NCLEX notes/ uworld LAPTOP

melena

(dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers

Exophthalmos (hyperthyroidism)

*protrusion of eyeballs caused by increased orbital tissue expansion and can be IRREVERSIBLE. *risk for cornea dryness, injury and infection

Exophthalmos Nursing care

-maintain HOBin a raised position to facilitate drainage from periorbital area -artificial tears or other similar products to moisten the eyes to prevent corneal drying (causing abrasions/ulcers) -taping the clt's eyelids shut during sleep if they do not close on their own

exophthalmos teaching

-regular visits to ophthalmologist to measure eyeball protrusion and evaluate condition -anti-thyroid drugs should be taken to prevent further exacerbation - smoking cessation -restrict salt intake to decrease periorbital edema -use dark glasses to decrease glare and prevent external irritants and infection -perform intraocular muscle exercises (turning the eyes using complete ROM) to maintain flexibility

Tetracycline, Doxycycline, Demeclocycline, Minocycline

-stains/discoloration in teeth don't give to younger than 8, -nephrotoxic -hepatotoxic -phototoxic -avoid lasix

Nurse should see the 6 yr old who just returned form bronchoscopy with a parent at the bedside

A bronchoscopy is an invasive procedure that allows visualization of the internal air passages via a flexible tube (bronchoscope) passed through either the nose or mouth to the internal airways. Following the procedure, the client will need to be monitored for complications such as bleeding, bronchial perforation, pneumothorax, and bronchial spasm. Potential for airway compromise requires that this client be seen first. (Option 1) A child with a potential hip dislocation will need to be evaluated, but this is not a priority. (Option 3) A CT scan can be done with or without the use of contrast (dye). Use of contrast would require monitoring for an allergic reaction to the dye. This client is young and has no parents present; the nurse will need to ascertain that basic needs are being met. (Option 4) This client is awaiting surgery. The nurse will need to assess that consent is signed and check for preoperative prescriptions. Although important, it is not a priority over the 6-year-old client's airway. Educational objective:When deciding which client to see first, the nurse should apply the "ABC" (airway, breathing, circulation) guideline to problems that clients may have or could develop. Additional Information Management of Care NCSBN Client Need

During the immediate postoperative period after a colostomy, which stoma appearance requires the nurse to contact the health care provider (HCP) immediately? 1. Brick red with slight moisture noted [4%] 2. Dusky with moderate edema present [86%] 3. Pink with slight oozing of blood [4%] 4. Rosy with no stool produced [4%]

A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. The stoma should be pink to brick red, indicating vascularity and viability (Option 1). Minor bleeding and oozing may occur (Option 3), and mild to moderate swelling is normal for 2-3 weeks after surgery. In the immediate postoperative period, stool will be absent. If the bowel is cleansed prior to surgery, the draining of stool will be delayed by several days. Otherwise, stool appears when peristalsis resumes (Option 4). (Option 2) Inadequate blood supply can cause a change in the stoma color. Indications of poor vascularity include pale, dusky, or cyanotic color changes, any of which requires immediate notification of the HCP and surgical intervention to prevent ischemia and necrosis. Educational objective:A healthy stoma has the characteristics of mucosal tissue and should appear vascular and moist. Indications of decreased blood supply (pale, dusky, or cyanotic) should be reported to the HCP immediately. Additional Information Physiological Adaptation NCSBN Client Need

The nurse provides post-procedure teaching for a female client who had a cystoscopy as an outpatient. Which client statement indicates the need for additional instruction? 1. "I can expect pink-tinged urine for at least 24 hours." [3%] 2. "I can take a warm bath and acetaminophen if I have discomfort or bladder spasms."[23%] 3. "I should expect frequency and burning when I urinate." [24%] 4. "I should expect to see blood clots in my urine for up to 24 hours." [48%]

A cystoscopy is a procedure that uses a flexible fiber-optic scope inserted through the urethra into the urinary bladder with the client in the lithotomy position. Complications associated with cystoscopy include urinary retention, hemorrhage, and infection. Therefore, clients are instructed to notify the health care provider (HCP) immediately if they have bright red blood when urinating, blood clots, inability to urinate, fever >100.4 F (38 C) and chills, or abdominal pain unrelieved by analgesia. These conditions necessitate evaluation by the HCP and may require antibiotic therapy or the insertion of a urinary catheter to irrigate the bladder, remove clots, or drain the bladder (Option 4). (Options 1 and 3) Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Clients are instructed to increase fluids, drink 4-6 glasses of water daily to help dilute the urine, and avoid alcohol and caffeine for 24-48 hours as these can irritate the bladder. (Option 2) Abdominal discomfort and bladder spasms may occur for up to 48 hours following the procedure. Clients are taught to take a mild analgesic (eg, acetaminophen, ibuprofen) and a warm tub/sitz bath (except with recurrent urinary tract infections) for pain relief. Educational objective:Clients can expect pink-tinged urine, frequency, dysuria, and abdominal discomfort for up to 48 hours after cystoscopy. They are instructed to increase fluid intake, avoid alcohol and caffeine, take a mild analgesic and tub/sitz bath to relieve discomfort, and notify the HCP immediately of inability to void, gross hematuria, blood clots, fever, chills, or severe pain.

Fast flush of the arterial line system (square wave test)

A fast flush of the arterial line system (square wave test) should be performed after the nurse has ruled out a physiological cause of the low pressure alarm. This test helps to verify if the arterial line is functioning correctly.

The nurse in the intensive care unit cares for a client with primary adrenocortical insufficiency (Addison's disease). The client reports nausea and abdominal pain. The blood pressure suddenly drops from 120/74 mm Hg to 88/48 mm Hg, heart rate increases from 80 to 100/min, and the client appears confused. Which action should the nurse take first? 1. Administer as-needed dose of hydrocortisone intravenous (IV) push 2. Complete a head-to-toe assessment to identify any sources of infection 3. Document the findings in the client's electronic medical record 4. Take blood pressure sitting and standing to assess for orthostatic hypotension

Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. Addisonian crisis or acute adrenocortical insufficiency is a potentially life-threatening complication. Clients report nausea, vomiting, and abdominal pain. Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push. (Options 2, 3, and 4) Assessment and documentation are important components of the nursing process, but emergency treatment of an addisonian crisis is the priority action. Educational objective: Addisonian crisis is a potentially life-threatening complication of Addison's disease and commonly presents with abdominal pain, hypotension, and hypoglycemia. Emergency management includes shock management with fluid resuscitation using 0.9% normal saline and 5% dextrose, and administration of high-dose hydrocortisone replacement IV push.

Addisonian crisis

Addisonian crisis or acute adrenocortical insufficiency is a potentially life-threatening complication. Clients report nausea, vomiting, and abdominal pain. Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push.

Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at ____

Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the morning, to avoid orthostatic hypotension.

The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? 1. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain 2. Severe lower back pain after lifting heavy boxes 3. Sharp calf ache with ambulation that improves with rest 4. Unilateral leg swelling with 2+ pitting edema after an airplane trip

An aortic dissection occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) layers. Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever," "tearing," or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure. (Option 2) Severe lower back pain after lifting heavy boxes is likely due to disc herniation. Some clients may report radiculopathy pain radiating down the leg below the knee. While uncomfortable, this is not life-threatening. (Option 3) This is a description of intermittent claudication in the lower extremity due to peripheral artery disease. It is an ischemic muscle pain (due to the buildup of lactic acid from anaerobic metabolism) related to exercise that resolves with rest. (Option 4) This is a description of a deep venous thrombosis (DVT) resulting from immobility during a flight. The embolization of DVT can cause life-threatening pulmonary embolism; the client with aortic dissection already has a life-threatening condition. Educational objective: An aortic dissection, which classically includes moving, "ripping" back pain, is a medical emergency. Hypertension is the most important contributing factor.

