NCLEX Prep 1

The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which of the following client statements show that teaching has been effective? Select all that apply. 1. "I need to call the health care provider (HCP) if I have trouble reading." 2. "I need to check my blood pressure before taking my medicine." 3. "I should call the HCP if I develop nausea and vomiting." 4. "I should check my heart rate prior to taking this medication." 5. "I will call the HCP if I feel dizzy and lightheaded."

1. "I need to call the health care provider (HCP) if I have trouble reading." 3. "I should call the HCP if I develop nausea and vomiting." 4. "I should check my heart rate prior to taking this medication." 5. "I will call the HCP if I feel dizzy and lightheaded." Rationale: Digoxin is a cardiac glycoside used to treat heart failure and atrial fibrillation. Cardiac glycosides have positive inotropic effects (eg, increased cardia output) and negative chronotropic effects (eg, decreased heart rate). However, drug toxicity is common due to digoxin having narrow therapeutic range levels (0.5-2.0 ng/mL) Cardiac arrhythmias are the most dangerous symptoms. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness (Option 5). Clients are instructed to check their pulse and if it is low (<60/min) or has skipped beats to hold medication and notify the health care provider (Option 4). Other manifestations of digoxin toxicity that clients should report include: -Visual symptoms (eg, alterations in color vision, scotomas, blindness) (Option 1) -Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) - frequently the earliest symptoms (Option 3) -Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) (Option 2) There is no need to routinely check blood pressure before taking digoxin as it does not affect blood pressure. Clients should check the pulse prior to administration. Educational objective: Cardiac glycosides (eg, digoxin) have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). Clients are instructed to check their pulse before administration and to report gastrointestinal (eg, anorexia, nausea), neurologic, and cardiac symptoms and visual changes).

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." 2. "I will not touch the lesions to prevent spreading the virus to other parts of my body." 3. "I will use a hair dryer on a cool setting to dry the lesions after taking a shower." 4. "I will use warm running water and mild soap without perfume to wash the area."

1. "I will be sure we use condoms during intercourse as long as I have lesions." Rationale: 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 a symptomatic relief. Mild soap containing no perfumes reduces the risk of irritation to the area. Educational objectives: 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.

The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? 1. 8-year-old with sickle cell crisis who has sudden-onset unilateral arm weakness 2. 11-year-old with viral meningitis requesting pain medication for headache 3. Male child scheduled for surgery for intussusception who has reddish mucoid stool 4. Male child with hemophilia who has hemarthrosis and is receiving desmopressin

1. 8-year-old with sickle cell crisis who has sudden-onset unilateral arm weakness Rationale: Children can have strokes. Ischemic strokes are common in children with sickle cell disease. Other causes can include carotid abnormalities/dissection. The most common presentation of an ischemic stroke is the sudden onset of numbness or weakness of an arm and/or leg. These are handled with a similar emergent approach as for stroke in an adult. Children may require exchange blood transfusion to prevent the stroke from worsening. (Option 2) Viral meningitis can cause fever, headache, and meningeal signs (neck stiffness). Headache is expected and not a priority over a client with stroke. (Option 3) Intussusception occurs when one portion of the intestine prolapses and then telescopes into another. It is a frequent cause of intestinal obstruction during infancy. Onset is abrupt, initially with pain and brown stool. This condition then progresses to bilious emesis, palpable abdominal mass, and stools with a red, "currant jelly" appearance due to blood and mucus. This is an expected finding for this condition, and surgery is already scheduled to address it. (Option 4) Hemophilia is seen primarily in males and is due to a lack of clotting factors. Symptoms include spontaneous bleeding (hemarthrosis into the joints, especially the knee, ankle, or elbow. Treatment includes replacing the missing clotting factor. Desmopressin (DDAVP) stimulates the release of factor VIII. The child is receiving treatment already and joint rest has been prescribed. The sudden neurological change in the child with sickle cell crisis is a priority. Educational objective: Children can have strokes. These usually are caused by clotting or vascular issues and require similar emergent care as adults. Desmopressin is used to treat hemophilia.

A client is seen in the ambulatory care center for treatment of a second episode of acute gout. Which lifestyle modifications would help prevent future exacerbations? Select all that apply. 1. Achieve and maintain a healthy weight 2. Avoid foods containing protein 3. Drink plenty of fluids 4. Increase meat intake 5. Limit alcohol consumption

1. Achieve and maintain a healthy weight 3. Drink plenty of fluids 5. Limit alcohol consumption Gout is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in uric acid control are often seen when weight loss is accompanied by dietary modifications (Option 1). Suggested modifications include: -Increasing fluid intake (2 L/day) to help eliminate excess uric acid (Option 3). -Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood (eg, sardines, shellfish) -Limiting alcohol intake, especially beer (Option 5) -Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates (Option 2) It is unpalatable and impractical to avoid all foods containing protein. The risk of developing gout increases with high dietary purine intake but not necessarily protein intake. Low-fat dairy products are good sources of protein that are associated with a reduced risk of gout. (Option 4) Increasing intake of meat, especially organ meats, will not prevent future gout attacks but may precipitate them. Educational objective: Weight loss and dietary modifications may reduce the frequency of acute episodes of gout. These strategies include increasing fluids, limiting daily alcohol consumption, and avoiding organ meats and seafood to reduce purine load.

