusion in a client with shock syndrome and possible organ dysfunction is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity temperature, and peripheral pulses. Capillary refill indicates adequacy of blood flow to the peripheral tissues. It is measured by the time taken for color (pink) to return to an external capillary bed (nail bed) after pressure is applied to cause blanching. In an adult, color should return in less than 3 seconds. Normal skin color and temperature are indicators of the adequacy of peripheral blood flow; these are usually within normal limits during the initial and compensatory stages of shock. (Option 1) Apical pulse is a central pulse and does not indicate adequacy of peripheral tissue perfusion. (Option 3) Lung sounds indicate the adequacy of ventilation and gas exchange, not peripheral tissue perfusion. (Option 4) Pupillary response is an indicator of cerebral function, not peripheral tissue perfusion. Educational objective:The adequacy of blood flow to peripheral tissues is determined by measuring capillary refill and assessing skin color and temperature; these are usually within normal limits during the initial and compensatory stages of shock.

Lithium

a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Chronic toxicity can result in: Neurologic manifestations - ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks) Nephrogenic diabetes insipidus - polyuria and polydipsia (increased thirst) (Option 4) Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals. (Option 1) Dietary potassium should be avoided when taking drugs such as potassium-sparing diuretics (eg, spironolactone, triamterene, amiloride) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. (Option 2) Regular exercise and a high-fiber diet can prevent constipation, which is not a known side effect of lithium. Opioids, anticholinergics, and iron supplements are medications that cause constipation. (Option 3) Good oral hygiene is ideal for every client but is not specially indicated for those taking lithium. Clients taking phenytoin should maintain oral hygiene to prevent gingival hyperplasia. Educational objective:Risk factors for lithium toxicity include dehydration, decreased renal function, low-sodium diet, and drug-drug interactions (eg, NSAIDs and thiazide diuretics). Chronic toxicity manifests with neurologic symptoms (ataxia, confusion or agitation, and neuromuscular excitability) and/or diabetes insipidus (polyuria and polydipsia).

Codeine

a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (eg, asthma, COPD). (Option 1) Calcium channel blockers (eg, amlodipine, nifedipine) are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (eg, metoprolol, atenolol). (Option 3) Ipratropium (Atrovent) is a short-acting inhaled anticholinergic often used in combination with a short-acting beta-agonist (eg, albuterol) to promote bronchodilation and reduce bronchospasm. (Option 4) Methylprednisolone (Solu-Medrol) is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD. Educational objective:Codeine is a narcotic medication with antitussive properties that can cause an accumulation of secretions in clients with chronic obstructive pulmonary disease and lead to respiratory distress. Caution is advised when sedatives are prescribed for clients with respiratory diseases.

Magnetic resonance cholangiopancreatography (MRCP)

a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less-invasive alternative to endoscopic retrograde cholangiopancreatography to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants (eg, aneurysm clip, pacemaker, cochlear implant) or any previous allergy or reaction to gadolinium (Option 4). A client with a history of rash following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy (Option 2). Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP (Option 3). (Option 1) Many clients should be NPO for 4 hours prior to the procedure to allow better visualization of the anatomical features. (Option 5) Smoking does not affect MRI visualization and is not a contraindication.

Arteriovenous fistula (AVF)

a permanent hemodialysis access surgically created by connecting an artery to a vein, typically in the forearm or upper arm. This anastomosis diverts arterial blood into the vein, which increases intravenous blood flow and causes the vein to thicken and expand (ie, "mature"). The matured AVF can then sustain frequent access by large-bore needles during hemodialysis. Arterial steal syndrome is an AVF complication that occurs when the anastomosed vein "steals" too much arterial blood, causing distal extremity ischemia. Symptoms occur distal to the AVF, including skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill. Without prompt intervention, ischemia may lead to limb necrosis (Option 3). (Option 1) After AVF creation, edema may occur due to venous congestion but typically improves spontaneously. Extremity elevation helps reduce edema. Severe or prolonged edema (eg, >2 weeks) could indicate venous hypertension that may require surgery to prevent AVF failure. (Option 2) A loud swooshing sound (ie, bruit) auscultated over the AVF is expected due to turbulent blood flow at the arteriovenous anastomosis. (Option 4) Hand-grip exercises (eg, ball squeezing, hand flexing) are encouraged after AVF creation to promote fistula maturation. Postoperative surgical site pain is expected; however, pain distal to the AVF may indicate tissue ischemia. Educational objective:Arterial steal syndrome is a complication of arteriovenous fistula (AVF) creation that impairs distal extremity perfusion and may result in tissue ischemia and necrosis. Symptoms include skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill distal to the AVF.

Multiple sclerosis (MS)

a progressive, demyelinating disease of the central nervous system that interrupts nerve impulses, causing a variety of symptoms. Symptoms may vary, but muscle weakness, spasticity, incoordination, loss of balance, and fatigue are usually present, causing impaired mobility and risk for fall and injury. Walking with the feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required as demyelination of the nerve fibers progresses. (Option 1) Range-of-motion, strengthening, and stretching exercises help limit spasticity and contractures in clients with MS. (Option 2) Fatigue is a common symptom with MS. Rather than increasing the duration, clients should balance exercise with rest. Clients should also exercise when the weather is cool and stay hydrated; dehydration and extremes in temperature cause symptom exacerbation. (Option 3) Wheelchairs are advised only if exercise and gait training are not successful as clients should maintain mobility and independence as long as possible. Educational objective:Clients with multiple sclerosis experience fatigue, incoordination, balance impairment, muscle weakness, and muscle spasticity from demyelination of nerve fibers. Gait training (eg, walking with the feet apart) and assistive devices can help prevent falls and injury and preserve independence as long as possible.

Bipolar disorder

a psychiatric condition characterized by cycling periods of depression and mania. Clients with acute mania often display elevated mood, increased and excessive activity levels, and altered decision-making that can result in high-risk behavior (eg, hypersexuality, excessive spending). Clients with mania are also easily distractible, leading to neglect of personal needs (eg, hydration, nutrition, sleep, hygiene) and the need for medical intervention. When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars). These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional meal (Option 2). (Option 1) Sweet potatoes and kale are low in energy and protein and difficult to eat on the go. (Option 3) Spaghetti with meatballs and fruit salad are difficult to eat on the go. (Option 4) Vegetable soups and salads are often low in protein and energy and difficult to eat on the go. Caffeinated drinks (eg, soda, tea, coffee) should be avoided as they may increase mania and activity. Educational objective:Clients with acute mania often have elevated activity levels that increase their risk for malnutrition and dehydration. Nurses should provide easily carried and consumed foods high in energy and protein (eg, burgers, sandwiches, shakes) to promote adequate nutritional intake.

neuroleptic malignant syndrome (NMS)

a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment. (Option 1) Administering acetaminophen may be appropriate, but it is more important to discontinue the haloperidol and notify the HCP immediately. (Option 2) Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU). (Option 4) Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms. Educational objective:NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication.

Osteomalacia

a reversible bone disorder caused by vitamin D deficiency. It is characterized by weak, soft, and painful bones that can fracture easily or become deformed. In vitamin D deficiency, calcium and phosphorus cannot be absorbed from the gastrointestinal tract and are unavailable for calcification of bone tissue. Vitamin D deficiency is also associated with increased risk of falls, especially in elderly clients due to muscle weakness. Nursing management focuses on: Implementing safety measures, such as canes or walkers, to prevent falls and injury (Option 5) Encouraging light to moderate physical activity, which can help promote bone strength and health (Option 4) Promoting increased dietary intake of:Calcium (eg, leafy green vegetables, dairy) (Option 1)Phosphorus (eg, milk, organ meats, nuts, fish, poultry, whole grains)Vitamin D (eg, vitamin D-fortified milk and cereal, egg yolks, saltwater fish, liver); exposure to sunlight is also recommended as it stimulates vitamin D synthesis (Options 2 and 3) Teaching about over-the-counter or prescription vitamin D supplements Educational objective:Osteomalacia occurs when the body is unable to use calcium and phosphorus for bone calcification due to a vitamin D deficiency. Nursing management focuses on implementing safety measures, encouraging activity, and promoting increased intake of vitamin D, calcium, and phosphorus.

Huff coughing

a series of low-pressure coughs using the following steps: Sit upright in a chair with feet spread shoulder-width apart and lean forward with shoulders relaxed; forearms supported on thighs or pillows; head and knees slightly flexed; and feet touching the floor (Option 5). Perform a slow, deep inhalation through the mouth or nose using the diaphragmatic muscle (Option 2). Hold breath for 2-3 seconds, keeping the throat open, and then perform a quick, forceful exhalation, creating an audible "huff" sound (Option 1). Repeat the "huff" once or twice more to expectorate any mucus (Option 3). Rest for 5-10 regular breaths and repeat as necessary until all mucus is cleared (Option 4) .Clients with chronic obstructive pulmonary disease benefit from breathing techniques to facilitate effective coughing. Huff coughing is a forced expiratory technique in which the client sits relaxed, upright, and leaning forward; slowly inhales using the diaphragmatic muscle; holds breath for 2-3 seconds and then quickly exhales; and repeats as necessary until remaining secretions are clear.