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. The client's hemoglobin is 9.7 g/dL (97 g/L) and hematocrit is 29% (0.29). What is the appropriate nursing action? 1. Administer the erythropoietin in the client's ventrogluteal muscle[42%] 2. Check blood pressure prior to administering the erythropoietin[39%] 3. Hold the client's next scheduled iron sucrose dose[3%] 4. Hold the erythropoietin and inform the health care provider[15%]

Anemia associated with chronic kidney disease is treated with recombinant human erythropoietin (Epogen/Procrit, epoetin). Therapy is initiated when hemoglobin is <10 g/dL (100 g/L) to alleviate the symptoms of anemia (eg, fatigue) and the need for blood transfusions. Therapy should be discontinued or the dose reduced for hemoglobin >11 g/dL (110 g/L) to prevent venous thromboembolism and adverse cardiovascular outcomes from blood thickened by high concentrations of RBCs. Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin (Option 2). (Option 1) Erythropoietin is administered intravenously or in any subcutaneous area (not intramuscularly). (Option 3) Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an adequate response to erythropoietin. Adequate stores of iron, vitamin B12, and folic acid are required for the erythropoietin to work. (Option 4) The dose should be held if the client has a hemoglobin level >11 g/dL (110 g/L) or uncontrolled hypertension. Educational objective: Anemia of chronic kidney disease is treated with recombinant human erythropoietin for hemoglobin <10 g/dL (100 g/L). Hemoglobin levels >11 g/dL (110 g/L) are associated with thromboembolic and cardiovascular events. Uncontrolled hypertension is a contraindication to recombinant human erythropoietin therapy.

Bacterial meningitis with stage 4 pressure injury, what should the nurse wear when performing a dressing change?

Bacterial meningitis (eg, Neisseria meningitidis) and many respiratory illnesses (eg, influenza) are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet (1.8 meters) away from the client. Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets (Option 5). Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care (eg, suctioning, wound care) (Options 1, 2, and 3). Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room to limit spread of infection. (Option 4) For client care involving airborne precautions, a class N95 or higher respirator must be used instead of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated only for barrier protection from droplet splashing and for filtration of large respiratory particles. Educational objective:When caring for clients on droplet precautions, a surgical mask is needed for routine care, such as assessment or medication administration. If there is risk of contact with body fluids during procedures (eg, wound care, suctioning), gloves, gown, and face shield are used.

12 months vaccine

Hep B #3 Haemophilus influenza type b (Hib) #4 Pneumococcal conjugate (PVC) 4 Inactivated Poliovirus (PV) 3 MMR 1 (live vaccine) VZV 1 (live vaccine)

The nurse reviews the serum laboratory results and medication administration records for assigned clients. Which prescriptions should the nurse question and validate with the health care provider before administering? Select all that apply. 1. Bumetanide in the client with heart failure who has hypokalemia 2. Calcium acetate in the client with chronic kidney disease who has hyperphosphatemia 3. Carvedilol in the client with heart failure who has an elevated B-type natriuretic peptide level 4. Isoniazid in the client with latent tuberculosis who has elevated liver enzymes 5. Metronidazole in the client with Clostridium difficile infection who has leukocytosis

Bumetanide is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance (Option 1). Isoniazid is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis (Option 4). (Option 2) Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia (normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney disease. Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate and excreting it in feces. (Option 3) Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the progression of heart failure. B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch. Elevated BNP is expected in a client with heart failure; the nurse need not question this prescription. (Option 5) Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection. Educational objective:Loop diuretics (eg, bumetanide, furosemide, torsemide) can cause hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]). Elevated liver enzymes in clients receiving the antitubercular drug isoniazid can indicate development of drug-induced hepatitis. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

Calcium acetate (PhosLo)

Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia (normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney disease. Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate and excreting it in feces

A nurse is screening clients at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? Select all that apply. 1. "For the past few years, I get a productive cough in the winter that goes away in spring." 2. "I occasionally have heartburn an hour after I eat fried foods and sausage." 3. "Last month when I was doing my breast self-examination, I noticed a marble-sized lump." 4. "My mole is itchy, and the borders have become uneven with a blackish to bluish color." 5. "Recently I have noticed that my bowel movements appear black."

Cancer is a growth of abnormal cells in an organ system that may impair the organ's function and spread throughout the body. Many cancers are invasive and life threatening if allowed to reach late stages of development. However, cancer is often difficult to identify early as the client may be asymptomatic or have only vague symptoms. Nurses should screen clients for and immediately report warning signs of cancer, which can be remembered with the mnemonic CAUTION: Change in bowel or bladder habits (Option 5) A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere (Option 3) Indigestion or difficulty in swallowing that does not go away Obvious change in a wart or mole (Option 4) Nagging cough or hoarseness (Option 1) A productive cough that is annual and seasonal, particularly occurring in the winter, may indicate chronic bronchitis. The nagging cough found in clients with lung cancer is persistent, rather than seasonal. (Option 2) A client report of occasional indigestion after specific triggers (eg, high-fat or spicy food, caffeine) may indicate gastroesophageal reflux disease. However, indigestion that is persistent or chronic indigestion may indicate cancer. Educational objective:Warning signs of cancer for nurses to monitor include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or a lump in the breast or elsewhere, indigestion or difficulty swallowing, any obvious change in a wart or mole, and nagging cough or hoarseness (mnemonic: CAUTION). Additional Information Health Promotion and Maintenance NCSBN Client Need

Carvedilol (Coreg)

Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the progression of heart failure. B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch. Elevated BNP is expected in a client with heart failure; the nurse need not question this prescription.

CSF

Cerebrospinal fluid (CSF) is assessed for color, contents, and pressure. Normal CSF is clear and colorless, and contains a little protein, a little glucose, minimal white blood cells, no red blood cells, and no microorganisms. Normal CSF pressure is 60-150 mm H2O. Abnormal CSF pressure or contents can help diagnose the cause of headaches in complicated cases. CSF is collected via lumbar puncture or ventriculostomy.

A client with a history of headaches is scheduled for a lumbar puncture to assess the cerebrospinal fluid pressure. The nurse is preparing the client for the procedure. Which statement by the client indicates a need for further teaching by the nurse? 1. "I may feel a sharp pain that shoots to my leg, but it should pass soon." [13%] 2. "I will go to the bathroom and try to urinate before the procedure." [2%] 3. "I will need to lie on my stomach during the procedure." [81%] 4. "The physician will insert a needle between the bones in my lower spine." [1%]

Cerebrospinal fluid (CSF) is assessed for color, contents, and pressure. Normal CSF is clear and colorless, and contains a little protein, a little glucose, minimal white blood cells, no red blood cells, and no microorganisms. Normal CSF pressure is 60-150 mm H2O. Abnormal CSF pressure or contents can help diagnose the cause of headaches in complicated cases. CSF is collected via lumbar puncture or ventriculostomy. Prior to a lumbar puncture, clients are instructed as follows: Empty the bladder before the procedure (Option 2) The procedure can be performed in the lateral recumbent position or sitting upright. These positions help widen the space between the vertebrae and allow easier insertion of the needle (Option 3). A sterile needle will be inserted between the L3/4 or L4/5 interspace (Option 4) Pain may be felt radiating down the leg, but it should be temporary (Option 1) After the procedure, instruct the client as follows: Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache Increase fluid intake for at least 24 hours to prevent dehydration Educational objective:Lumbar puncture can be performed with clients in the sitting position or positioned on the left side with the knees drawn up (fetal position).