The emergency department nurse receives several prescriptions for a client who was found unresponsive after drinking beer and consuming unidentified pills. Which prescription should the nurse implement first? Vital signs: Temperature 96.4 F (35.8 C) Blood pressure 90/62 mmHg Heart rate 53/min Respirations 6/min O2 saturation or SpO2 92% 1. Administer IV push naloxone once now 2. Draw specimen for blood alcohol content testing STAT 3. Initiate continuous lactated Ringer solution infusion 4. Obtain urine sample for drug abuse screening ASAP

1. Administer IV push naloxone once now Rationale: The goals of emergency care for the client with suspected substance abuse who exhibits signs of central nervous system depression (eg, altered level of consciousness, bradypnea, hypotension, bradycardia) are to promote adequate ventilation and oxygenation and preserve hemodynamic stability. Interventions are prioritized according to ABCs (ie, airway, breathing, circulation). Initial actions involve maintaining patency of the client's airway, including appropriate positioning, oropharyngeal suctioning, and artificial airway placement (if needed). Respiratory depression, occurring after the ingestion of an unknown substance (eg, depressants [opioids, benzodiazepines, barbiturates]) should initially be treated with administration of reversal agents (eg, naloxone, flumazenil). Naloxone rapidly reverses the effects of opioids and may restore spontaneous respiration and normal ventilatory pattern, averting initiation of mechanical ventilation, the possibility of respiratory arrest, and death (Option 1). (Option 2 and 4) Obtaining blood and urine for toxicology screening assists in guiding care decisions but should occur after interventions that support the client's airway, breathing, and circulation. (Option 3) Administration of IV fluids to support blood pressure and prevent dehydration should be performed after securing the client's airway and supporting effective breathing Educational objective: Nurses providing emergency care to clients with suspected substance abuse who exhibit signs of central nervous system depression (eg, bradypnea, bradycardia) prioritize interventions according tot he ABCs (ie, airway, breathing, circulation). Administration of naloxone is a priority action in the setting of respiratory depression from an unknown substance because it rapidly reverses the depressant effects of opioids.

A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? Select all that apply. 1. Administering IM betamethasone 2. Administering penicillin via IV piggyback 3. Assisting with artificial rupture of membranes 4. Initiating IV magnesium sulfate 5. Obtaining fetal heart tones once per shift

1. Administering IM betamethasone 2. Administering penicillin via IV piggyback 4. Initiating IV magnesium sulfate Rationale: Preterm labor (PTL) is defined as progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate the following interventions for clients in PTL before 34 weeks gestation: -Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development (Option 1). -Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs (Option 2). -Initiating an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation (Option 4). -Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows antenatal glucocorticoids time to have a therapeutic effect. -Monitoring pertinent laboratory results, including cultures for vaginal or urinary tract infection and group B Streptococcus, if obtained. (Option 3) Artificial rupture of membranes (AROM), or amniotomy, is performed to augment labor or assess amniotic fluid in client who are at term gestation. For clients in PTL, the goal is to prolong pregnancy if possible. Therefore, AROM is contraindicated. (Option 5) Clients with suspected PTL should be placed on continuous fetal monitoring to assess for increasing frequency and duration of contractions and to evaluate fetal tolerance of labor. Continuous fetal monitoring is also required if the client is receiving a magnesium sulfate infusion. Educational objective: Preterm labor is progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate several interventions, including administration of IM antenatal glucocorticoids, antibiotics, and IV magnesium sulfate.

The nurse is monitoring a client who ahs been on clopidogrel therapy. Which assessments are essential? Select all that apply. 1. Assess for bruising 2. Assess for tarry stools 3. Monitor intake and output 4. Monitor liver function tests 5. Monitor platelets

1. Assess for bruising 2. Assess for tarry stools 5. Monitor platelets Rationale: Antiplatelet therapy (eg, aspirin, prausgrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenic purpura, so platelets should be monitored periodically (Option 5). (Option 3) Monitoring intake and output is indicated while a client is on diuretic medications (eg, furosemide, torsemide, bumetanide) but not for antiplatelet agents. (Option 4) Baseline liver enzymes are obtained for clients taking statins (eg, rosuvastatin, atorvastatin) and isoniazid (for tuberculosis). Elevated liver enzymes are an infrequent side effect of clopidogrel, and regular monitoring is usually not required in clients with hepatic impairment. Educational objective: Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) can pose a risk for serious bleeding. Clients should be monitored for bruising, signs of bleeding (eg, tarry stools, hematuria), and decreased platelet counts.

The nurse is preparing to irrigate the ears of a 67-year-old client with impacted cerumen. Place the following steps for ear irrigation in the correct order. All options must be used. 1. Assess the client for fever, ear infection, or tympanic membrane injury 2. Gently irrigate the ear canal with a slow, steady flow of solution 3. Place a towel and an emesis basin under the ear 4. Place the client in a sitting position with the head tilted toward the affected ear 5. Straighten the ear canal by pulling the pinna up and back

1. Assess the client for fever, ear infection, or tympanic membrane injury 4. Place the client in a sitting position with the head tilted toward the affected ear 3. Place a towel and an emesis basin under the ear 5. Straighten the ear canal by pulling the pinna up and back 2. Gently irrigate the ear canal with a slow, steady flow of solution Rationale: Ear irrigation may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure: 1. Assess the client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies (Option 1). 2. Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth). 3. Place the client in a side-lying or sitting position with the head tilted toward the affected ear (Option 4). Place a towel and an emesis basin under the ear (Option 3). 4. Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort. 5. Straighten the ear canal, pulling the pinna up and back for adults or down and back for children </= 3 years (Option 5). 6. Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal (Option 2). Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences severe pain, nausea, or dizziness. 7. Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled. 8. Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching. Educational objective: To perform ear irrigation, assess for contraindications (fever, ear infection, tympanic membrane injury); tilt the affected ear down; straighten the ear canal; and use a solution at body temperature to irrigate gently, aiming toward the top of the ear canal until it is clear.