Trazodone (Oleptro),

a serotonin modulator, is used to treat major depressive disorder. In addition to affecting serotonin levels, the drug blocks alpha and histamine (H1) receptors. Blockade of alpha receptors can cause orthostatic hypotension similar to that from other alpha blockers (eg, terazosin, tamsulosin) used to treat benign prostatic hyperplasia. Blockade of H1 receptors leads to sedation. Therefore, this drug is particularly effective in treating insomnia associated with depression. However, concurrent intake of other medications or substances that cause sedation can be detrimental; these include benzodiazepines (eg, alprazolam, lorazepam, diazepam), sedating antihistamines (eg, chlorpheniramine, hydroxyzine), and alcohol (Option 4). (Option 1) Priapism is a known serious side effect of trazodone. A client with an erection lasting several hours should go to the hospital. (Option 2) Clients should be advised to rise from supine to standing slowly, in stages, due to the risk of orthostatic hypotension. (Option 3) The drug should be taken at bedtime to avoid daytime sedation. Educational objective:Trazodone modulates serotonin levels in the brain. It also blocks alpha and H1 receptors, leading to orthostatic hypotension and sedation, respectively. Priapism, although rare, is another serious side effect.

Open endotracheal (ET) suctioning

a skill performed to remove pulmonary secretions and maintain airway patency in clients who are unable to clear secretions independently. ET suctioning is important to promote gas exchange and prevent alveolar collapse, but inappropriate technique increases the client's risk for complications (eg, pneumonia, hypoxemia) or tracheal injury (eg, trauma, bleeding). To reduce the risk of complications and injury during ET suctioning, the nurse should: Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes (Option 1) Suction only while withdrawing the catheter from the airway (Option 2) Use strict sterile technique throughout suctioning (Option 5) Limit suctioning to ≤10 seconds on each suction pass (Option 3) Instilling sterile normal saline solution or sterile water (ie, lavaging) in the client's airway, a practice no longer supported by evidence, greatly increases the risk for infection by potentially transporting bacteria from the upper airway into the lower airways. (Option 4) Suctioning longer than 10 seconds increases risk for collapse of airway structures (eg, alveoli, bronchioles) and hypoxemia (ie, oxygen saturation <90%). Educational objective:Open endotracheal (ET) suctioning is a skill used to clear secretions and maintain airway patency. When performing ET suctioning, the nurse preoxygenates with 100% oxygen, applies suction only while withdrawing the catheter, uses sterile technique, and limits each suction pass to ≤10 seconds.

The second trimester (14 wk 0 d to 27 wk 6 d)

a time of positive changes for many pregnant clients (eg, improved nausea) and when physical evidence of the pregnancy is noted (eg, increased fundal height). The nurse should prepare clients for expected physical changes and discuss prevention of potential complications. Quickening, or a client's first perception of light fetal movement, is expected around 16-20 weeks gestation, depending on parity (Option 1). Weight gain increases by approximately 1 lb (0.5 kg) per week if pre-pregnancy BMI has been normal (Option 3). Increasing intake of iron-rich foods (eg, meat, dried fruit) and continuing prenatal vitamins both help to prevent anemia caused by increased fetal iron requirements after 20 weeks gestation (Option 4). Preterm labor warnings and signs of preeclampsia should be reviewed beginning at 20 weeks gestation. The nurse should also discuss routine screening/diagnostic tests performed during the second trimester. An ultrasound is performed around 18-20 weeks gestation to evaluate fetal anatomy and the placenta (Option 2). Screening for gestational diabetes mellitus (GDM) occurs between 24-28 weeks gestation (ie, 1-hour glucose challenge test) (Option 5). GDM is a complication of pregnancy caused by hormonally related maternal insulin resistance. Educational objective:During the second trimester, the nurse should provide guidance regarding fetal movements, weight gain, screening/diagnostic tests (eg, fetal anatomy ultrasound, 1-hour glucose challenge test), and increased requirements for iron to maintain maternal and fetal health.

A do not resuscitate (DNR) prescription

a type of advance directive that expresses the client's wish not to be resuscitated in the event of cardiac or respiratory arrest. Many health care professionals automatically react to an emergency situation. Some states will penalize health care workers with loss of their professional license if they fail to render CPR in an emergency situation. Health care professionals will not be penalized for an honest mistake; however, resuscitation must end immediately after they are notified of a DNR prescription (Option 3). (Options 1 and 4) Gross negligence of a client's advance directive can result in legal action. A DNR is legally binding, and the client's wishes should be honored. (Option 2) Continuing treatment until the code status is verified with the health care provider (HCP) constitutes malpractice. Before a DNR prescription can be posted in a client's medical record/chart, the HCP must provide documentation that the client's code status has been established through consultation with the client or family. Educational objective:Do not resuscitate prescriptions are legally binding. Failure to stop an erroneous code on a client with an advance directive in a timely fashion may result in legal action.

sublingual nitroglycerin (NTG) tablets to a client with stable angina

a vasodilator used to treat stable angina. It is a sublingual tablet or spray that is placed under the client's tongue. It usually relieves pain in about 3 minutes and lasts 30-40 minutes. The recommended dose is 1 tablet or 1 spray taken sublingually for angina every 5 minutes for a maximum of 3 doses (Option 2). If symptoms are unchanged or worse 5 minutes after the first dose, emergency medical services (EMS) should be contacted (Option 1). Previously, clients were taught to call EMS after the third dose was taken, but newer studies suggest that this leads to a significant delay in treatment. The NTG should be easily accessible at all times. Tablets are packaged in a light-resistant bottle with a metal cap. They should be stored away from light and heat sources, including body heat, to protect from degradation. Clients should be instructed to keep the tablets in the original container. Once opened, the tablets lose potency and should be replaced every 6 months. The car is not a good place to store NTG due to heat (Option 4). (Option 3) Waking up at night with chest pain can signify that angina is occurring at rest and is no longer considered stable angina. This should be reported to the health care provider. Educational objective:Education about sublingual NTG should include placing the tablet or spray under the tongue; repeating the dose every 5 minutes, with up to 3 total doses if angina is not relieved; notifying EMS if the first dose does not improve the symptoms; keeping the tablets in the original container away from light and heat; and replacing the bottle every 6 months once opened.

Autonomic dysreflexia

an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke (Option 4). Noxious stimuli may include: Bladder distention (eg, obstructed urinary catheter, neurogenic bladder) Fecal impaction Tight clothing (eg, shoelaces, waistbands) (Options 1 and 2) Hypertension, headache, and nausea due to uncontrolled sympathetic activity will resolve once the cause is identified and removed. (Option 3) Lowering the head of the bed would increase blood pressure. The head of the bed should be raised to lower the blood pressure. Educational objective:Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli (eg, bladder distention, tight clothing) in clients with spinal cord injuries above T6. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. The nurse must immediately identify and remove noxious stimuli to prevent a stroke and resolve symptoms.

Nystatin

an antifungal medication commonly used to treat mucocutaneous candidal infections (ie, oral, intestinal, vaginal, skin). When caring for a client prescribed nystatin, the nurse should: Assist clients with oral candida who wear dentures in removing them and soaking them in nystatin suspension because dentures often become a reservoir for reinfection (Option 1). Assess the appearance of the affected area (eg, oral cavity, skin lesions) frequently throughout nystatin therapy (eg, before administration, during routine assessments) to monitor treatment efficacy and identify potential side effects (eg, mucous membrane irritation) (Option 2). Instruct clients prescribed nystatin liquid suspension for oral thrush to swish the suspension in the mouth for several minutes and then swallow the medication to allow treatment of any esophageal candida (Option 4). Ensure that liquid suspension forms of nystatin are shaken well before being measured for dosing because medication precipitates and causes unequal concentrations within the liquid (Option 5). (Option 3) Clients receiving nystatin should be educated to take the medication as prescribed each day and avoid missing doses; nystatin therapy is continued for at least 48 hours after symptoms subside to prevent recurrence of the infection. Educational objective:Oral nystatin suspension is an antifungal medication used to treat oral thrush caused by candidal infections. Nurses administering nystatin should assist the client in removing and soaking dentures, if present; assess the affected area frequently; educate the client to swish the medication in the mouth before swallowing; and ensure that the suspension is well shaken before dosing.

Licorice root

an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. When used in combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting" diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should report this finding to the registered nurse (RN), and the client should be discouraged from using this herbal remedy. The primary health care provider (PHCP) should also be informed. (Option 1) Bananas are rich in potassium. Eating one each morning is beneficial. (Option 2) Diuretics and calcium channel blockers (eg, nifedipine, amlodipine, felodipine) commonly cause postural hypotension or dizziness on rising. The nurse should reinforce the importance of rising slowly and sitting on the side of the bed for a few minutes before standing up. Persistent dizziness should be reported to the RN and PHCP. (Option 4) Diuretics should be taken in the morning as nighttime dosing will cause nocturia and interrupted sleep. Educational objective:Licorice root can potentiate potassium loss and increase the risk for hypokalemia in a client taking thiazide diuretics. Use of licorice root should be reported to the registered nurse and primary health care provider, and the client should be discouraged from continued use.