Codeine

Codeine is an opioid drug prescribed as an analgesic to treat mild to moderate pain and as an antitussive to suppress the cough reflex. Although the antitussive dose (10-20 mg orally every 4-6 hours) is lower than the analgesic dose, clients can still experience the common adverse effects (eg, constipation, nausea, vomiting, orthostatic hypotension, dizziness) associated with the drug. Codeine decreases gastric motility, resulting in constipation. Increasing fluid intake and fiber in the diet and taking laxatives are effective measures to prevent constipation (Option 2). Changing position slowly is effective in preventing the orthostatic hypotension associated with codeine, especially in the elderly (Option 4). Taking the medication with food is effective in preventing the gastrointestinal irritation (eg, nausea, vomiting) associated with codeine (Option 5). (Options 1 and 3) These statements are inaccurate as photosensitivity, insomnia, palpitations, and anxiety are not adverse effects associated with codeine. Educational objective:The common adverse effects of codeine, an opioid drug, include constipation, nausea, vomiting, orthostatic hypotension, and dizziness. Interventions to help prevent them include increasing fluid intake and bulk in the diet, laxatives, taking the medication with food, and changing position slowly.

initiate K IV when serum K is 3.5-5

Diabetic ketoacidosis (DKA) is an acute, serious complication generally due to lack of insulin in clients with type 1 diabetes. DKA is characterized by hyperglycemia, ketosis, and acidosis. Hyperglycemia causes osmotic diuresis, resulting in profound dehydration. Clients with DKA may initially develop hyperkalemia as a compensatory response to acidosis despite having a total body potassium deficit from urinary loss. Management of DKA includes fluid resuscitation, IV insulin, and hourly blood glucose monitoring. When serum glucose is <250 mg/dL (13.9 mmol/L), D5W is administered to prevent hypoglycemia until ketoacidosis is resolved. Hypokalemia often occurs with resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent hypokalemia and subsequent life-threatening arrhythmias (Option 4). (Option 1) Serum potassium, glucose, and anion gap or bicarbonate levels are regularly monitored in DKA to monitor treatment effectiveness. Although serum creatinine and BUN levels may be elevated due to dehydration and may be monitored, hourly monitoring is not indicated. (Option 2) IV insulin infusion may be discontinued on resolution of acidosis and ketosis, which generally occurs with a blood glucose level of <200 mg/dL (11.1 mmol/L). (Option 3) As blood glucose is reduced, the insulin infusion rate is decreased to prevent a hypoglycemic event. Educational objective:Hypokalemia often occurs with resolution of diabetic ketoacidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent life-threatening arrhythmias. Additional Information Physiological Adaptation NCSBN Client Need

Lumbar puncture Pre-op and Post-op

Empty the bladder before the procedure The procedure can be performed in the lateral recumbent position or sitting upright. These positions help widen the space between the vertebrae and allow easier insertion of the needle A sterile needle will be inserted between the L3/4 or L4/5 interspace Pain may be felt radiating down the leg, but it should be temporary After the procedure, instruct the client as follows: Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache Increase fluid intake for at least 24 hours to prevent dehydration

The nurse assesses for cancer risk factors during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply. 1.m "A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week." 2. "I am proud that I was able to lose 10 lb, but I'm still considered obese for my height." 3. "I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently." 4. "I have struggled with daily episodes of acid reflux for years, especially at nighttime." 5. "I snack on a lot of salted foods like popcorn and peanuts."

Esophageal cancer is a rare, rapidly growing malignancy of the esophageal lining with a low 5-year survival rate. Squamous cell carcinoma usually develops in the upper part of the esophagus, whereas adenocarcinoma usually develops in the lower part. Major risk factors include smoking (eg, cigarettes, pipe, cigars) and excessive alcoholconsumption (ie, approximately >15 drinks/week for men, >8 drinks/week for women) (Options 1 and 3). Barrett esophagus is also a significant risk factor for esophageal cancer; this condition occurs when the distal portion of the esophagus develops precancerous changes. Obesity (which allows stomach acid to flow upward into the esophagus due to increased abdominal pressure) and uncontrolled gastroesophageal reflux disease contribute to the development of Barrett esophagus; they are both closely linked with esophageal cancer (Options 2 and 4). (Option 5) Consumption of salty foods is not associated with an increased risk of esophageal cancer but increases the risk of gastric cancer. Dietary factors that may increase a client's risk of esophageal cancer include high intake of nitrosamine-containing foods (eg, pickled foods, beer), frequent ingestion of extremely hot beverages (thermal injury), and deficient intake of fruits and vegetables. Educational objective:Esophageal cancer is a rapidly growing malignancy of the esophageal lining. Risk factors for esophageal cancer include smoking, excessive alcohol consumption, obesity, and gastroesophageal reflux disease. Additional Information Health Promotion and Maintenance NCSBN Client Need

Client prescribed ferrous sulfate for iron deficiency anemia, which action requires nursing intervention? * administering prescribed calcium supplement with ferrous sulfate

Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia, which occurs when the body lacks sufficient iron, an essential mineral in the formation of new RBCs. Low iron levels may result from malabsorption, insufficient intake, increased requirements (eg, pregnancy), or blood loss. The nurse should avoid administering calcium supplements or antacids with or within 1 hour of ferrous sulfate because calcium decreases iron absorption (Option 4). (Option 1) Taking an iron supplement increases the client's risk for constipation. Instructing the client to increase fluid intake during therapy may help prevent hard stools. (Options 2 and 3) Taking an iron supplement with vitamin C (eg, orange juice) further enhances duodenal acidity and increases absorption. An acid-rich environment enhances iron absorption, so oral supplements should be taken 1 hour before or 2 hours after meals. Educational objective:Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia. The nurse should administer the medication 1 hour before or 2 hours after meals because it is best absorbed in an acidic environment. Antacids or calcium supplements decrease absorption of iron if administered with or within 1 hour of ferrous sulfate. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

Evening Primrose

For eczema or skin irritations

Terazosin and grapefruit : NO INTERACTION

Grapefruit juice can cause significant interactions with drugs such as calcium channel blockers and sildenafil. However, it does not appear to interact with alpha blockers such as terazosin.

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment? 1. Color of sputum [7%] 2. Lung sounds [37%] 3. Saturation level [6%] 4. White blood cell count (WBC) [48%]

HAP is a bacterial infection acquired in a health care facility that was not present on admission. Almost all clients with bacterial pneumonia develop leukocytosis (WBC >11,000/mm3). Antibiotic therapy is the first-line treatment, but antibiotic resistance frequently occurs in HAP. If antibiotic therapy is effective, clinical improvement usually occurs within 3-4 days of initiation of IV antibiotics. The nurse monitors WBC as the best indicator of treatment effectiveness as antibiotics cause bacterial lysis or hinder bacterial DNA reproduction. The reduced number of bacteria and the resulting decrease in inflammation cause a decrease in the number of white blood cells needed to fight the infection. Other indicators of treatment effectiveness include improvement of infiltrates on chest x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production). (Option 1) The color of sputum (eg, clear, yellow, green, grey, rusty, blood-tinged) can vary with different types of pneumonia; it is not the best indicator of treatment effectiveness. (Option 2) Adventitious/abnormal lung sounds (crackles, low-pitched wheeze, bronchial breath sounds) can be present as the pneumonia resolves or can be a sign of further complication (pleural effusion). However, these are not the best indicators of treatment effectiveness. (Option 3) Saturation is an indicator of oxygenation but can be affected by many other factors, such as coexisting disease, peripheral circulation, and drugs. It is not the best indicator of treatment effectiveness. Educational objective:Indicators of treatment effectiveness for HAP include decreased WBC on complete blood count with differential and improvement of infiltrates on chest-x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production). Additional Information Physiological Adaptation NCSBN Client Need