Ten minutes after an infusion of packed red blood cells (PRBCs) is initiated through a central venous catheter (CVC), the client has shortness of breath and slight chest tightness. What initial actions would be appropriate for the nurse to complete? Select all that apply. 1. Assess the client' breath sounds 2. Flush the blood IV tubing with normal saline 3. Notify the health care provider (HCP) 4. Remove the CVC 5. Stop the infusion of PRBCs

1. Assess the client' breath sounds 3. Notify the health care provider (HCP) 5. Stop the infusion of PRBCs Rationale: Signs and symptoms of blood transfusion reaction typically will occur within the first 15 minutes after initiation of the transfusion. These include shortness of breath, chest tightness, fever, back pain, anxiety, tachycardia, and hypotension. When a transfusion reaction is suspected, the first step is to stop the infusion (Option 5). An infusion of normal saline is typically started. It is important that normal saline be administered through a different port of the CVC using new tubing or at the closest access point to the client. Flushing the blood in the IV tubing into the client will expose the client to more of the causative agent and increase complications from the transfusion reaction (Option 2). The HCP must then be notified (Option 3). Because the client has shortness of breath and chest tightness, an assessment of breath sounds is appropriate. Adventitious sounds could indicate bronchospasm or excess fluid in the lungs (Option 1). (Option 4) A CVC will not be discontinued due to the transfusion reaction. Iv access will be required for administration of fluids and medications. Educational objective: if an adverse blood transfusion reaction is suspected, the first action is to stop the infusion. An infusion of normal saline through a different port for the CVC is typically started. A client assessment and notification of the HCP are also required.

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

1. Barotrauma Rationale: Positive end-expiratory pressure (PEEP) applies a given pressure at the end of expiration during mechanical ventilation. It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange. PEEP is usually kept at 5 cm H2O (3.7 mm Hg). However, a higher level of PEEP is an effective treatment strategy for acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type II surfactant-producing pneumocytes that then leads to atelectasis, noncompliant lungs, poor gas exchange, and refractory hypoxemia. High levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema. (Option 2) PEEP opens up collapsed alveoli and improves gas exchange at a lower fraction of inspired oxygen (FiO2), resulting in increased, not decreased, oxygen saturation. (Option 3) Hemodynamic effects of PEEP included increased intrathoracic pressure, which leads to reduced venous return, decreased preload and cardiac output, and hypotension, not hypertension (Option 4) Keeping the alveoli open between breaths with PEEP improves gas exchange across the alveolar-capillary membrane, reduces hypoxemia, and allows for the use of a lower FiO2, which can reduce the risk for oxygen toxicity. Educational Objective: High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10-20 cm H2) [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension.

The clinic nurse is reviewing the laboratory results of a 35-year-old client who reports fatigue for the last month. Based on the laboratory results, which additional clinical manifestations would the nurse expect? Select all that apply. 1. Bradycardia 2. Cold intolerance 3. Constipation 4. Hair loss 5. Warm, moist skin 6. Weight loss

1. Bradycardia 2. Cold intolerance 3. Constipation 4. Hair loss Rationale: Clinical features of hypothyroidism: Generalizes slowing of metabolic processes -Weakness & fatigue -Weight gain -Bradycardia -Delayed deep tendon reflexes -Constipation -Cognitive slowing -Cold intolerance Mucopolysaccharide accumulation -Coarse, dry skin -Hoarseness -Nonpitting edema (myxedema) -Macroglossia Other mechanisms -Depression -Myalgia & arthralgia -Hypercholesterolemia Primary hypothyroidism is an endocrine disorder identified by low circulating thyroid hormone (ie, triiodothyronine [T3], thyroxine [T4], and high thyroid-stimulating hormone (TSH) levels. Primary hypothyroidism occurs when TSH is unable to stimulate the thyroid to produce thyroid hormones, often after trauma or autoimmune-related tissue damage (eg, Hashimoto thyroiditis). Therefore, TSH levels remain elevated as primary counterregulatory hormone (ie, T3, T4) levels remain low. Thyroid hormones act in multiple body sites to stimulate and increase metabolic functions (eg, body temperature, cellular energy, oxygen consumption, neuron conduction). Therefore, clients with hypothyroidism exhibit clinical manifestations of low metabolic state, including: -Bradycardia and hypotension (Option 1) -Hypothermia and cold intolerance (Option 2) -Constipation (Option 3) -Fragile, dry skin and hair loss (Option 4) -Forgetfulness, slurred speech, and confusion (Options 5 and 6) Clients with hypothyroidism often gain weight and develop dry, fragile skin because of decreased metabolic activity. Weight loss and warm, moist skin are characteristic of an increased metabolic rate, as found in clients with hyperthyroidism. Educational objective: Primary hypothyroidism is a condition identified by low thyroid hormone and elevated thyroid-stimulating hormone levels, which result in decreased metabolic function throughout the body. Clinical manifestations include weight gain, constipation, dry skin, hair loss, cold intolerance, bradycardia, and confusion.