Sucralfate

an oral medication that forms a protective layer in the gastrointestinal mucosa, which provides a physical barrier against stomach acids and enzymes. It does not neutralize or reduce acid production but is prescribed to treat and prevent both stomach and duodenal ulcers. Sucralfate is generally prescribed 1 hour before meals and at bedtime and, for effective results, is taken on an empty stomach with a glass of water. Sucralfate forms a better protective layer at a low pH level. Therefore, antacids or other acid-reducing medications (eg, proton pump inhibitors, H2 blockers) should be avoided within 30 minutes of taking sucralfate to prevent altered absorption (Option 2). (Option 1) Sucralfate should be taken 1 hour before meals to protect the stomach. (Option 3) Sucralfate binds with many medications (eg, digoxin, warfarin, phenytoin), reducing their bioavailability and effectiveness. Therefore, all other medications are generally taken ≥1-2 hours before or after taking sucralfate. (Option 4) Constipation is a common side effect of sucralfate. Educational objective:Sucralfate should be taken on an empty stomach with a glass of water because it forms a better protective layer at a low pH level. Therefore, acid-reducing agents (eg, antacids, proton pump inhibitors, H2 blockers) should be avoided within 30 minutes of taking sucralfate, and all other medications should be taken ≥1-2 hours before or after sucralfate.

Shoulder dystocia

an unpredictable obstetrical emergency that occurs during vaginal birth when the fetal head delivers but the anterior (top) shoulder becomes wedged behind or under the mother's symphysis pubis. Shoulder dystocia lasting ≥5 minutes is correlated with almost certain fetal asphyxia resulting from prolonged compression of the umbilical cord. Minimizing the time it takes to deliver the fetal body is essential for reducing adverse outcomes (eg, hypoxia, nerve injury, death). When shoulder dystocia occurs, the primary nursing interventions include: Documenting the exact time of events (eg, birth of fetal head, shoulder dystocia maneuvers) (Option 2) Verbalizing passing time to guide decision-making by the health care provider (eg, "two minutes have passed") Performing maneuvers to relieve shoulder impaction (eg, McRoberts maneuver, suprapubic pressure) (Option 3) Requesting additional help from staff (eg, nurses, neonatologist) immediately (Option 5) (Options 1 and 4) Fundal pressure and the use of forceps or a vacuum to facilitate birth are contraindicated because they may further wedge the fetal shoulder into the maternal symphysis pubis and increase the risk for neurological complications (eg, brachial plexus injury) in the newborn. Educational objective:Shoulder dystocia occurs when the anterior shoulder becomes wedged behind or under the maternal symphysis pubis. The nurse should document the timing of events (eg, birth of fetal head), verbalize passing time, perform McRoberts maneuver, apply suprapubic pressure, and request additional assistance.

ACE inhibitors ("-prils")

and angiotensin II receptor blockers (ARBs) ("-sartans") create a risk for hyperkalemia. ACE inhibitors decrease the excretion of aldosterone. Ordinarily, aldosterone would increase sodium and decrease potassium. However, when the ACE inhibitor suppresses aldosterone, potassium rises, placing clients at risk for hyperkalemia, especially in the presence of impaired renal function. The nurse should question the administration of an ACE inhibitor in a client who is hyperkalemic (Option 5). In general, certain herbs (garlic, gingko), vitamin E, and anticoagulation medications (eg, warfarin) are held prior to surgery as they can increase bleeding risk (Option 3). (Option 1) Lactulose is administered to excrete ammonia in cirrhosis with hepatic encephalopathy and not solely to treat constipation. The dose is adjusted to achieve 2-3 soft stools each day. (Option 2) Vancomycin should be infused over at least 60 minutes (100 minutes if infusing ≥1 g). When the medication is given too fast, the client may develop red man syndrome, which is characterized by facial and upper body flushing. If this occurs, the infusion needs to be slowed or stopped and restarted after a certain amount of time elapses, depending on flushing severity. However, it is not an anaphylactic rash and not a true allergy. This client is experiencing only a mild reaction; therefore, by slowing the infusion rate, the nurse can manage this side effect independently. (Option 4) Basal insulin glargine (Lantus) and the rapid-acting insulin aspart (NovoLOG) are used for glucose control in diabetic clients. The insulin is given at mealtime to prevent postprandial hyperglycemia. The client should receive the prescribed insulin prior to the meal even if blood glucose is within normal limits.

Polypharmacy

and physiologic changes associated with aging (eg, decreased renal and hepatic function, orthostatic hypotension, decreased visual acuity, balance and gait problems) place the elderly at increased risk of adverse drug effects. The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of drug-induced toxicity, cognitive dysfunction, and falls. Some commonly used medications in this list include antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales. Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision, and dysrhythmias (Option 1). Chlorpheniramine (ChlorTrimeton) is a sedating histamine H1 antagonist used to treat allergy symptoms. Increased central nervous system effects (eg, drowsiness, dizziness) may occur due to its reduced clearance in the elderly (Option 2). Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness, ataxia, and confusion (Option 5). (Option 3) Docusate is a stool softener and does not increase risk of injury in the elderly. (Option 4) Donepezil (Aricept) is an acetylcholinesterase inhibitor used to treat Alzheimer dementia. It does not place the elderly at increased risk of adverse effects. Educational objective:The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of adverse effects and potential for injury. The list includes antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales.

Factor Xa inhibitors (eg, rivaroxaban [Xarelto], edoxaban, apixaban)

are anticoagulants used to prevent and treat venous thromboembolism. Factor Xa inhibitors are being prescribed more frequently than other oral anticoagulants (eg, warfarin), as they have a lower risk of bleeding and require less ongoing monitoring (eg, PT/INR). Clients prescribed rivaroxaban should be educated to avoid taking over-the-counter medications or supplements that increase bleeding risk, such as NSAIDs (eg, aspirin), garlic, and ginger. The combined effects of rivaroxaban and other anticoagulants may greatly increase the risk of uncontrolled bleeding (eg, epidural, intracranial, gastrointestinal) and hemorrhage (Option 3). (Option 1) Unlike warfarin, factor Xa inhibitors are not affected by vitamin K, which is found in many green, leafy vegetables (eg, spinach, kale). (Option 2) Anticoagulants, particularly factor Xa inhibitors, increase the risk for spontaneous intracranial bleeding or formation of epidural hematomas. Clients taking factor Xa inhibitors should be instructed to immediately contact their health care provider for symptoms of neurological impairment (eg, extremity weakness, altered sensation, numbness). (Option 4) Routine monitoring of clotting times (eg, PT/INR, PTT) is unnecessary for clients prescribed factor Xa inhibitors. Educational objective:The nurse should instruct clients receiving factor Xa inhibitors (eg, rivaroxaban, edoxaban, apixaban), which are anticoagulants, to avoid taking additional medications or supplements with anticoagulant effects (eg, NSAIDs, garlic, ginger). The combined anticoagulant effects increase the risk for uncontrolled bleeding and hemorrhage.

The major adverse effects of sulfonylurea medications (eg, glyburide, glipizide, glimepiride)

are hypoglycemia and weight gain. Weight gain should be addressed. Clients taking glyburide should be taught to use sunscreen and protective clothing as serious sunburns can occur. (Option 1) Clients taking sulfonylureas should avoid alcohol as it lowers blood glucose and can lead to severe hypoglycemia. (Option 2) Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) is a major side effect of sulfonylurea medications. A fasting blood glucose <60 mg/dL (3.3 mmol/L) indicates moderate to severe hypoglycemia and the medication needs to be reassessed. (Option 3) Even foods labeled "diabetic", "sugar free," or "sugarless" may contain carbohydrates such as honey, brown sugar, and corn syrup, all of which can elevate blood sugar. Educational objective:The major adverse effects of sulfonylurea medications are hypoglycemia and weight gain. Alcohol must be avoided while taking these medications due to the risk of severe hypoglycemia. Glyburide can also make clients sunburn easily.

S1 and S2

are the normal "lub-dub" heart sounds that result from closure of valves. Systole occurs between S1 and S2, with S1 indicating closure of the atrioventricular (tricuspid, mitral) valves and S2 indicating closure of the pulmonic and aortic valves. S3 is an adventitious (extra) heart sound heard as "DUB" immediately following S2 (Option 3). S3 occurs during early diastole as a result of rapid ventricular filling and is a normal finding in children and young adults. In older adults, S3 is an abnormal finding that often indicates heart failure because the sound results from decreased ventricular compliance. S3 can be difficult to distinguish from S4. S4 is a "LUB" sound that occurs immediately before S1, during late diastole, and indicates ventricular hypertrophy. (Option 1) A pericardial friction rub is a creaky, grating sound heard throughout systole and diastole. Friction rub occurs with pericarditis and is due to friction between inflamed layers of pericardium. (Option 2) S1 and S2 are the normal heart sounds heard during cardiac auscultation. (Option 4) A murmur is a swooshing, blowing, or rumbling sound caused by turbulent blood flow (eg, from valve regurgitation or stenosis). Educational objective:S3, the third heart sound, is a "DUB" sound that immediately follows S2. It is a normal finding in children and young adults. S3, an abnormal finding in older adults, often indicates heart failure.