The nurse is teaching self-care management to a client experiencing an outbreak of genital herpes. Which statement by the client indicates a need for further teaching? 1. "I will be sure we use condoms during intercourse as long as I have lesions." [63%] 2. "I will not touch the lesions to prevent spreading the virus to other parts of my body."[6%] 3. "I will use a hair dryer on a cool setting to dry the lesions after taking a shower."[26%] 4. "I will use warm running water and mild soap without perfumes to wash the area."[4%]

Herpes simplex virus type 2 (HSV-2) is usually associated with genital herpes. Lesions are painful and appear as multiple small, vesicular lesions. Management strategies focus on disease spread, including autoinoculation (eg, fingers) and pain relief, and include: Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak (Option 1). After the outbreak has resolved, condoms should be used in future sexual encounters as transmission is possible even in the absence of active lesions. Keep the area with lesions clean and dry. Avoid use of perfumed soaps and bubble baths. Maintain proper hand hygiene and avoid touching the lesions to prevent spreading. Use sitz baths and oatmeal baths to provide comfort and relief of itching and burning. (Option 2) Vesicles contain numerous virus particles, leading to the possibility of self-inoculation. This can be prevented by avoidance of hand contact with lesions during an outbreak. (Option 3) Use of a hair dryer on a cool setting is an effective means of drying the lesions and promoting client comfort. (Option 4) Warm water provides symptomatic relief. Mild soap containing no perfumes reduces the risk of irritation to the area. Educational objective:Clients experiencing an outbreak of genital herpes should abstain from sexual activity when lesions are present and use condoms in future sexual encounters as transmission is possible even in the absence of active lesions.

HIV teaching

Human immunodeficiency virus (HIV) is a viral infection of the CD4+(helper T) cells, resulting in progressive immune system impairment. Clients with HIV are susceptible to opportunistic infections that typically occur during periods of low CD4+ counts. To reduce the risk of infection, nurses should educate clients with HIV to: · Obtain and remain up to date on vaccinations, including the annual influenza vaccination (Option 2). · Avoid eating undercooked meats (eg, steak that is pink) and having contact with cat feces (eg, cat litter box) because both are sources of Toxoplasma gondii, an opportunistic parasite that causes encephalitis (Options 1 and 3). · Avoid drinking water from poorly sanitized (eg, developing countries) or potentially contaminated (eg, rivers, wells) sources because it may contain infectious pathogens (eg, Cryptosporidium, Isospora, Giardia). Instead, use bottled or purified water when drinking and brushing teeth (Option 4). (Option 5) Educate clients with HIV to always use synthetic barriers (eg, condoms) during sex to reduce the risk of transmitting HIV and being infected with additional HIV strains or other sexually transmitted infections. Clients with an undetectable viral load have a lower risk of transmitting HIV to a sexual partner but should still use barrier contraception.

The nurse is providing education to a 32-year-old female client diagnosed with human papillomavirus (HPV). Which client statement indicates a need for further instruction? 1. "I can transmit the virus when I don't have symptoms." [5%] 2. "I know the virus can be spread through oral sex." [13%] 3. "I need to have a Papanicolaou test on an annual basis." [11%] 4. "My partner won't get HPV as long as we use a condom." [68%]

Human papillomavirus (HPV), one of the most common sexually transmitted infections, is associated with genital warts and cervical cancer. There are many different strains of HPV, with types 16 and 18 causing nearly all cases of cervical cancer. HPV infection is often asymptomatic, and genital warts due to HPV are typically painless. Prevention includes vaccination against HPV before sexual activity begins and safe sex practices/abstinence. The recommended age for vaccination in both boys and girls is age 11-12, but the vaccine can be given as early as age 9 and up to age 26. Clients with HPV and their partners should be educated that the virus can still be spread through skin-to-skin contact, even with the use of condoms (Option 4). Safe sex practices decrease the risk of disease transmission but do not prevent it entirely. (Option 1) HPV can be spread through sexual contact, even if symptoms are not present. (Option 2) HPV may be transmitted through vaginal, anal, or oral sex. (Option 3) Clients with HPV need to have annual Papanicolaou tests as the virus increases the risk of cervical cell changes (ie, dysplasia) and subsequent risk of cervical cancer. Educational objective:Human papillomavirus (HPV) is associated with genital warts and cervical cancer. Condoms used during sex decrease, but do not completely eliminate, the risk of transmission. Prevention includes vaccination against HPV, preferably before sexual activity begins, and safe sex practices. Additional Information Health Promotion and Maintenance NCSBN Client Need

Cephalosporin HAIRY

Hyperglycemic Anaphylactic shock if allergic Insufficient platelet (thrombocytopenia) Renal problem if they are allergic Yellow poop (diarrhea)

erythropoietin administered not IM

IV , SUBQ

In DKA management, BG of <200mg/dL IV insulin infusion may be discontinued

IV insulin infusion may be discontinued on resolution of acidosis and ketosis, which generally occurs with a blood glucose level of <200 mg/dL (11.1 mmol/L).

Impaired gas exchange in pneumonia patient

Impaired gas exchange is a deficit in oxygenation and/or elimination of carbon dioxide at the alveolar-capillary membrane. Impaired gas exchange related to a bacterial infectious process as evidenced by shortness of breath and tachypnea is an appropriate ND for a client with pneumococcal pneumonia. (Option 2) Impaired spontaneous ventilation is the inability to maintain independent ventilation to support life and requires mechanical ventilation. Based on this client's assessment data, it is not an appropriate ND. (Option 3) This client is demonstrating an ineffective breathing pattern; however, this problem is secondary to impaired gas exchange. An increased respiratory rate is the body's attempt to compensate for hypoxia caused by consolidations and secretions preventing adequate gas exchange in the lungs. Impaired gas exchange is the primary problem that is causing the ineffective respirations and is the more appropriate ND for this client. (Option 4) Risk for infection is the increased risk for invasion of microorganisms. However, this client has an actual, not potential infection, so this is not an appropriate ND. Educational objective:Impaired gas exchange related to a bacterial infectious process as evidenced by shortness of breath and tachypnea is an appropriate nursing diagnosis for a client with pneumonia.

The nurse is caring for a client diagnosed with endometrial cancer who is receiving brachytherapy. Which interventions should the nurse implement while caring for this client? Select all that apply. 1. Cluster care to limit each staff member's time in the room to 30 minutes a shift 2. Instruct the client to be up and around in the room but not to leave the room 3. Keep the door to the room closed as radiation is emitting constantly from the client 4. Teach family members and visitors to stay at least 6 feet away from the client 5. Use a lead apron when providing direct client care to reduce exposure to radiation 6. Wear a radiation film-badge while in the client's room to monitor radiation exposure