The night nurse receives a call at 4 AM from the laboratory regarding a client's blood cultures that have tested positive for bacteria. Which action by the nurse is appropriate at this time? 1. Call the answering service and speak to the health care provider now 2. Document the results of the culture in the client's medical record 3. Leave a message on the health care provider's office phone 4. Speak to the health care provider on rounds in the morning

1. Call the answering service and speak to the health care provider now Rationale: Critical laboratory results (eg, positive blood cultures, severe electrolyte derangements) require immediate intervention for client safety. The nurse receiving a critical laboratory result should notify the health care provider (HCP) as soon as possible. Hospital organizations have individual policies regarding the time frame for notification of the HCP and HCP response, usually </= 60 minutes. Bacteremia requires timely treatment to prevent further complications (eg, septic shock) (Option 1). (Option 2) The critical laboratory result should be documented in the client's medical record, but only after immediate communication with the HCP. (Option 3) The nurse must make direct contact, either via telephone or in person, when reporting a critical result. A telephone message may not be received promptly, and a critical value requires immediate intervention. (Option 4) Even if the HCP usually makes rounds early in the morning, a critical value requires immediate, real-time notification to prevent delay of potentially urgent intervention. Educational objective: Critical laboratory results, such as positive blood cultures, require immediate communication with the health care provider (HCP) and timely intervention for client safety. The nurse must contact the HCP directly as soon as possible to avoid life-threatening complications (eg, septic shock).

A home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect? Select all that apply. 1. Client breaks eye contact when discussing caregiver 2. Client has lost 8 lbs (3.63 kg) in the pervious 4 weeks 3. Client is wearing clothing that is out of style 4. Client's eyeglasses have been visibly broken for 1 month 5. Client's prescription medication is expired

1. Client breaks eye contact when discussing caregiver 2. Client has lost 8 lbs (3.63 kg) in the pervious 4 weeks 4. Client's eyeglasses have been visibly broken for 1 month 5. Client's prescription medication is expired Rationale: Elder Abuse Risk Factors -Female -Dementia, chronic mental illness -Functional impairments -Social isolation -Shared living environment -Poor socioeconomic status/financial stress Physical & Sexual Abuse -Atypical abrasions, lacerations, contusions, fractures -Pain not consistent with reported etiology -Anogenital injuries -Newly acquired STI Psychological & Verbal Abuse -Change in behavior/personality -Depression/anxiety Neglect -Inadequate nutrition or hydration -Pressure injuries -Deterioration in comorbid conditions Financial Exploitation -Failure to adhere to medication regimen -Multiple missed appointments -Unpaid expenses or rent payments Elder abuse or neglect occurs when caregivers intentionally or unintentionally fail to meet the older adult client's physical, emotional, or social needs. Approximately 1 in 10 older adult clients are victims of physical, psychological, or sexual abuse by a caregiver. Commonly neglected necessities include water, food, medication, hygiene, and clothing. The client's living conditions may be unsafe or have inadequate access to public utilities. Objective findings consistent with abuse or neglect include: -Dehydration, malnutrition, and weight loss (Option 2) -Poor hygiene, soiled bedding or clothing, and pressure ulcers -Missing/broken assistive devices (eg, eyeglasses); medications withheld or expired (Options 4 and 5) Clients who have experienced abuse or neglect may find the situation difficult to discuss and display apprehension, restlessness, withdrawal, poor eye contact, shame, and despair (Option 1). The client may also deny or minimize the extent of the abuse out of fear or embarrassment. (Option 3) Clothing that is out of style is not indicative of neglect. However, soiled clothing or clothing unsuitable for the weather (eg, no jacket on a cold day) does indicate possible neglect. Educational objective: Manifestations of abuse or neglect in an older adult may include development of pressure ulcers, poor hygiene, dehydration, malnutrition, weight loss, soiled bedding/clothing, missing/broken assistive devices, and missing or expired medications.

The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction? 1. "Drowsiness is a common side effect of this medication and will improve over time." 2. "I can begin driving again after I have been on this medication for a few weeks." 3. "I need to immediately report any new or increased anxiety when on this medication." 4. "I need to immediately report any new rash when on this medication."

2. "I can begin driving again after I have been on this medication for a few weeks." Rationale: Levetiracetam is an anticonvulsant prescribed for seizure disorders. As with any other antiseizure medications, levetiracetam has a depressing effect on the central nervous system (CNS), which may cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is common and typically improves within 4-6 weeks (Option 1). However, the CNS-depressing effects of levetiracetam may be enhanced if taken with other CNS-depressing substances (eg, alcohol or medications). New or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation (Option 3). Like other anticonvulsants, levetiracetam can trigger Stevens-Johnson Syndrome, a rare but life-threatening blistering reaction of the skin. Rash, blistering, muscle/joint pain, or conjunctivitis should be reported and assessed immediately (Option 4). (Option 2) Clients with a seizure disorder should avoid driving or operating heavy machinery until they have permission from their health care provider and have met the requirements of their department of transportation. Typically, the client must be free from seizures for an allotted period of time. Educational objective: Levetiracetam is an anticonvulsant prescribed for seizure disorders. It may have depressing effects on the CNS (eg, drowsiness) as the body adjusts to therapy. Serious adverse effects include suicidal ideation and Stevens-Johnson syndrome. Clients with seizure disorders must meet the guidelines of their department of transportation and receive permission from their health care provider to legally operate a motor vehicle.

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate? 1. "I don't know because I am off duty right now." 2. "Let's step away from the crowd to discuss it." 3. "Mrs. Jones was fine when I last checked on her during rounds." 4. "You will have to talk with the nurse caring for her while I am on break."