Endometrial cancer

arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth (ie, hyperplasia). Although typically slow growing, it can metastasize to the myometrium (ie, uterine muscle tissue), cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific (eg, lower back or abdominal pain), but the hallmark symptom is abnormal uterine bleeding (eg, heavy, prolonged, intermenstrual, and/or postmenopausal bleeding). As with many cancers, the client's family and genetic history (eg, BRCA mutation carrier) are significant risk factors; however, prolonged estrogen exposure without adequate progesterone is the greatest risk factor for developing endometrial cancer. Factors increasing estrogen exposure and endometrial cancer risk include: Conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility, late menopause, early menarche) (Option 3) Obesity Tamoxifen (a medication given for breast cancer) (Option 1) Progestin-containing contraceptives (ie, birth control pills) are associated with a decreased endometrial cancer risk because progestins thin the uterine lining, therefore preventing endometrial hyperplasia. (Option 2) Ectopic pregnancy with a ruptured ovary or preterm birth is not associated with endometrial cancer, although never giving birth at term gestation may increase ovarian cancer risk. (Option 4) Infection with a high-risk type of human papillomavirus increases cervical (not endometrial) cancer risk. Educational objective:Endometrial cancer is a slow-growing malignancy that arises from the inner lining of the uterus. Major risk factors include conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility), obesity, and tamoxifen therapy.

Adolescent clients

at increased risk for developing depressive and anxiety-related mood disorders as they begin to identify their role in adult life and develop new personal relationships. However, they frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. Signs of depression in adolescent clients include: Hypersomnolence or insomnia; napping during daily activities (Option 3) Low self-esteem; withdrawal from previously enjoyable activities (Option 4) Outbursts of angry, aggressive, or delinquent behavior (eg, vandalism, absenteeism); inappropriate sexual behavior (Option 1) Weight gain or loss; increased food intake or lack of interest in eating (Option 2) Depression is also a significant cause of suicide in adolescents. (Option 5) Adolescent clients begin to become more aware of body image and may express concern regarding their appearance. It is normal for clients in this age group to experience insecurity about their appearance (eg, acne, body hair). These insecurities do not correlate with the onset of a depressive disorder. Educational objective:Adolescent clients with depression frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. In addition, changes in sleep patterns; low-self esteem; withdrawal from previously enjoyable activities; outbursts of aggressive or delinquent behavior; and precipitous weight changes may indicate the onset of a depressive disorder.

During adolescence,

being with a peer group is part of the process of achieving individual identity, the most important developmental task at this age. An adolescent's friends have more influence than parents, teachers, or any other adults. Social relationships and activities help to provide a sense of belonging, acceptance, and approval. Having face-to-face visits and spending time with friends will help counteract feelings of isolation and loneliness during the client's recuperative period. In addition, the client is at risk for body image disturbance related to the scoliosis and surgery. The client may be particularly sensitive about body image and needs understanding and acceptance from peers. (Option 1) The client can attend school functions or social activities with friends when off all pain medication and when the spine has healed sufficiently. (Option 2) It is important for the client to keep up with schoolwork, but it is not a priority for recovery. (Option 3) Reading teen magazines can be a diversionary activity and may help distract the client from any pain, but it is not a priority. Educational objective:Friends play a significant role in the adolescent's quest for identity and provide a source of support, belonging, and understanding. Interacting with friends during recuperation after surgery is important to help counteract feelings of loneliness and isolation.

Amoxicillin/clavulanate

belongs to the aminopenicillin group and is often used to treat respiratory infections. Instructions for parents about amoxicillin use include the following: The medication may be taken with or without food as food does not affect absorption. The most common side effects of this medication are nausea, vomiting, and diarrhea. If nausea or diarrhea develops, the medicine may be administered with food to decrease the gastrointestinal side effects (Option 1). Shake the liquid well prior to administration. Administer at evenly spaced intervals throughout the day to maintain therapeutic blood levels (Option 4). Ensure that the child receives the full course of therapy; do not discontinue the medication if the child is feeling better or symptoms have resolved (Option 2). (Option 3) Rash, itching, dyspnea, and/or facial/laryngeal edema may indicate an allergic reaction. If any of these occur, the medication should be discontinued. (Option 5) Pediatric liquid medications are often dispensed with a measuring device designed to administer the exact dose prescribed. A dropper, oral syringe, plastic measuring cup, or measuring spoon is an example of a calibrated dispensing device that may be included with the medication. Educational objective:Amoxicillin/clavulanate in liquid form should be shaken well prior to administration; the correct dose is administered using a calibrated measuring device. The medication is taken with or without food, at evenly spaced intervals, and until the prescribed dose is consumed. If nausea or diarrhea develops, the medication may be administered with food.

Chemotherapy

can cause suppression of rapidly reproducing cells, including bone marrow suppression. This can result in decreased red blood cells, white blood cells, and platelets, all manufactured in the bone marrow. It is most likely to be seen with chemotherapy (versus radiation), with the lowest counts (the nadir) usually at 7-10 days after therapy initiation. Leukopenia is a decrease in total circulating white blood cell count (<4,000/mm3) and neutropenia is a decrease in circulating neutrophils (usually <1500/mm3). Filgrastim (Neupogen) and pegfilgrastim (Neulasta) stimulate neutrophil production and are given prophylactically or if the client has an infection and more neutrophils are needed to fight it (Option 3). (Option 1) Cancer chemotherapy causes cell lysis, which results in tumor lysis syndrome due to massive release of nucleic acid and its metabolic product, uric acid. Uric acid deposition leads to acute kidney injury. Medications such as allopurinol or rasburicase and aggressive IV hydration are used to prevent this complication. (Option 2) Anemia is also common with chemotherapy. Epoetin (Procrit), a form of erythropoietin, stimulates the body to make additional red blood cells. (Option 4) Low platelet count is not considered an urgent need until it is at <50,000/mm3. Usually, platelet transfusions are given. Educational objective:Bone marrow suppression from chemotherapy can cause decreased red blood cells, white blood cells, and platelets. Erythropoietin is used to increase red blood cell production, and filgrastim is administered to stimulate neutrophil production.

An implantable cardioverter defibrillator (ICD)

can sense and defibrillate life-threatening dysrhythmias. It also includes pacemaker capabilities such as overdrive pacing for rapid heart rhythms or back-up pacing for bradycardias that may occur after defibrillation. The ICD consists of a lead system placed into the endocardium via the subclavian vein. The pulse generator is implanted subcutaneously over the pectoral muscle. Postoperative care and teaching are similar to those for pacemaker implantation. Clients are instructed to refrain from lifting the affected arm above the shoulder (until approved by the health care provider) to prevent dislodgement of the lead wire on the endocardium (Option 2). (Option 1) Firing of the ICD may be painful. Clients have described the feeling as a blow to the chest. (Option 3) Driving may be approved by the health care provider after healing has occurred. Long-term decisions are based on the ongoing presence of dysrhythmias, frequency of ICD firings, and state laws regarding drivers with ICDs. (Option 4) Travel is not restricted. The ICD may set off the metal detector in security areas. A hand-held wand may be used but should not be held directly over the ICD. The client should carry the ICD identification card and a list of medications while traveling. Educational objective:After placement of an implantable cardioverter defibrillator, clients are instructed to avoid lifting the arm on the side of the ICD above the shoulder (until cleared by the health care provider) to avoid dislodging the lead wire system.

Diabetic neuropathy

caused by nerve damage as a result of the metabolic disturbances associated with diabetes mellitus. Autonomic neuropathy is nerve damage to the autonomic nervous system, the system responsible for involuntary body functions such as blood pressure, heart rate, perspiration, sexual function, and digestion. Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension, tachycardia, painless myocardial infarction, bowel incontinence, diarrhea, urinary retention, and hypoglycemic unawareness. The client with postural hypotension is also at risk for falls and should be taught to get up from a lying or sitting position slowly. (Options 1, 2 & 3) Sensory or peripheral neuropathy affects the peripheral nervous system and may cause problems with the extremities. Educational objective:Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension and put the client at risk for falls.

VF

characterized on the ECG by irregular waveforms of varying shapes and amplitudes. This represents the firing of multiple ectopic foci originating in the ventricle. Mechanically, the ventricle is quivering with no effective contraction or cardiac output. VF is considered a lethal dysrhythmia. It results in an unresponsive, pulseless, apneic state. If not treated rapidly, the client will not recover. VF commonly occurs in acute myocardial infarction and myocardial ischemia and in chronic heart diseases such as heart failure and cardiac myopathy. It may occur in cardiac pacing or catheterization procedures due to catheter stimulation of the ventricle. Treatment consists of rapid initiation of CPR, defibrillation, and the use of drug therapy (eg, epinephrine, vasopressin, amiodarone). (Option 1) Asystole is the total absence of ventricular electrical activity. (Option 2) Atrial fibrillation is characterized by total disorganization of atrial, not ventricular, activity. QRS complexes are usually normal in morphology. P waves are not seen. (Option 4) Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle. Educational objective:The nurse should recognize VF, a potentially lethal dysrhythmia. The ECG shows irregular waveforms of varying shapes and amplitudes. The client is unresponsive, pulseless, and apneic. Rapid treatment should include CPR, defibrillation, and drug therapy (eg, epinephrine, vasopressin, amiodarone).