Internal radiation (brachytherapy) involves direct application of a radioactive implant to the cancerous site or tumor for a short time, usually 24-72 hours. This technique is used to treat cervical and endometrial cancer and delivers a high dose of radiation to the cancerous tissues with a limited dose to adjacent normal tissues. Implementation of the following nursing measures is vital as the client receiving brachytherapy emits radiation. Following the principles of time, distance, and shielding provides staff and visitors protection from exposure to radiation. Time spent near the radiation source is restricted. The guideline is to limit staff time spent in the room to 30 minutes per shift.Cluster nursing care to minimize exposure to the radiation sourceRotate daily staff responsibilities to limit time spent in the client roomAll staff must wear a dosimeter film badge when assigned to care for a client receiving internal radiationNo individuals who are pregnant or under age 18 may be in the room All staff and visitors must keep the maximum distance possible from the radiation source. Maintaining a distance of at least 6 feet is an established standard.Assign the client to a private room with a private bathKeep the door to the room closedEnsure that a sign stating, "Caution, Radioactive Material" is affixed to the doorInstruct the client to remain on bedrest to prevent dislodgement of the implant Shielding with lead diminishes exposure to radiation. All staff providing nursing care that requires physical contact must wear a lead apron. (Option 2) The client receiving brachytherapy for endometrial cancer is instructed to remain on bedrest while the radiation implant is in place. If the implant dislodges from the vaginal cavity, the implant is never touched with the hands; instead, long-handled forceps are used to pick it up for placement in a lead container. Educational objective:Following the principles of time, distance, and shielding provides staff protection from exposure to internal radiation emissions. Staff should spend no more than 30 minutes in a client's room; should remain at least 6 feet away from the radiation source; and should wear lead aprons when providing direct client care. Additional Information Safety and Infection Control NCSBN Client Need

Client 8 days post-op ileostomy who reports nausea, vomiting, and abdominal bloating should be called back first

Nausea, vomiting, abdominal distension, and decreased stool production may signal a bowel obstruction or obstructed ileostomy. Bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis. It is urgent and potentially life-threatening. The client must be evaluated by the health care provider in a timely manner. (Option 1) Constipation is common after abdominal surgery due to opioid usage and decreased peristalsis from bowel manipulation. Increasing food or fluids might help the client have a bowel movement. (Option 3) Phantom limb pain is a sensation of pain or tingling in the amputated body part. Wrapping the extremity or applying ice or heat might help until the client can be evaluated by the health care provider. (Option 4) Active infection is a relative contraindication for elective surgical procedures. The client should be called back for assessment and likely rescheduling of surgery but would not take priority over a client with bowel obstruction. Educational objective:A bowel or stoma obstruction is urgent and requires immediate medical attention. Signs of obstruction may include nausea, vomiting, abdominal pain, bloating, and decreased stool output. If left untreated, bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis.

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? 1. Black, sticky stools 2. Greasy, foul-smelling stools 3. Stools mixed with blood and mucus 4. Thin, "ribbon-like" stools

Intussusception is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass. (Option 1) Melena (dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers. (Option 2) Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease. (Option 4) Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax. Educational objective: The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a sausage-shaped abdominal mass. However, it is more common for clients to have episodes of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal behavior.

A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider? 1. Diarrhea, vomiting, and mild tremor [52%] 2. Dry mouth and mild thirst [3%] 3. Hyperactivity and auditory hallucinations [25%] 4. Lithium level of 1.3 mEq/L (1.3 mmol/L) [18%]

Lithium carbonate is used for the initial and maintenance treatment of bipolar mania. Typical symptoms of mania include extreme hyperactivity, delusions and hallucinations, grandiosity, elation, poor judgment, aggressiveness, impulsivity, pressure of speech, insomnia, flight of ideas, and sometimes hostility. Acute lithium toxicity presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurologic symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. Severe toxicity results in seizures and encephalopathy (Option 1). Serum lithium levels and clinical condition must be monitored before medication administration. Serum levels ≥1.5 mEq/L (1.5 mmol/L) and/or even the mildest symptomsof lithium toxicity must be reported to the health care provider. (Option 2) Dry mouth and thirst are common and expected side effects of lithium when treatment is initiated. They will resolve spontaneously and lithium need not be discontinued. (Option 3) Hyperactivity and auditory hallucinations are clinical findings associated with bipolar mania. Because lithium may take up to 3 weeks to become effective, it would not be unusual for a client to experience these symptoms after only 7 days of treatment. (Option 4) Lithium has a very narrow range of therapeutic serum levels; the usual ranges are 1.0-1.5 mEq/L (1.0-1.5 mmol/L) for treatment of acute mania and 0.6-1.2 mEq/L (0.6-1.2 mmol/L) for maintenance therapy. Educational objective:Acute lithium toxicity (>1.5 mEq/L [1.5 mmol/L]) presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurological symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. The health care provider must be notified at the earliest indication of lithium toxicity.

Low CD4 count defined as

Low CD4 counts are defined as <750/mm3 for infants 12 months or younger, <500/mm3 for children between age 1-5 years <200/mm3 for children age >5 years and adults

In DKA management, when serum glucose is <250mg/dL, D5W is administered to prevent hypoglycemia until ketoacidosis is resolved.

Management of DKA includes fluid resuscitation, IV insulin, and hourly blood glucose monitoring. When serum glucose is <250 mg/dL (13.9 mmol/L), D5W is administered to prevent hypoglycemia until ketoacidosis is resolved. Hypokalemia often occurs with resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent hypokalemia and subsequent life-threatening arrhythmias

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? 1. Auscultate breath sounds to assess for crackles [49%] 2. Monitor for >50 mL/hr urine output [28%] 3.Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 [13%] 4. Press over the tibia to assess for pitting edema [8%]

Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function. (Option 2) Urine output would be expected to increase from the diuretic effect of mannitol. This is not a complication. (Option 3) Glasgow Coma Scale scores range from 3-15. Improved mental status (orientation, alertness) is a desired effect of treatment. (Option 4) The presence of crackles is a more sensitive sign of fluid overload than pedal edema. Furthermore, in a bedridden client, the assessment should take place at a dependent part of the body, usually the sacral area. Educational objective:Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema.

Vegan megaloblastic anemia

Megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B12 supplement is recommended when dietary intake is inadequate.

Normal CSF pressure

Normal CSF pressure is 60-150 mm H2O.

Clients with end-stage renal disease commonly have elevated creatinine and blood urea nitrogen levels. These are expected findings.

Normal creatinine 0.6 -1.2 mg/dL Normal BUN: 8- 20 mg/dL or 2.9 -7.1 mmol/L

Which of the following diets would place a client at the highest risk for macrocytic anemia? 1. Lacto-ovo-vegetarian [13%] 2. Lacto-vegetarian [8%] 3. Macrobiotic [15%] 4. Vegan [61%]

Megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiencycan also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B12supplement is recommended when dietary intake is inadequate. (Option 1) Lacto-ovo-vegetarian — eggs, milk, and milk products are included, but no meat is consumed. (Option 2) Lacto-vegetarian — milk and milk products are included in the diet; eggs and meats are excluded. (Option 3) Macrobiotic — whole grains, vegetables, fruits, and seaweeds are emphasized; fish and seafood may be included in the diet up to several times a week. Educational objective:Individuals who follow a plant-based diet, especially vegans, are at risk for vitamin B12deficiency and the resulting macrocytic anemia.

melatonin

Melatonin supplements are thought to help the body adjust quickly to new surroundings and time zones (jet lag). Most practitioners agree that the lowest possible dose should be used and should be taken only for a short time. There are no long-term studies on the safety of melatonin. Higher doses may cause side effects such as vivid dreams and nightmares. Research suggests that taking melatonin once a person has reached the travel destination is sufficient and that starting it prior to or during air travel may actually slow the recovery of jet lag, energy, and alertness. (Option 1) Evening primrose may be used for eczema or skin irritations. (Option 2) Ginseng is used to promote mental alertness and enhance the immune system. (Option 4) St. John's wort is used for treatment of depression. It has many interactions with other prescription medications. Educational objective:Short-term use of low-dose melatonin may be considered to treat jet lag and fatigue from traveling across time zones.