2. "Let's step away from the crowd to discuss it." Rationale: The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. If another staff member asks a question about a client's medical information in an open area with visitors, the nurse should first move the conversation to a secure area. Answering the question will promote further conversation, making it likely that the client's privileged health care information will be discussed and overheard by others. The best response is to suggest changing the location of the conversation so that the information can be discussed privately (Option 2). (Option 1) This response is neither accurate nor helpful because the nurse knows how the client was earlier in the day. It is best to make the conversation private so that the nurse can respond to the question appropriately. (Option 3) Although vague, this response in a public area (ie, cafeteria) violates the client's privacy by acknowledging the client's presence in the hospital, where the response may be overheard by others. In addition, it does not provide accurate information. (Option 4) It is appropriate to direct questions about the client to the currently assigned nurse; however, this response violates the client's privacy by confirming the client's presence in the hospital. It is best to make the conversation private before sharing any information. Educational objective: The nurse must protect clients' privacy and ensure that their medical information remains confidential. Conversations about the client with other staff, even those regarding the client's presence in the hospital, should occur in a private area.

The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate? 1. Assign the same nurses and caregivers to the child each day 2. Avoid mentioning the loved one's death in the child's presence 3. Explain the importance of being with the child to the parents 4. Schedule time each day for age appropriate play

2. Avoid mentioning the loved one's death in the child's presence Rationale: Children's beliefs about death: -Birth to age 2 (No understanding of death. Sensitive to loss & separation; may be distressed by changes in the environment, caregivers & regular routines). -Age 3-5 (Believes that death is reversible. Thoughts may include magical thinking & fantasy [eg, they wish that a person would die]). -Age 6-9 (Understands the concrete finality of death. Difficultly in perceiving their own death; may be preoccupied with the medical or physical aspects of dying). -Age 10-12 (Understands that death is final & eventually affects everyone. Thinks about how a death will affect them personally). -Adolescence (Views death on an adult level. Understands that their own death is inevitable, but it is a difficult concept for them to perceive. Able to think about the spiritual & religious aspects of death). The preschool age (3-5 years) child's view of death is related to their developmental stage. They believe death is temporary and reversible, similar to a prolonged nap. The child may ask repeatedly when the deceased individual will return, or they may feel guilty and responsible for the death because of their wishes or thoughts (magical thinking). (Option 1) Familiar faces are comforting to the child, and consistently assigning the same nurses and caregivers promotes therapeutic relationships and trust. (Option 3) When considering the idea of death, preschool children have significant fear of separation from their parents. Therefore, it is appropriate to explain the importance of remaining with the child as much as possible to the parents. (Option 4) Play allows the child to cope with grief and provides an outlet to express or work through feelings/experiences that the child bay not be able to vocalize. Educational objective: Therapeutic interventions for preschool-age children who are experiencing the death of a loved one include providing familiarity (eg, same nurses, parental presence), ensuring that time each day is devoted to play, and speaking openly to the child about the death as often as needed.

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first? 1. Client with a head injury and fixed, dilated pupils 2. Client with an open right femur fracture and palpable pedal pulses 3. Client with full-thickness burns covering 85% total body surface area 4. Client with shallow lacerations over legs and arms

2. Client with an open right femur fracture and palpable pedal pulses Rationale: Disaster-Triage Emergent (Red) -Life-threatening injuries with high probability for survival if immediate treatment is received -Examples: shock, compromised airway, unstable wounds, chest trauma Urgent (Yellow) -Serious injuries requiring treatment within 30 minutes and 2 hours -Examples: Open fractures with palpable distal pulse, large wounds Nonurgent (Green) -Injuries requiring treatment but can wait for 2 hours or longer -Examples: Infections, minor burns or lacerations, closed fractures Expectant (Black) -Extensive injuries with poor prognosis regardless of treatment -Examples: pulselessness, apnea, severe neurological trauma, full-thickness burns >60% total body surface area During a mass casualty event, the goal of the nurse is to triage rapidly and provide the greatest good for the greatest number of people. Clients are commonly triaged using a color-coded system and placed into four categories. When prioritizing clients for treatment, emergent needs should be managed first followed by urgent and non-urgent needs. If no clients are identified as having emergent needs, clients with urgent needs (eg, open fractures with palpable pulses) should be treated first (Option 2). (Options 1 and 3) Clients who are expectant due to the severity of their injuries (eg, severe neurological trauma, full-thickness burns >60% of total body surface area) are the lowest priority for treatment. However, the nurse should provide palliative care, if possible, while addressing the needs of others. (Option 4) Clients with nonurgent needs (eg, minor lacerations) should receive treatment after emergent and urgent clients. Educational objective: During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that ranks them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant).

A nurse is completing discharge teaching to the parent of a child who is postoperative following a tonsillectomy. Which finding should be reported as a priority? 1. Ear pain 2. Frequent swallowing 3. Low-grade fever 4. Objectional mouth odor

2. Frequent swallowing Rationale: Tonsillectomy is usually performed as an outpatient procedure. Postoperative bleeding is an uncommon but important complication and it can last up to 2 weeks. It manifests with frequent or continious swallowing and/or cough from the trickling blood; some clients may also develop restlessness. Discharge teaching includes: -Avoid coughing, clearing the throat, or blowing the nose -Limit physical activity -Milk products are discouraged due to their coating effect, which can prompt clearing of the throat -Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation (Options 1, 2, and 4) The presence of slight ear pain, a low-grade fever, and objectionable mouth odor are common findings during the first 5-10 days after the procedure. Persistent moderate-to-severe earache, fever, or cough requires further evaluation. Educational objectives: Postoperative bleeding after a tonsillectomy is uncommon but can last up to 14 days after surgery. Continuous swallowing, restlessness, and frequent coughing are early indicators of bleeding. To prevent hemorrhage, the client should avoid clearing the throat, blowing the nose, and coughing.