Angina pectoris

defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium (Option 4) Deep sleep doesn't increase oxygen demand. Educational objective:Angina pectoris is chest pain caused by myocardial ischemia. Any factor that increases oxygen demand or decreases oxygen supply may deprive the myocardium of necessary oxygen needed to function effectively.

Serious adverse reactions to aminoglycosides (eg, gentamicin, tobramycin, amikacin) include

include ototoxicity and nephrotoxicity and are affected by age, renal function, and drug dose. Careful dosing is especially important for older clients. Tinnitus and vertigo are early signs of ototoxicity. The nurse should monitor the client carefully and report any changes in the client's hearing, balance, or urinary output. (Option 1) This client's blood pressure is low, and so the nurse should compare it to previous readings. Blood pressure is generally not affected by IV antibiotics. The client may be taking antibiotics for sepsis. (Option 2) This client's blood urea nitrogen is within normal range (6-20 mg/dL [2.1-7.1 mmol/L]) but is at the high end of normal and should continue to be monitored. (Option 4) Urine output in this client is adequate (>30 mL/hr) but should be monitored closely. Educational objective:The nurse should closely monitor renal function and assess for any changes in hearing or balance in a client receiving aminoglycoside antibiotics. Ototoxicity and nephrotoxicity are serious adverse reactions related to this type of medication.

Constipation is a common discomfort ofpregnancy

due to an increase in the hormone progesterone, which causes decreased gastric motility. Ferrous sulfate (iron) supplementation may also cause constipation. Interventions to prevent or treat constipation include: High-fiber diet: High amounts of fruits, vegetables, breakfast cereals, whole-grain bread, prunes High fluid intake: 10-12 cups of fluid daily Regular exercise: Moderate-intensity exercise (eg, walking, swimming, aerobics) Bulk-forming fiber supplements: Psyllium, methylcellulose, wheat dextrin (Option 1) Dairy is a great source of calcium, which is essential for fetal bone development. However, dairy products should be consumed at least 2 hours before or 1 hour after iron supplements as they bind to iron and decrease absorption. (Option 4) Laxatives are not recommended during pregnancy due to the risk of dehydration and electrolyte imbalance, which can lead to uterine cramping and contractions. The client should consult with the health care provider before using any over-the-counter stool softeners or laxatives. (Option 5) Caffeine consumption in pregnancy should be limited to 200-300 mg/day. Coffee may contain 100-200 mg caffeine per cup and should therefore be consumed in moderation during pregnancy. Educational objective:Constipation in pregnancy may be caused by increased progesterone levels and iron supplementation. It is best treated with 10-12 cups of fluid daily, a high-fiber diet/supplementation, and regular exercise. Clients should not take laxatives without first discussing this with the health care provider.

Ulcerative colitis

haracterized by chronic inflammation and ulcerations in the large intestines, resulting in bloody diarrhea and decreased nutrient absorption. A low-residue, high-protein, high-calorie diet, along with daily vitamin and mineral supplements, is encouraged to meet the client's nutritional and metabolic needs. The low-residue diet limits trauma to the inflamed colon and may lessen symptoms. Easily digested foods such as enriched breads, rice, pastas, cooked vegetables, canned fruits, and tender meats are included in the diet. Raw fruits and vegetables, whole grains, highly seasoned foods, and fried foods are avoided. Clients should also drink at least 2000-3000 mL/day of fluid to maintain fluid and electrolyte balance and hydration (Options 4 and 5). Sulfasalazine is a 5-aminosalicylate used to decrease inflammation in the intestines. To prevent relapse, the medication should be continued even when symptoms subside. Because sulfasalazine hinders the absorption of folate, folic acid supplements are encouraged (Option 3). (Option 1) Small, frequent meals are encouraged to decrease the amount of fecal material in the gastrointestinal tract and to decrease stimulation. (Option 2) Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestines and should be avoided. Educational objective:Dietary management of ulcerative colitis includes eating small, frequent meals; following a low-residue, high-protein, high-calorie diet; taking supplemental vitamins and minerals; avoiding caffeine, alcohol, and tobacco; and drinking at least 2000-3000 mL/day of fluid. Continued use of sulfasalazine prevents relapse and prolongs symptom remission.

The client has sinus bradycardia, which can be caused by:

he client has sinus bradycardia, which can be caused by: Drugs (eg, beta blockers, calcium channel blockers, digoxin). Consider withholding beta blockers if systolic blood pressure <100 mm Hg or heart rate <60 and notify the provider. Vagal stimulation (eg, carotid sinus massage, Valsalva maneuver) Diseases (eg, hypothyroidism, myocardial infarction, increased intracranial pressure) The clinical significance of sinus bradycardia depends on how the client tolerates the effect of slow heart rate on cardiac output. Sinus bradycardia is usually asymptomatic. However, symptomatic bradycardia can manifest as pale, cool skin; hypotension; weakness; confusion; dyspnea; chest pain; and syncope. (Options 1, 3, and 4) The side effects of these drugs include tachycardia (Table). Educational objective:Sinus bradycardia may be caused by drugs (eg, beta blockers), vagal stimulation, hypothyroidism, inferior wall myocardial infarction, and increased intracranial pressure. It is normal in some people (eg, trained athletes).

The creation of an AVF

hemodialysis access involves an anastomosis between an artery and a vein (usually the cephalic or basilic vein). The fistula permits the arterial blood to flow through the vein, causing the vein to become larger in diameter and the walls to thicken, enabling blood to flow at high pressures. After the AVF is placed, it takes 2-4 months for it to mature to accommodate the repeated venipunctures necessary for hemodialysis access. The major complications of an AVF are infection (especially in end-stage kidney disease and diabetes), stenosis, thrombosis, and hemorrhage. Clients are taught the following preventive interventions: Report numbness or tingling of the extremity to the HCP to prevent neuromuscular damage (Option 1) Do not allow anyone (other than dialysis personnel) to draw blood or take blood pressure measurements on the extremity to prevent thrombosis (Option 2) Avoid wearing restrictive clothing or jewelry to prevent thrombosis Do not use the arm with vascular access to carry heavy objects (more than 5 lb [2.26 kg]); however, exercises to increase strength could include squeezing a soft ball or sponge several times a day (Option 3) Check the function of the vascular access several times a day by feeling for vibration to assess for patency, stenosis, and clotting (Option 4) Do not sleep on the arm with vascular access or use creams or lotions on the site (Option 5) Monitor for signs of infection and bleeding after dialysis and report immediately Keep the site clean to help prevent infection Educational objective:The creation of an AVF for hemodialysis access involves an anastomosis between an artery and a vein. Clients are taught interventions to help prevent the major complications associated with an AVF (infection, stenosis, thrombosis, and hemorrhage).

Complications of circumcision

include hemorrhage, infection, and voiding difficulty. The area should be cleaned with warm water (without soap) to remove urine and feces and prevent infection. Prepackaged alcohol-based wipes delay healing, cause discomfort, and should be avoided until the circumcision scar is healed (usually 5-6 days). (Option 1) Immediately after the procedure, the glans penis should appear dark red and, after 24 hours, will be covered with a yellow exudate that will persist for 2-3 days. Parents should not try to wipe or forcefully remove the exudate as this is part of the normal healing process. However, redness, swelling, odor, and discharge indicate infection. (Option 3) Crying is expected during diaper and petroleum (Vaseline) gauze changes. Parents are often anxious and concerned about inflicting pain on their newborn. They should be informed that the discomfort is only brief and be encouraged to provide extra comfort measures (holding, feeding, nonnutritive suckling) after diaper changes.In a recently circumcised newborn, parents should be taught to use only warm water for cleaning and avoid soap and alcohol-based wipes. After 24 hours, a yellow exudate forms as part of the normal healing process; it should not be removed. Pain is expected, and parents can provide additional comfort measures after diaper changes to minimize discomfort.

Opioids,

including morphine sulfate, dilate peripheral blood vessels and can cause hypotension. The side effect is not as noticeable when the client is lying down; however, once the client attempts to stand, it can cause orthostatic hypotension. It is more common in clients who have some underlying volume depletion (eg, opioid-induced nausea/vomiting). Due to the safety risk, clients must be taught to rise slowly from a sitting to a standing position. The nurse should first assist the client to sit if the client feels lightheaded in a standing position. Safety is the client's priority. If orthostasis is evident, fluid bolus may be needed and should be communicated to the health care provider. (Options 1 and 4) Assessing the client's orthostatic vital signs and recommending bed rest until the lightheadedness resolves are important but not first-priority actions. (Option 3) Walking with the client is not recommended when the client is symptomatic on standing. Educational objective:Client safety is the priority action in any situation. The nurse should assist the client to a safe position prior to proceeding with other interventions.