Metronidazole (Flagyl)

Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection.

LPN/LVN scope of practice

Monitoring RN findings Reinforcing education Routine procedures (eg, catheterization) Most medication administrations Ostomy care Tube patency & enteral feeding Specific assessments* (lung sounds, bowel sounds, neurovascular checks, stoma color) Collect and report data (VS, CBC, coagulation studies) Measurement and application of compression devices

Spinal immobilization: NSAIDS

N - Neurological examination. Focal deficits include numbness and decreased strength.S - Significant traumatic mechanism of injuryA - Alertness. The client may be disoriented or have an altered level of consciousness .I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1).D - Distracting injury. Another significant injury could distract the client from spinal pain.S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present

Postoperative leukocytosis (leukocytes >11,000 mm3 [>11X109/L]) is common in the first 48 hours after orthopedic surgery from normal inflammatory immune responses.

Normal leukocyte count 4,500 - 11,000/mm^3 (4.5 - 11 x10^9)

steatorrhea

Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease.

The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions? 1. "I have a leftover prescription at home I can use if I have pain." [95%] 2. "I will cancel the wine tasting I have planned for this weekend." [1%] 3. "I will have someone drive me home and will take a couple of days off work." [1%] 4. "I will have someone stay with me and make sure I am okay." [0%]

Opioid pain medications should be avoided following a head injury; therefore, the nurse should clarify what medication the client has at home (Option 1). Any change in level of consciousness, dizziness, nausea, or other side effects of opioids could be misinterpreted as symptoms of a worsening condition related to the head injury. Clients are typically advised to use non-narcotic or nonsteroidal anti-inflammatory pain medications. A client with a head injury should be taught the following: Notify the health care provider if you experience increased drowsiness, nausea or vomiting, worsening headache, seizures, vision changes, behavioral changes, weakness or numbness, or difficulty with balance or walking Avoid alcohol and other central nervous system (CNS) depressants (eg, benzodiazepines) (Option 2) Have someone stay with you (Option 4) Avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days (Option 3) Educational objective:Clients should avoid opioid pain medications and CNS depressants (eg, alcohol) when recovering from a head injury. They should also avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days.

Bumetanide

is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort. The nurse assesses the client's abdomen by pressing one hand firmly into the abdominal wall. The client experiences pain when the nurse quickly withdraws the hand. The client's most recent blood glucose level is 210 mg/dL (11.65 mmol/L). What is the priority action by the nurse? 1. Collect peritoneal fluid for culture and sensitivity [48%] 2. Heat the remaining dialysate fluid and increase the dwell time [8%] 3. Place the client in high Fowler's position [23%] 4. Prepare to administer regular insulin intravenously [19%]

Peritonitis is a common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion connections or disconnections. Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effluent. Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness. To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn. Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity. The nurse should collect peritoneal effluent from the drainage bag for culture and sensitivity (Option 1). Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously. (Option 2) The client's chills and rebound tenderness are signs of infection that require further assessment. Dialysate is typically warmed to body temperature before instillation to prevent abdominal discomfort and increase urea clearance through vessel dilation. Dry heating with a heating cabinet or incubator rather than a microwave is recommended to reduce the danger of burning the peritoneum. The dwell time is based on the prescribed dialysis method and should not be extended without a prescription. (Option 3) High Fowler's position can help reduce shortness of breath if the client has volume overload, but it may worsen abdominal pain. (Option 4) Glucose (dextrose) is the osmotic agent in dialysate. Therefore, glucose levels must be monitored closely, particularly in clients with diabetes. However, a glucose level of 210 mg/dL (11.65 mmol/L) does not necessitate IV administration of regular insulin. Regular insulin can be added to the dialysate before the solution is instilled, or it can be administered subcutaneously to control glucose levels. Educational objective:Peritonitis is a common but serious complication of peritoneal dialysis. Manifestations include cloudy effluent, fever, abdominal pain, and rebound tenderness. Treatment is based on culture of the peritoneal fluid. Additional Information Reduction of Risk Potential NCSBN Client Need

Common applications of droplet precautions Neisseria meningitidis Haemophilus influenzae type B Diphtheria Mumps Rubella Pertussis Group A Streptococcus (strep throat) Viral influenza

Personal protective equipment: Surgical mask Private room As needed for procedures with risk of splash or body fluid contact: gloves, gown, goggles/face shield

Intusussception

is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass.

Lumbar puncture position

lateral recumbent fetal position or sitting upright

St. John's Wort

may be used for tx of depression, has many interactions with other prescription meds

Increased brain natriuretic peptide levels can indicate stretching of the chambers of the heart in heart failure. Levels >100 pg/mL (>100 pmol/L) can indicate heart failure and would be expected in this client.

normal BNP : less than 100

Client admitted for cocaine OD with creatinine kinase of 30,00 U/L priority to report to HCP

Rhabdomyolysis occurs when muscle tissue is damaged and myoglobin (protein found in muscle tissue) is released into the blood, usually after an injury from overexertion, dehydration, severe vasoconstriction (eg, cocaine use), heat stroke, or trauma. Acute kidney injury can occur when myoglobin overwhelms the kidneys' filtration ability. As myoglobin is excreted, the urine becomes very dark and is described as being a cola-brown color. Severely elevated creatine kinase levels, typically >15,000 U/L (>250 µkat/L), are observed with severe muscle damage and can be a precursor to kidney injury (Option 2). Forced saline diuresis with intravenous fluids (to prevent blockage of the renal tubules with myoglobin) is necessary to prevent permanent kidney damage. (Option 1) Postoperative leukocytosis (leukocytes >11,000 mm3 [>11X109/L]) is common in the first 48 hours after orthopedic surgery from normal inflammatory immune responses. (Option 3) Clients with end-stage renal disease commonly have elevated creatinine and blood urea nitrogen levels. These are expected findings. (Option 4) Increased brain natriuretic peptide levels can indicate stretching of the chambers of the heart in heart failure. Levels >100 pg/mL (>100 pmol/L) can indicate heart failure and would be expected in this client. Educational objective:Rhabdomyolysis occurs when large amounts of muscle tissue break down and is associated with elevated creatine kinase levels, myoglobinemia, and myoglobinuria. Acute kidney injury, a complication of rhabdomyolysis, can be prevented by prompt administration of intravenous fluids.

Aortic dissection

occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) layers. Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever," "tearing," or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure.

Ginseng

promote mental alertness enhance immune system risk for bleeding

The most recent laboratory results for a 12-month-old who is HIV-positive show a CD4 lymphocyte count of 500/mm3 and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? Select all that apply. 1. Haemophilus influenza type b (Hib) 2. Hepatitis A 3. Measles, mumps, rubella 4. Pneumococcal conjugate vaccine 5. varicella

Routine immunization is particularly beneficial to children who are HIV-positive as they are more susceptible to preventable diseases due to a compromised immune system. The standard vaccine schedule for a 12-month-old includes Hib, PCV (PVC13), MMR, varicella, and Hep A. HIV-positive children who are asymptomatic and not extremely immunocompromised can receive the appropriate age-specific immunizations as recommended. However, live vaccine preparations (eg, MMR, varicella) are contraindicated in the presence of marked immunosuppression, as determined by CD4 lymphocyte percentages and/or counts (Options 3 and 5). An individual with a CD4 lymphocyte percentage <15% is considered to be severely immunocompromised. Low CD4 lymphocyte counts vary slightly by age due to the normal occurrence of elevated CD4 counts during infancy and early childhood. Low CD4 counts are defined as <750/mm3 for infants 12 months or younger, <500/mm3 for children between age 1-5 years, and <200/mm3 for children age >5 years and adults. Educational objective:Children who are HIV-positive and not severely immunocompromised can receive routine childhood immunizations. Children with severe immunosuppression as indicated by CD4 lymphocyte counts and/or percentages should not receive any live vaccines, including MMR and varicella.