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply. 1. Advance the entire stylet into the vein upon venipuncture 2. Insert the IV line into the most distal site of the right arm 3. Place an appropriate precaution sign above the bed 4. Review the medical record for history of mastectomy 5. Teach the client to keep the left arm in a dependent position

2. Insert the IV line into the most distal site of the right arm 3. Place an appropriate precaution sign above the bed 4. Review the medical record for history of mastectomy Rationale: A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated. The nurse should insert the IV line into the most distal site of the unaffected side (Option 2). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client's bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) (Options 3 and 4) In general, venipuncture is contraindicated in upper extremities affected by: -Weakness -Paralysis -Infection -Arteriovenous fistula or graft (used for hemodialysis) -Impaired lymphatic drainage (prior mastectomy) (Option 1) The stylet should be advanced until blood return is seen (approximately 1/4 inch). If advanced fully, the stylet may penetrate the posterior wall of the vein and cause a hematoma. (Option 5) Keeping the affected arm in a dependent position for a long time can increase lymphedema. The client should be reminded that raising the limb helps drainage. Educational objective: IV line insertion is contraindicated on the operative side of clients with a prior mastectomy. Additional contraindications for IV line insertion include weakness, paralysis, or infection of the arm; or presence of an arteriovenous fistula.

The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct? Select all that apply. 1. No sexual activity for at least 6 weeks postoperatively 2. Notify health care provider (HCP) of redness, swelling, or drainage at the incision site 3. Refrain from lifting objects weighing >5 lbs (2.26 kg) until approved by the HCP 4. Take a shower daily without soaking chest and leg incisions 5. Use lotion on incision sites with dressing changes if the area is dry

2. Notify health care provider (HCP) of redness, swelling, or drainage at the incision site 3. Refrain from lifting objects weighing >5 lbs (2.26 kg) until approved by the HCP 4. Take a shower daily without soaking chest and leg incisions Rationale: The RN providing discharge instructions for a client recovering from a CABG should include the following guidelines: 1. Explain the need for modification of cardiac risk factors, including smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise. 2. Encourage a daily shower (Option 4) as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens (Option 5). 3. Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lbs (2.26 kg) without approval of the HCP (Option 3). Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program. 4. Clarify no driving for 4-6 weeks or until the HCP approves 5. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity (Option 1). 6. Notify the HCP if the following symptoms occur: -Chest pain or shortness of breath that does not subside with rest -Fever > 101 F (38.8 C) -Redness, drainage, or swelling at the incision sites (Option 2). Educational objective: Discharge teaching for a client recovering from a CABG should include instructions related to medications, activity level, driving, sexual activity, and symptoms to report to the HCP.

The nurse prepares to insert an indwelling urinary catheter for a female client. The nurse assessess for allergies, explains the procedure to the client, gathers equipment, and then performs perineal care. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used. 1. Apply sterile gloves and place sterile drape under the client's buttocks 2. Perform hand hygeine and open a sterile urinary catheterization kit 3. Use the dominant hand to cleanse the labial folds with antiseptic swabs 4. Use the dominant hand to cleanse the urethral meatus with antiseptic swabs 5. Use the dominant hand to insert the catheter until urine return is observed 6. Use the nondominant hand to gently spread the labial folds

2. Perform hand hygeine and open a sterile urinary catheterization kit 1. Apply sterile gloves and place sterile drape under the client's buttocks 6. Use the nondominant hand to gently spread the labial folds 3. Use the dominant hand to cleanse the labial folds with antiseptic swabs 4. Use the dominant hand to cleanse the urethral meatus with antiseptic swabs 5. Use the dominant hand to insert the catheter until urine return is observed Steps for indwelling urinary catheter insertion for the female client include -Position the client supine with knees flexed and hips slightly externally rotated -Perform hand hygiene and open a sterile catheterization kit (Option 2) -Apply sterile gloves and place a sterile drape underneath the client's buttocks (Option 1). -Remove the protective covering from the catheter, lubricate the catheter tip, and pour antiseptic solution over cotton balls or swab sticks while maintaining sterility of gloves and sterile field. -Use the nondominant hand to gently spread the labia. The nondominant hand is now contaminated (Option 6). -Use the dominant (sterile) hand to cleanse the labia and urinary meatus with antiseptic-soaked cotton balls or swab sticks. Cleanse in an anteroposterior direction (from the clitoris to the anus). Use a new swab for each swipe to avoid transferring bacteria between areas. Cleanse the labia majora first, then the labia minora, then lastly the urinary meatus (Options 3 and 4). -Use the dominant hand to insert the catheter until urine return is visualized in the tubing (usually 2-3 inch [5-7.6 cm]), and then advance it an additional 1-2 inch [2.5-5 cm]) (Option 5). -Hold the catheter in place with the nondominant hand, and then use the dominant hand to inflate the balloon. Educational objective: To insert an indwelling urinary catheter in a female client: perform hand hygiene; apply sterile gloves and place a sterile drape under the client; arrange supplies on a sterile field; gently spread the labia with the nondominant hand; clenase the labia majora, then the labia minora, and lastly the urinary meatus; insert the catheter until urine return is visualized; advance an additional 1-2 inch (2.5-5 cm); and inflate the balloon.