AOM

is an infection of the middle ear resulting from dysfunction of the Eustachian tube. OM typically occurs in infants and children age <2, often following a respiratory tract infection. Clinical manifestations of AOM include high fever (up to 104 F [40 C]), ear pain, irritability/restlessness, loss of appetite, and pulling on the affected ear. In AOM, the tympanic membrane will typically be bulging and very red. If the tympanic membrane ruptures from the buildup of fluid, the client will experience immediate pain relief and a gradually decreasing fever; purulent drainage may be observed in the external ear canal. (Option 4) Retracted tympanic membranes occur when there is negative pressure in the middle ear, which can occur with a blocked Eustachian tube or as a complication of chronic infections. In acute otitis media, pus/fluid inside the ear produces bulging and red membranes. (Option 5) Severe pain experienced with direct pressure on the tragus or with pulling on the pinna is a manifestation of otitis externa, an infection of the outer ear. The pain associated with AOM is not affected by manipulation of the outer ear. Educational objective:Clinical manifestations of AOM include high fever; ear pain; irritability; pulling on the affected ear; and bulging, red tympanic membranes.

Cholecystectomy (removal of the gallbladder)

is performed through laparoscopic or open surgery. Signs of postoperative infection typically appear 3-7 days after surgery. Systemic signs may include fever, elevated WBC count, and fatigue. Some potential postoperative infections include: Pneumonia can occur when atelectasis (alveolar collapse) prevents clearing of secretions, promoting bacterial growth. Symptoms include cough with or without sputum, tachypnea, and shortness of breath. Postoperative incentive spirometry, ambulation, and cough/deep breathing exercises help keep alveoli open and prevent pneumonia (Option 3). Surgical site infections present with localized redness, warmth, swelling, and purulent drainage. Proper wound care and sterile dressing changes help prevent infection (Options 2 and 5). Urinary tract infections (UTIs), caused by the use of indwelling urinary catheters during surgery, can present with frequency, urgency, and dysuria. Prompt removal of catheters after surgery helps prevent UTIs. Peritonitis (peritoneal infection) presents with rebound tenderness, boardlike abdominal rigidity, and shallow breathing related to abdominal distension. Peritonitis may lead to sepsis and death if untreated (Option 4). (Option 1) Clients recovering from laparoscopic surgery may experience referred left shoulder pain during the first few postoperative days. This is due to diaphragmatic nerve irritation caused by the carbon dioxide used to inflate the abdomen during laparoscopic surgery. Educational objective:Some potential postoperative infections related to abdominal surgery include pneumonia, surgical site infection, and peritonitis. Signs of infection may include cough, tachypnea, and shortness of breath; warmth or redness around the incision; purulent incisional drainage; or rigid, painful abdomen.

Allopurinol

is prescribed to prevent gout attacks (pain and inflammation in joints caused by uric acid deposits). It inhibits uric acid production and improves solubility. Allopurinol should be taken with a full glass of water, and it is very important for the nurse to educate the client about fluid intake with this medication. The client should also increase daily fluid intake as this will help prevent the formation of renal stones and promote diuresis (increase drug and uric acid excretion). (Option 1) Biosynthesis of uric acid occurs in the liver, and antigout medications are excreted via the kidneys; therefore, liver and renal function should be checked periodically. In addition, blood counts should be monitored as some antigout medications can cause blood dyscrasias. This is important but does not have priority over the daily need for increased fluids. (Option 2) This is a common instruction given about the storage of many medications. It helps to ensure potency of the medication and prevent deterioration. (Option 3) Taking allopurinol with food or after a meal can help to prevent gastric upset. Educational objective:It is important for the nurse to educate the client taking allopurinol about drinking a full glass of water with each dose and increasing overall fluid intake. Increased fluids help to prevent renal stones and promote diuresis and uric acid excretion.

Retinal detachment

is separation of the sensory retina from the underlying pigment epithelium. Clients experiencing retinal detachment may report a gradual, curtain-like loss of the visual field. Traumatic retinal detachment may also result in abrupt vision loss. Retinal detachment requires emergency surgery to attempt to restore vision. Surgical repair involves rebinding the choroid and retina. After repair, interventions focus on promoting retinal reattachment. Postoperative teaching should include: Avoiding activities that increase intraocular pressure (eg, rubbing the eye, straining) (Options 1 and 2) Reporting sudden pain, flashes of light, vision loss, or bleeding, which may indicate detachment or infection, to the health care provider (Option 4) Avoiding focused activities (eg, reading, writing, sewing), which can cause rapid eye movements and increase the risk for detachment (Option 5). Wearing an eye patch or shield as directed to prevent rubbing/scratching of the eye and minimize eye movement Ensuring appropriate positioning as instructed by the surgeon because clients may receive intravitreal oil or gas, which holds the retina in a specific position to allow healing (Option 3) Signs of retinal detachment include floaters, sudden flashes of light, and loss of vision. If signs of detachment occur, the surgeon should be notified immediately. Educational objective:After retinal detachment repair, clients should avoid activities that increase intraocular pressure (eg, rubbing the eye, straining); report pain, flashes of light, or floaters; wear an eye patch; avoid focused activities that may cause eye strain; and minimize eye movement.

Sudden infant death syndrome (SIDS)

is the leading cause of death among infants age 1 month to 1 year. Nurses should inform caregivers about childcare practices that reduce the risk of SIDS, including: Placing the infant on the back to sleep on a firm surface every time. Infants should not share a bed with anyone. Avoiding soft objects (eg, stuffed animals, pillows) in the infant's bed; nothing in the bed with the infant is safest (Option 4). Avoiding bumper pads for the crib. Newer cribs do not require bumper pads because improved side rails prevent the infant's head from getting stuck between slats. Maintaining a smoke-free environment. Avoiding overheating. Infants require only one layer of clothing more than adults do to be comfortable. Breastfeeding and ensuring immunizations are up to date. (Option 1) Using a pacifier during sleep is appropriate and has been associated with a reduced incidence of SIDS. However, pacifiers should be delayed until after breastfeeding is well established. (Option 2) A sleeper ("onesie") or a sleeping sack and a comfortable room temperature reduce the need for a blanket, which could obstruct the infant's mouth and/or nose. (Option 3) Infants should sleep on a firm surface or mattress that fits the crib and is covered with a fitted sheet. Educational objective:To reduce the risk of sudden infant death syndrome, infants should always be placed in their own bed, on their back, and on a firm surface without loose bedding or toys. Prevention also includes a smoke-free environment, avoidance of bumper pads, breastfeeding, pacifiers, avoidance of overheating, and immunizations.

Hematocrit (Hct)

is the percentage of red blood cells (RBCs) in a volume of whole blood. Hct and hemoglobin (Hgb) values are related (approximately 3 x Hgb = Hct); when one value is decreased, the other is also. This client likely has hemoglobin of 7 g/dL (70 g/L) (normal, 13.2-17.3 g/dL [132-173 g/L] for males and 11.7-15.5 g/dL [117-155 g/L] for females). Hgb is a component of the RBC that carries oxygen to the body's tissues. A decrease in Hgb decreases oxygen-carrying capacity and transport to tissues. RBCs may be 100% saturated with oxygen at rest, but desaturation may occur with increased activity and oxygen demand in the presence of decreased Hct and Hgb. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia. (Option 1) Brain natriuretic peptide (BNP) >100 pg/mL (100 pmol/L) is considered elevated and indicates ventricular stretch (heart failure) as the cause of the dyspnea. This client has normal BNP levels, making heart failure an unlikely cause. (Option 3) The leukocyte count is decreased (normal, 4,000-11,000/mm3 [4.0-11.0 x 109/L]). Leukocytes play a role in protecting the body from disease. (Option 4) The platelet count is decreased (normal, 150,000-400,000/mm3 [150-400 x 109/L]). Platelets play a role in blood clotting. Educational objective:Hemoglobin is a component of red blood cells that carries oxygen to the body's tissues. In the presence of decreased hematocrit and hemoglobin, decreased oxygen-carrying capacity and transport occur. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia.

Ethambutol (Myambutol)

is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a possible although potentially reversible adverse effect. The client is instructed to report any signs of decreased visual acuity or loss of color (red-green) discrimination. (Options 2 and 4) Dark-colored urine and yellow skin can indicate the presence of hepatotoxicity, which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, rifampin). However, hepatotoxicity is not common with ethambutol. (Option 3) Difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to streptomycin. Streptomycin, an aminoglycoside antibiotic, is a second-line drug sometimes used to treat multidrug-resistant tuberculosis and has ototoxic and nephrotoxic adverse effects. Educational objective:Clients taking ethambutol must have a baseline eye examination and periodic checkups during therapy as optic neuritis is a possible although potentially reversible adverse effect.