Elevated creatinine kinase typically >15,000 U/L

Severely elevated creatine kinase levels, typically >15,000 U/L (>250 µkat/L), are observed with severe muscle damage and can be a precursor to kidney injury. Forced saline diuresis with intravenous fluids (to prevent blockage of the renal tubules with myoglobin) is necessary to prevent permanent kidney damage.

The emergency department nurse is assessing a client brought in after a car accident in which the client's head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? Select all that apply. 1. Breath smells of alcohol 2. Client disoriented to place 3. Client reports eyes burning 4. History of multiple sclerosis 5. Point tenderness over spine

Spinal immobilization is not a benign procedure. An acronym to help determine the need for spinal immobilization is NSAIDs: N - Neurological examination. Focal deficits include numbness and decreased strength.S - Significant traumatic mechanism of injuryA - Alertness. The client may be disoriented or have an altered level of consciousness (Option 2).I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1).D - Distracting injury. Another significant injury could distract the client from spinal pain.S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present (Option 5). (Option 3) The sensation of burning eyes could be related to many issues and does not necessarily have a direct correlation to spinal trauma. (Option 4) There is no direct correlation of multiple sclerosis (autoimmune progressive nerve demyelinization) with the need for spinal immobilization. Educational objective:Indications for spinal immobilization include abnormal neurological findings, significant mechanism of injury, change in orientation or level of consciousness, intoxication, distracting injury, and point tenderness over the spine. Additional Information Reduction of Risk Potential NCSBN Client Need

The health care provider is starting an elderly client on terazosin to treat benign prostatic hyperplasia (BPH). Which information should be included when teaching this client about the new medication? 1. Change positions slowly when going from lying to standing [44%] 2. Do not drink grapefruit juice when taking this drug [44%] 3. Take this medication first thing in the morning, before breakfast [7%] 4. Your stool may become darker and that's normal [3%]

Terazosin is an alpha-adrenergic blocker that can relieve urinary retention in clients with BPH. It relaxes the smooth muscle in the bladder neck and prostate gland; however, it also relaxes smooth muscle in the peripheral vasculature, which can cause orthostatic hypotension, syncope (blacking out), and falls. This is particularly common when the drug is started (first-dose hypotension) or when the dosage is increased. The serious effects can be avoided by instructing the client to take the medication at bedtime, change positions slowly when going from lying to standing, and avoid any medications that also increase smooth muscle relaxation (eg, phosphodiesterase-5 inhibitors [sildenafil or vardenafil] used to treat erectile dysfunction). Some clients may also experience ejaculatory dysfunction (decreased or absent ejaculation). (Option 2) Grapefruit juice can cause significant interactions with drugs such as calcium channel blockers and sildenafil. However, it does not appear to interact with alpha blockers such as terazosin. (Option 3) Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the morning, to avoid orthostatic hypotension. (Option 4) Oral iron tablets and bismuth salts (Pepto-Bismol) can turn stools dark, an expected side effect. This can be confused with upper gastrointestinal bleeding, which can also cause melena. Educational objective:Alpha blockers are commonly used to treat symptoms of urinary retention in clients with BPH. Orthostatic hypotension is a common side effect that can be avoided by teaching the client to take the medication at bedtime, avoid abrupt position changes, and avoid medications for erectile dysfunction, which can worsen hypotension. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

A client's arterial blood gases (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs? Click on the exhibit button for additional information. 1. Decrease in bicarbonate reabsorption [26%] 2. Decrease in respiratory rate [14%] 3. Increase in bicarbonate reabsorption [21%] 4. Increase in respiratory rate [37%] PH: 7. 25 PO2: 79 PaCO2: 35 HCO3: 12

The client's ABGs have low pH consistent with acidosis. If it is a primary respiratory acidosis, pCO2 would be higher. If it is metabolic acidosis, bicarbonate would be lower. Because this client has low pH coupled with low bicarbonate, the most likely diagnosis is primary metabolic acidosis. Respiratory alkalosis is the body's natural compensation for metabolic acidosis. Respiratory alkalosis is achieved by blowing more CO2 off from the system through rapid breathing. (Option 1) Decreased bicarbonate reabsorption would produce metabolic acidosis; this would occur as a compensation for primary respiratory alkalosis (decreased pCO2 and high pH). (Option 2) When the respiratory rate is decreased, pCO2 would increase, creating a respiratory acidosis; this would occur in response to a primary metabolic alkalosis. (Option 3) Increased bicarbonate reabsorption would produce metabolic alkalosis; this would occur as a compensation for primary respiratory acidosis (increased pCO2 and low pH). Educational objective:Respiratory alkalosis is the body's natural compensation for metabolic acidosis. It is achieved by blowing more CO2 off from the system through rapid breathing. Additional Information Reduction of Risk Potential NCSBN Client Need

When the nurse assesses an erratic plethysmograph waveform, the first action is to assess the client's oxygenation/perfusion status and assess for a motion artifact

The erratic pulse oximeter tracing is representative of an artifact plethysmograph waveform caused by motion. When an electronic assessment reading is questionable, the nurse should always assess the client first for possible etiology. The assessment includes the client's oxygenation and perfusion status (skin temperature, color), the level of consciousness (in sedated clients), and restlessness or agitation. This assessment data guides the nurse in the correct analysis of the tracing. (Option 2) The artifact is most likely from movement or loose contact between the sensor and the area of the body to which it is attached. It is not an electrical artifact and does not require the device to be disconnected from this client. (Option 3) The pulse oximeter reading is 95%. Unless there are audible or visual secretions, increased ventilator peak pressure readings, coughing, or rhonchi, this client does not require immediate endotracheal suctioning. (Option 4) The reading on the device is 95% and the low alarm is set to 90%. Therefore, alarm parameters do not need to be reset. Educational objective:When the nurse assesses an erratic plethysmograph waveform, the first action is to assess the client's oxygenation/perfusion status and assess for a motion artifact. This assessment data guides the nurse in the correct analysis of the tracing. Additional Information Reduction of Risk Potential NCSBN Client Need

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first? 1. Check for bleeding at tube connection sites 2. Perform a fast flush of the arterial line system 3.Re-level the transducer to the phlebostatic axis 4. Zero and re-balance the monitor and system

The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client to the ICU. (Option 2) A fast flush of the arterial line system (square wave test) should be performed after the nurse has ruled out a physiological cause of the low pressure alarm. This test helps to verify if the arterial line is functioning correctly. (Option 3) The transducer should be leveled to the client's phlebostatic axis to measure arterial pressure correctly. However, this should be done after the client has been checked for a physiological cause of the alarm. (Option 4) Zeroing the monitor should be done if measurement accuracy is questioned. However, this should be done after the client has been taken care of. Educational objective:A low pressure alarm for an arterial line can indicate the presence of hypotension or disconnected tubing. Hemorrhage can rapidly occur with a disconnected arterial catheter line. The nurse should check the client for the presence of hypotension and its causes before troubleshooting the system. Additional Information Physiological Adaptation NCSBN Client Need

Why is voiding prior to RBC infusion necessary?