A 6-month-old client has been diagnosed with cystic fibrosis. Which of the following would be appropriate for the registered nurse to teach to the parents? 1. Monitor for and report development of a "white pupil" 2. Perform manual chest physiotherapy 3. Place child in knee-chest position during hypercyanotic episode 4. Provide a low-calorie diet to prevent obesity

2. Perform manual chest physiotherapy Rationale: Cystic fibrosis is an inherited autosomal recessive disorder of the exocrine glands that results in physiologic alterations in the respiratory, gastrointestinal, and reproductive systems. It is theorized that the chloride transport alternation and resulting thickened mucus inhibit normal ciliary action and cough clearance, and the lungs become clogged with mucus. The thickened mucus harbors bacteria. Over time, airways develop chronic colonization and frequent respiratory infections result. Bronchial hygiene therapy, such as manual chest physiotherapy, is used. For physiotherapy, various positions are used, and this should be performed before meals to avoid a full stomach and resultant regurgitation or vomiting. (Option 1) A white pupil (leukocoria, or cat's-eye reflex) is one of the first signs of retinoblastoma, an intraocular malignancy of the retina. Other symptoms include an absent red reflex, asymmetric or of a differing color in the affected eye, and

A client diagnosed with vaginal candidiasis is instructed on self-care management techniques and proper administration of the prescribed miconazole vaginal cream. Which statement by the client indicates that further teaching is needed? 1. "Each time I use the bathroom, I will wipe myself from the front to the back." 2. "I should choose loose-fitting cotton underwear instead of nylon undergarments." 3. "I will refrain from having sex until my partner is also tested and treated for the infection." 4. "Prior to going to bed at night, I will apply miconazole cream using the vaginal applicator."

3. "I will refrain from having sex until my partner is also tested and treated for the infection." Rationale: Candida albicans (yeast) can colonize and cause infections of the vulvovaginal region. Vaginal candidiasis often causes itching and painful urination due to urine stinging the inflamed areas of the vulva. Assessment shows a thick, white, curd-like vaginal discharge and reddened vulvar lesions. Miconazole (Monistat), an antifungal cream commonly prescribed to treat vaginal candidiasis, is inserted high into the vagina using an applicator. It is best applied at bedtime so that it will remain in the vagina for an extended period (Option 4). Sexual intercourse is avoided until the inflammation is resolved, typically for the duration of treatment, approximately 3-7 days (Option 3). However, sexual activity is not a significant cause of infection or reinfection of candida, and partner evaluation is not needed. Trichomoniasis, syphilis, gonorrhea, and HIV are mainly sexually transmitted; therefore, partners should be evaluated and treated. Other teaching points for this client should include: -Ensuring proper hygiene of the perineum - cleansing from anterior to posterior (front to back) to prevent accidental introduction of fecal organisms (Option 1). -Wearing loosely fitted cotton underwear and avoiding synthetic undergarments to promote ventilation, decrease friction, and reduce moisture (Option 2) -Refraining from douching, which can introduce organisms higher up into the vaginal canal and cervix. Educational objective: Miconazole cream is commonly prescribed to treat vaginal candidiasis. Miconazole is best applied at bedtime so that it will remain in the vagina longer. Clients being treated for vaginal candidiasis should wear loose-fitting cotton underwear and refrain from sexual intercourse for the duration of treatment.

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the best response by the nurse? 1. "Do you have any relatives or close friends who can help you through this?" 2. "Has your spouse seemed depressed lately?" 3. "This has been overwhelming for you. What are you feeling right now?" 4. "Well, you did find your spouse. You need to focus on helping your spouse get better."

3. "This has been overwhelming for you. What are you feeling right now?" Rationale: This client's spouse has experienced a traumatic or crisis event (also referred to as "a critical incident"). When faced with a traumatic situation, clients are often overwhelmed and respond with a wide range of emotions and thoughts, including shock, denial, anger, helplessness, numbness, disbelief, and confusion. Clients may also experience physical symptoms, such as hyperventilation, abdominal pain, and dizziness. Priority nursing actions need to be directed at the here and now, providing therapeutic interventions aimed at alleviating the immediate emotional impact of this disruptive crisis event. Acknowledging the severity of the event validates and normalizes the spouse's reaction. Assisting the spouse in identifying feelings and giving the spouse opportunity to ventilate will help reduce immediate emotional stress. (Option 1) Assessing this family's support system is important. However, it is not the priority action at this time. (Option 2) This statement does not address what this client's spouse is experiencing at the moment. At a later time, the nurse can explore the client's history and any events that may have lead to this situation. (Option 4) This response does not address the spouse's concerns. Also, the wording is judgmental and nontherapeutic. Educational objective: Initial reactions to a crisis event may include shock, disbelief, denial, helplessness, and confusion. Nursing actions are directed at providing support to the client. Acknowledging the impact of the event and encouraging the client to ventilate are therapeutic interventions.

A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level? 1. 30 seconds 2. 35 seconds 3. 60 seconds 4. 85 seconds

3. 60 seconds Rationale: Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients receiving heparin. The normal aPTT is 23-35 seconds. Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5-2 times the normal value. Therapeutic value for aPTT is 46-70 seconds. The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin as needed. (Options 1 and 2) these are normal aPTT levels for clients not being anticoagulated. (Option 4) This aPTT is too high. This client is at risk for bleeding. The heparin should be titrated down based on the heparin drip protocol. Educational objective: The nurse caring for a client receiving a heparin infusion should monitor the aPTT and follow the heparin infusion protocol for titration. A therapeutic level is 1.5-2 time normal, or an aPTT of 46-70 seconds.

The nurse is triaging clients in the emergency department. Which client needs to be seen first? 1. 18-year-old female with fever, suprapubic pain, and dysuria 2. 21-year-old male with diffuse abdominal pain and a rigid abdomen 3. 64-year-old male with a pulsatile mass in the periumbilical area and back pain 4. 75-year-old with nausea, fever, and left lower quadrant pain

3. 64-year-old male with a pulsatile mass in the periumbilical area and back pain Rationale: Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. (Option 1) Fever, suprapubic pain, and dysuria in a young female client indicates urinary tract infection, a much lower priority than AAA. (Option 2) Diffuse pain and a rigid abdomen indicate peritonitis (eg, from ruptured appendicitis or perforated bowel). Peritonitis is also an emergency but not immediately life-threatening like AAA rupture. This client should be seen next after the client with AAA. (Option 4) Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis. The client needs bowel rest, antibiotics, and IV fluids. This is a lower priority than AAA and peritonitis. Educational objective: Clients with an impending aortic aneurysm rupture present with abdominal/back pain, and a pulsatile abdominal mass. They may also have a bruit. Rupture of an abdominal aneurysm can lead to exsanguination and death in minutes.