Acetylcysteine (Mucomyst)

may be given via nebulizer to help loosen and liquefy respiratory secretions to more easily clear them from the airway. Inhaled acetylcysteine may be used for clients with cystic fibrosis or other respiratory conditions with thick bronchial mucus. Acetylcysteine has no therapeutic effect on airway smooth muscle as it works primarily on secretions and has been shown to cause and/or worsen bronchospasm. Nurses caring for clients with reactive airway diseases (eg, asthma) prescribed acetylcysteine should clarify the prescription with the health care provider (Option 1). (Option 2) Chronic obstructive pulmonary disease (COPD) is a respiratory illness in which excess mucus, inflamed bronchioles, and easily collapsible airways trap air within the alveoli. Oral corticosteroids (eg, prednisone) may be used to reduce airway inflammation and improve ventilation in clients with acute COPD exacerbation. (Option 3) Cystic fibrosis is a genetic condition that causes dehydration and thickening of mucus in the respiratory, gastrointestinal, and genitourinary systems. Thick mucus within the pancreas impairs the release of digestive enzymes (eg, lipase), requiring supplementation to improve digestion and prevent malnutrition in clients with CF. (Option 4) Levofloxacin (Levaquin) is a broad-spectrum antibiotic that may be used to treat respiratory tract infections, such as bacterial pneumonia. Educational objective:Acetylcysteine is a medication that can be inhaled to help loosen thick respiratory secretions. Nurses caring for clients with reactive airway diseases (eg, asthma) who are prescribed acetylcysteine should clarify the prescription with the health care provider as it may cause and/or worsen bronchospasm.

IV furosemide

may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the dose above, use the following formula: (160 mg) / (4 mg/min) = 40 min (Option 1) Bradycardia is an adverse effect of beta blockers (eg, metoprolol, atenolol), calcium channel blockers (eg, verapamil), and digoxin. It is not an adverse effect of furosemide. (Option 2) Hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic. However, slower infusion is unlikely to prevent this adverse effect. (Option 3) Although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of administration. Educational objective:High doses of IV furosemide should be administered slowly to prevent ototoxicity.

Urine output of <30 mL/hr

may indicate low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). Given this client's heart failure, low urine output is likely due to decreased cardiac function and buildup of fluid in the lungs. The nurse should assess the lung sounds for crackles and report to the supervising registered nurse (RN) and the health care provider (HCP), who can prescribe loop diuretics. (Option 2) The client with heart failure is at risk for fluid overload. Fluids should not be encouraged before consulting with the HCP to determine the cause of decreased urine output. If this client is dehydrated, fluids should be encouraged. (Options 3 and 4) The nurse should always assess the client first and then report to the supervising RN and HCP. A diuretic may be prescribed by the HCP if crackles and dyspnea are present. Educational objective:Decreased urine output of <30 mL/hr could be due to low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). The nurse should always assess the client first and then report to the supervising registered nurse and health care provider.

Narrow therapeutic index

medications have a higher chance of producing adverse effects due to a very small difference between therapeutic and toxic levels. These medications require close monitoring of serum drug levels for adequate, but not toxic, dosing. Clients should also be monitored for signs of toxicity, which are specific to each medication. Phenytoin (Dilantin) is an antiseizure medication with a therapeutic index of 10-20 mcg/mL (40-79 mcmol/L) (Option 1). Tube feedings decrease phenytoin absorption, which reduces serum drug concentrations and may precipitate seizures. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration to ensure adequate absorption. Phenytoin toxicity produces nystagmus, dysarthria, ataxia, and encephalopathy. (Option 2) A heart rate of 62/min is expected in a client taking digoxin (therapeutic index 0.5-2.0 ng/mL [0.6-2.6 nmol/L]). Digoxin toxicity produces gastrointestinal symptoms (nausea, vomiting, diarrhea), bradycardia, and visual disturbances (blurred vision, yellow-green halos). (Option 3) The therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. (Option 4) Anorexia is a common side effect of lithium (therapeutic index 0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Lithium toxicity produces nausea, vomiting, ataxia, and tremors. Educational objective:Tube feedings decrease phenytoin (Dilantin) absorption, which reduces serum drug concentrations (therapeutic index 10-20 mcg/mL [40-79 mcmol/L]) and may precipitate seizures. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration to ensure adequate absorption.

Skin cancers

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 deadliest form of skin cancer. Basal cell and squamous cell carcinomas generally have a much lower risk of metastasis. Risk factors for skin cancer include: Family or personal history of skin cancer (Option 1) Celtic ancestry traits (eg, light skin, red or blond hair, blue or green eyes, many freckles) Aging Atypical or high number of moles because some skin cancers develop from pre-existing moles (Option 2) Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations (Option 4) Ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation, tanning bed use, history of severe sunburns) (Option 5) 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 significantly improve outcomes. (Option 3) Acne is not a known risk factor for skin cancer. Educational objective:Risk factors for skin cancer include family or personal history of skin cancer, Celtic ancestry traits (eg, light skin, blue eyes), aging, atypical or high number of moles, immunosuppression, and ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation).

nosocomial infection

occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections. The 74-year-old client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. (Option 1) This client does have a surgical incision, which poses a risk for infection. However, this client is younger and does not have any underlying chronic condition to compromise the immune system. (Option 2) This client does not fall in the category of elderly and has no surgical incision or indwelling catheters other than a possible IV site. (Option 4) This client is at risk due to age and presence of an IV catheter. However, the risk is not as high as the client with the urinary catheter. Educational objective:The nurse should be aware of the risk for nosocomial infections in young children, elderly, and immunocompromised clients, especially those with long hospital stays, indwelling catheters, and surgical incisions.

Mitral valve stenosis

often produces a diastolic murmur best heard at the apex of the heart (5th intercostal space, midclavicular line) with a stethoscope. Educational objective:When auscultating for a murmur associated with mitral valve stenosis, the nurse should place the stethoscope at the 5th intercostal space, midclavicular line.

Neonatal abstinence syndrome (NAS)

or opioid withdrawal results from maternal, habitual use of illicit drugs during pregnancy and begins within days or weeks after birth. Opioid abuse (eg, hydrocodone, methadone, heroin) is the most common cause, although other medications (eg, benzodiazepines) can contribute to the condition. Some affected newborns require pharmacologic management of symptoms. Clinical manifestations of NAS may be: Central nervous system findings (eg, irritability, restlessness, high-pitched crying, abnormal sleep pattern, increased muscle tone, hyperactive primitive reflexes), which may require interventions such as swaddling and minimizing stimulation (Option 1) Related to the autonomic nervous system (eg, nasal congestion, sweating, frequent yawning, sneezing, tachypnea) (Option 4) Gastrointestinal (eg, poor feeding, vomiting, diarrhea), which may require smaller, more frequent feedings and skin protection (Option 5) (Option 2) Meconium ileus (ie, intestinal obstruction) is a classic finding in clients with cystic fibrosis. Floppy muscle tone is typical of clients with Trisomy 21 (Down syndrome). (Option 3) Microcephaly and cleft palate are manifestations of early prenatal exposure to teratogenic agents (eg, alcohol, cytomegalovirus, valproic acid) and are not associated with NAS. Limited evidence has shown that opioids are generally not teratogenic. Educational objective:Prenatal exposure to illicit drugs may result in neonatal abstinence syndrome. A history of opioid abuse is the most common cause. Manifestations may include irritability, restlessness, a high-pitched cry, nasal congestion, frequent yawning/sneezing, poor feeding, and diarrhea.

Clients with acute pancreatitis are at risk for

pancreatic abscess development. This mainly results from secondary infection of pancreatic pseudocysts or pancreatic necrosis. High fever, increasing abdominal pain, and leukocytosis may indicate abscess formation (Option 4). The abscess must be treated promptly to prevent sepsis. The health care provider should be notified immediately as antibiotic therapy and immediate surgical management may be required. (Option 1) Elevated blood glucose is an expected finding in clients with pancreatitis. Elevated blood glucose is associated with pancreatic dysfunction and may necessitate insulin administration, but this is not the most concerning finding. (Option 2) Clients with acute pancreatitis often report severe, burning midepigastric abdominal pain that radiates to the back. Clients may seek relief from pain by positioning themselves in the knee-chest position to decrease intra-abdominal pressure. Pain relief interventions should be attempted, but this is not the priority. (Option 3) The client with pancreatitis may develop steatorrhea (eg, fatty, yellow, foul-smelling stools) due to a decrease in lipase production. Although fluid and nutritional status are important, these does not take precedence over a possible surgical emergency. Educational objective:Acute pancreatitis may cause severe midepigastric abdominal pain, elevated blood glucose levels, and steatorrhea. The nurse should watch closely for high fever, increasing abdominal pain, and leukocytosis as these findings may indicate infection of the necrosed pancreas or pancreatic abscess formation.