The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started (Option 4). (Options 1 and 2) Hypotension is a sign of a transfusion reaction and is not expected. Bedrest is not required, but the client should be assisted if out of bed during a transfusion to prevent falls. Educational objective:An acute hemolytic transfusion reaction is a life-threatening reaction caused primarily by blood incompatibility. If it occurs, the transfusion should be stopped and a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. Asking the client to void prior to starting the transfusion helps ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion. Additional Information Pharmacological and Parenteral Therapies NCSBN Client Need

The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action? 1. 26-year-old with splenectomy reports a headache and chills [52%] 2. 40-year-old with immune thrombocytopenic purpura has petechiae on the arms [19%] 3. 60-year-old with marked anemia reports shortness of breath when ambulating [12%] 4. 68-year-old with polycythemia vera has a hematocrit of 66% (0.66) [16%]

The spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections (eg, pneumococcal pneumonia, meningococcal meningitis). Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major lifelong complications in a client without a functioning spleen. A minor infection can quickly become life-threatening, and so any indicator of infection such as a low-grade fever, chills, or headache needs immediate intervention (eg, cultures, imaging, antibiotic therapy). Therefore, the client with the splenectomy who is reporting headache and chills requires immediate action. (Option 2) Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which clients have abnormal platelet destruction with a count <150,000/mm3 (150 x 109/L). ITP is associated with an increased risk of bleeding. A common manifestation of ITP includes petechiae, which are pinpoint flat, red or brown microhemorrhages under the skin caused by leakage of red blood cells. Petechiae are an expected finding. (Option 3) A client with marked anemia can develop exertional dyspnea due to the body's inability to meet the metabolic demands (oxygen supply) associated with activity. This is an expected finding. (Option 4) Polycythemia vera (true primary polycythemia) is a chronic myeloproliferative disease characterized by bone marrow overproduction of red blood cells, white blood cells, and platelets. This leads to increased hematocrit (>53% [0.53]) and blood volume, enhanced blood viscosity, and abnormal clotting. A hematocrit of 66% (0.66) is an expected finding. Educational objective:Overwhelming postsplenectomy bacterial infection is a major lifelong complication in clients without a functioning spleen. A minor infection can quickly become life-threatening and septic; therefore, any indicator of infection requires immediate attention and treatment intervention. Additional Information Reduction of Risk Potential NCSBN Client Need

The transducer should be leveled to the client's phlebostatic axis to measure arterial pressure correctly

The transducer should be leveled to the client's phlebostatic axis to measure arterial pressure correctly. However, this should be done after the client has been checked for a physiological cause of the alarm.

Ribbon like stool

Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax.

clt at risk for wound dehisence and evisceration

Vomiting and dry heaving place increased mechanical stress on surgical wound edges and increase the risk for wound dehiscence and evisceration. Obese clients who have undergone extensive abdominal surgery are especially vulnerable. Therefore, the nurse should first assess the client who is nauseated and dry heaving and administer an antiemetic medication (Option 3). (Option 1) This client trying to leave against medical advice is the second priority. The nurse needs to assess this client for pain and determine when pain medication was administered last. If this situation cannot be resolved quickly, the nurse should notify the client's health care provider immediately to determine level of competency and inform the client of the risks of refusing treatment. (Option 2) The nurse must follow-up 30 minutes after the morphine is administered, not immediately, to assess the effectiveness of the pain medication. (Option 4) Providing discharge instructions to this client can wait without consequence. Educational objective:Postoperative nausea, vomiting, and dry heaving should be treated with antiemetic medication as soon as possible as it increases a client's risk for wound dehiscence and evisceration (medical emergency).

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm. Which of the following critical values is most likely due to laboratory error? 1. Blood urea nitrogen (BUN) of 60 mg/dL (21.4 mmol/L) 2. Creatinine of 4.0 mg/dL (354 µmol/L) 3. Potassium of 7.0 mEq/L (7.0 mmol/L) 4. Sodium of 155 mEq/L (155 mmol/L)

With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/L) in any client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L (7.0 mmol/L) would normally constitute a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. An assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the health care provider (HCP). In this case, it is likely that a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnated hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching, and use of a larger gauge needle for the sample. (Option 1) This blood urea nitrogen (BUN) value is elevated (normal 6-20 mg/dL [2.1-7.1 mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the most likely erroneous result. (Option 2) Similar to the BUN level, this creatinine value is significantly elevated (normal 0.6-1.3 mg/dL [53-115 µmol/L]). Further nursing assessment is indicated, with documentation and involvement of the HCP in evaluating the impact of this kidney damage on the client's health. (Option 4) This sodium value is high (normal 135-145 mEq/L [135-145 mmol/L]) and requires further exploration. The nursing assessment should be documented and reported to the HCP. Educational objective: High serum potassium levels could be due to hemolysis or clotting during the blood draw. If a clinical assessment does not correlate with the laboratory values, repeat testing is needed. Additional Information Reduction of Risk Potential NCSBN Client Need

Med-surge LPN delegation

Wound care and routine medication administration are the most appropriate tasks to assign to the LPN. The LPN can perform sterile procedures and cleanse and dress wounds for which there is an established prescription plan (Option 4). Pain rated at 8/10 is an expected finding in a client with chronic back pain, and the oral analgesic may be administered as scheduled by the LPN (Option 1). If this client were experiencing new-onset, unexplained pain requiring intravenous analgesic administration, the client would need assessment by the RN. (Option 2) The LPN may perform specific assessments, but evaluating the fluid volume status of a heart failure client is a comprehensive assessment involving multiple body systems (eg, heart and lung sounds, peripheral edema, adequacy of urine output). This client will also require discharge education on home management of heart failure, which is the responsibility of the RN. (Options 3 and 5) UAP have the appropriate skills and knowledge to meet clients' elimination, hygiene, and comfort needs. Although these tasks could be safely carried out by an LPN, underutilizing UAP would be an ineffective use of resources. Educational objective:LPNs may safely perform sterile procedures and routine medication administration. The RN is responsible for discharge planning and performing comprehensive clinical assessments. The nurse should also consider appropriate use of resources when making assignments or delegating tasks. Additional Information Management of Care NCSBN Client Need

LPN skills

Wound care and routine medication administration are the most appropriate tasks to assign to the LPN. The LPN can perform sterile procedures and cleanse and dress wounds for which there is an established prescription plan. Pain rated at 8/10 is an expected finding in a client with chronic back pain, and the oral analgesic may be administered as scheduled by the LPN

RN delegates what to LPN in a client with established colostomy ?

he RN may delegate care of stable clients with established ostomies to the licensed practical nurse (LPN). The following actions related to ostomy care are generally within the LPN scope of practice: Provide ostomy care and observe for skin breakdown (Option 2) Perform specific assessments (eg, bowel sounds, stoma color) (Option 3) Monitor drainage characteristics (eg, color, amount) (Option 5) Reinforce education Irrigate an established ostomy Document observations and interventions (Option 1) The RN may delegate specific assessments to the LPN. The LPN focuses on data collection and determining normal versus abnormal findings. For example, the LPN may determine that a client's colostomy stoma is an abnormal color whereas the RN synthesizes assessment findings (eg, color, temperature, capillary refill) to determine the quality of tissue perfusion. (Option 4) Developing the plan of care is the responsibility of the RN and cannot be delegated. Educational objective:Tasks requiring initial assessment, initial or discharge education, care planning, or care of an unstable client require the clinical judgment of the registered nurse (RN) and may not be delegated. The licensed practical nurse may perform basic care activities of the client with an established ostomy, perform specific assessments, monitor RN findings, and reinforce education. Additional Information Management of Care NCSBN Client Need

Give erythropoietin

hgb less than 10

Eryhtropoietin (EPO) hold

if Hgb greater than 11

Isoniazid

is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis Normal ALT: 8-40 AST: 8-40