Use of fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin), especially ciprofloxacin,

places clients at increased risk for tendinitis and tendon rupture that most often occur in the Achilles tendon. This class of antibiotics carries a black box warning about this risk. The Food and Drug Administration recommends that at the first sign of tendon pain or swelling, clients should stop taking the fluoroquinolone, abstain from moving the affected area, and contact their health care provider promptly for further evaluation and a change of antibiotic. (Option 1) Turning urine into a harmless brown color is a common side effect of nitrofurantoin, another antibiotic commonly prescribed for urinary tract infections. (Option 2) Hearing and balance problems (vertigo) result from aminoglycoside ototoxicity (eg, gentamicin). (Option 4) Ciprofloxacin can cause photosensitivity. The client should be instructed to avoid sun exposure and use sunscreen while taking the medication. Educational objective:Fluoroquinolones (ciprofloxacin) carry a black box warning citing an increased risk of tendinitis and rupture, especially of the Achilles tendon.

Planning care during a pediatric hospitalization

requires the nurse to consider the child's stage of psychosocial and cognitive development. For the school-age child (age 6-12 years), developing a sense of industry (ie, confidence in skills and abilities) is a primary psychosocial need, and cognitive development is marked by concrete thinking (ie, based on actual objects or activities). During preprocedural education, the nurse should foster a sense of industry by involving the child in discussions about the procedure, interacting with the child directly, and using correct anatomical terminology. In addition, the use of simple diagrams helps to meet the child's need for concrete learning (Option 1). (Option 2) A school-age child has a concrete way of thinking and may not think abstractly about the future until adolescence. (Option 3) Adolescents are more aware of body image than school-age children. Exploring feelings and concerns regarding the appearance of a surgical scar is not a primary focus. (Option 4) Toddlers (age 1-3 years) should receive initial teaching about a procedure immediately before it occurs due to a limited concept of time. School-age children can be prepared in advance of a procedure (eg, a day before), which gives them time to process. Educational objective:During preprocedural education, the nurse should use developmentally appropriate methods of teaching. Using simple diagrams with correct anatomical terminology appropriately meets the psychosocial (ie, sense of industry) and cognitive needs (ie, concrete thinking) of school-aged children.

Ovarian cancer

results in more deaths than any other gynecologic cancer. Symptoms are often subtle and may include abdominal bloating; pelvic pain or pressure; abdominal girth increase; early satiety; abdominal, back, or leg pain; urinary urgency/frequency; and gastrointestinal disturbances (Option 4). Due to the lack of routine screening and reports of vague symptoms, ovarian cancer may not be diagnosed until an advanced stage. (Option 1) A fish-like vaginal odor is often caused by bacterial vaginosis, an overgrowth of vaginal bacterial flora. This condition is not usually serious and is treated with oral or vaginal antibiotics (eg, metronidazole). (Option 2) Heavy menstrual bleeding is a common disadvantage of having an intrauterine device. If the client cannot tolerate heavy bleeding or if excessive bleeding results in anemia, another form of birth control should be considered. (Option 3) Reports of painful intercourse are not unusual in clients with endometriosis. Disease management and pain control should be discussed. Educational objective:Symptoms of ovarian cancer are often subtle, and the condition is often not discovered until an advanced stage due to a lack of routine screening guidelines. Clients may present with bloating, early satiety, urinary symptoms (pressure on the bladder), and pelvic pressure.

Sodium polystyrene sulfonate (Kayexalate)

retention enema is a medicated enema administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level. Kayexalate can also be given orally and is much more effective. Kayexalate can rarely be associated with intestinal necrosis. (Option 1) A barium enema uses contrast medium (barium) administered rectally to visualize the colon using fluoroscopic x-ray. (Option 2) A fleet enema relieves constipation by infusing a hypertonic solution into the bowel, pulling fluid into the colon and causing distension and then defecation. (Option 4) A neomycin enema is a medicated enema that reduces the number of bacteria in the intestine in preparation for colon surgery. Educational objective:Kayexalate retention enemas are medicated enemas administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level.

The telltale symptom of bladder cancer,

seen in >75% of cases, is painless hematuria; the client will report seeing blood in the urine but will have no associated pain. As with many other types of cancer, the primary factor contributing to bladder cancer is cigarette smoking or other tobacco use (Option 3). Poorer outcomes are seen in those who have smoked longer and those who have smoked a higher number of cigarette packs per day. (Option 1) Clients who have family members with bladder cancer have an increased risk of developing bladder cancer themselves; however, the primary risk factor is tobacco use. (Option 2) Occupational carcinogen exposure is the second most common risk factor. Occupational exposures include printing, iron and aluminum processing, industrial painting, metal work, machining, and mining. Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols, vapors). (Option 4) Consuming a high-fat diet and using artificial sweeteners may contribute to the development of bladder cancer, but tobacco use is the most commonly associated contributing factor. Educational objective:Painless hematuria is the most common presenting symptom of bladder cancer. Cigarette smoking or other tobacco use is the primary risk factor.

Clients with elevated ICP

should avoid anything that increases intrathoracic or intraabdominal pressure as these also indirectly increase ICP. These activities include straining, coughing, and blowing the nose. Respiratory interventions, if needed, may include deep breathing and incentive spirometry in the absence of coughing. The head of the bed should be maintained at 30 degrees, high enough to allow for cerebrospinal fluid drainage, but low enough to maintain cerebral perfusion pressure. Clients should have minimal stimuli, including no bright lights or multiple visitors, as stimulation can increase ICP. (Option 1) The head of the bed should be raised to 30 degrees and maintained. This may require follow-up, but not immediate intervention, by the nurse. (Option 2) Turning down the lights is appropriate as clients with ICP benefit from a quiet, nonstimulating environment. (Option 3) Bringing items closer to the client prevents straining from reaching and is appropriate. Educational objective:Clients with increased ICP should be encouraged not to cough, strain, or increase abdominal or thoracic pressure. The head of the bed should be maintained at 30 degrees, and stimulation in the room should be minimized.

The Valsalva maneuver

straining during defecation) involves holding the breath while bearing down on the perineum to pass a stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased intracranial pressure, stroke, or head injury as straining increases intra-abdominal and intrathoracic pressure, which raises the intracranial pressure (Option 1). The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease (Option 3). Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding (Option 5). The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery (Option 6). (Option 2) The otherwise healthy client recovering from reconstructive augmentation mammoplasty is not at risk for complications related to the Valsalva maneuver. (Option 4) The client recently diagnosed with pancreatic cancer is not at risk for complications related to the Valsalva maneuver. Educational objective:The Valsalva maneuver is contraindicated in the client diagnosed with increased intracranial pressure, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis.

Transsphenoidal hypophysectomy

the surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones (eg, antidiuretic hormone [ADH], growth hormone, adrenocorticotropic hormone). Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus (DI), a metabolic disorder of low ADH levels. ADH promotes water reabsorption in the kidneys. Therefore, loss of circulating ADH results in massive diuresis of dilute urine. Clinical manifestations associated with DI include: Decreased urine specific gravity (<1.003) (Option 5) Elevated serum osmolality (>295 mOsm/kg [295 mmol/kg]) (Option 4) Hypernatremia (>145 mEq/L [145 mmol/L]) (Option 1) Hypovolemia and potential hypotension Polydipsia (Option 2) Polyuria (2-20 L/day) (Option 3) Educational objective:Diabetes insipidus (DI) is a metabolic disorder of decreased antidiuretic hormone, which is responsible for water retention in the kidneys. DI is often related to a preceding trauma, pituitary tumors, or neurosurgery (eg, hypophysectomy). Clinical manifestations of DI include polyuria, polydipsia, hypernatremia, hypovolemia, increased serum osmolality, and decreased urine specific gravity.

latex allergy

usually have a cross-allergy to foods such as bananas, kiwis, avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food proteins. Latex sensitivity increases with exposure and should be suspected in the following situations: Allergic contact dermatitis (rash, itching, vesicles) developing 3-4 days after exposure to a rubber latex product. This is a type IV hypersensitivity reaction (delayed onset). Anaphylaxis - many cases of anaphylaxis have been reported in both medical and non-medical settings. These represent a type I hypersensitivity reaction and should be treated with intramuscular epinephrine injections. Some common settings include:Glove useProcedures involving balloon-tipped catheters (eg, arterial catheterization)Blowing up toy balloonsUse of bottle nipples, pacifiersUse of condoms or diaphragms during sex Clients with severe allergies should wear a Medic Alert bracelet and carry an injectable epinephrine pen due to cross-sensitivity with many food and industrial products that can be impossible to avoid. (Option 1) Foods rich in vitamin K reduce the effects of warfarin (which works by inhibiting vitamin K-dependent clotting factors). Consumption of these foods decreases the effectiveness of warfarin; clients must be taught to eat the same amount of or avoid dark, green, leafy vegetables. (Option 2) Nitroglycerine is a vasodilator and a headache from dilating cerebral vessels is an expected finding. The side effect is treated with acetaminophen (Tylenol). (Option 3) Peripherally acting calcium channel blockers (eg, nifedipine, amlodipine, felodipine) cause vasodilation, and clients may develop peripheral edema. This is an expected, frequent side effect and is not an allergic reaction. Clients are advised to elevate the legs when lying down and to use stockings.