The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collision. Which client should the nurse assess first? 1. Client with a fractured pelvis who has a large area of ecchymosis and bruising over the pelvic region 2. Client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes 3. Client with a lung contusion how has an oxygen saturation of 90% and severe inspiratory chest pain 4. Client with a pneumothorax and a chest tube who has intermittent bubbling the water-seal chamber

3. Client with a lung contusion how has an oxygen saturation of 90% and severe inspiratory chest pain Rationale: A lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95% - 100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary. (Option 1) Ecchymosis and bruising due to trauma would be expected (Option 2) Skin irritation under rough case edges is common; oval strips of adhesive or moleskin tape applied to the cast edge (petals) can provide padding. Neurovascular assessment and elevation are necessary as swelling can indicate venous compression. This is not a life-threatening priority. (Option 4) In a client with a pneumothorax, intermittent bubbling in the water-seal chamber consistent with respirations (due to air escaping from the pleural space) is expected until the lung has fully expanded Educational objective: A lung contusion (bruised lung) caused by a blunt force to the chest is potentially life-threatening. Clients should be monitored for 24-48 hours after the injury for manifestations of hypoventilation and hypoxemia as these are usually absent initially but develop as the bruise worsens.

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention? 1. Administer oxygen via nasal cannula for client comfort and safety 2. Clean area with povidone iodine in a circular motion moving outward 3. Hold the child with the head and knees tucked in and the back rounded out 4. Monitor and record vital signs every 15 minutes throughout the procedure.

3. Hold the child with the head and knees tucked in and the back rounded out Rationale: The optimal position for access during a lumbar puncture is to have the client's head and knees tucked in and the back rounded out. This provides the most room for the health care provider (HCP) to perform the procedure and allows for a good hold to keep the client still. A lumbar puncture is a sensitive procedure, and it is important to keep the child from moving during needle insertion. (Option 1) Unless the client has improper air exchange, oxygen administration is not needed. The nasal cannula will most likely bother the child and lead to unnecessary movement during needle placement. (Option 2) The HCP performing the lumbar puncture will feel the spine for correct needle placement and then sterilize and prepare the chosen area for needle insertion. (Option 4) Unless the client is unstable, there is no need to record vital signs every 15 minutes. The client should be awake and alert, and the procedure should be fairly short in duration. Educational objective: Performing a lumbar puncture on a child is a very sensitive procedure that requires accuracy. The correct position and ability to hold the child still are important to achieve the best result and minimize the risk for complications.

The registered nurse (RN) delegates to the unlicensed assistive personnel (UAP) the ambulation of a client. The RN observes the UAP placing the client's Foley bag on the IV pole at the level of the client's chest during the ambulation down the length of the hallway. What action should the RN take initially? 1. Discuss the need for UAP inservice education with the nurse manager 2. Give praise to the UAP for encouraging the client to walk the entire hall 3. Immediately lower the bag and speak privately to the UAP 4. Let the UAP complete assigned tasks and speak to the UAP at the end of the shift

3. Immediately lower the bag and speak privately to the UAP Rationale: The Foley bag is too high and needs to be lowered. When observing a provider making a error, the RN should immediately intervene to stop any potential harm to the client. It is important to timely correct a staff member who is making a mistake to help ensure that the error is not repeated. Correction of staff should always be done privately, not in front of the client.

During a camping trip, a camp counselor falls and gets a small splinter of wood embedded in the right eye. What action should the volunteer camp nurse take first? 1. Gently flush the eye with cool water 2. Instill optic antibiotic ointment 3. Patch both eyes with eye shields 4. Remove the splinter using tweezers

3. Patch both eyes with eye shields Rationale: The camp nurse protects the injured eye suing an eye shield (eg, small Styrofoam or paper cup), ensuring the shield does not touch the foreign body. The eyes work in synchrony with each other; therefore, the no-injured eye is patched to prevent further eye movement. The nurse also facilitates transport to the neared emergency care center for assessment and treatment by an ophthalmologist. (Option 1) Flushing the eye with cool water is contraindicated as it may cause further damage by moving the splinter and/or introducing potential wound pathogens. (Option 2) Instilling option antibiotic ointment would interfere with ophthalmologic medical examination. Optic antibiotic ointment may be prescribed by the health care provider to reduce the risk of infection once the object is removed from the eye. (Option 4) The nurse should not attempt to remove a foreign body embedded in the eye. An ophthalmologist, a health care provider who specializes in the surgical and nonsurgical evaluation and treatment of eye conditions, should remove the embedded object as soon as possible. Educational objective: When a foreign body becomes accidentally embedded in the eye, both eyes should be shielded to prevent eye movement and additional injury. The nurse should immediately refer the client to an ophthalmologist for further evaluation and treatment.

A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate? 1. Eye drops in the abnormal eye 2. Measurement of intraocular pressure (IOP) 3. Patching the stronger eye 4. Correction with laser surgery

3. Patching the stronger eye Rationale: Strabismus (crossed eyes) is a disorder involving misalignment of the eyes caused by a congenital defect of acquired weakness of an eye muscle. One eye may appear deviated inward (esotropia) or outward (exotropia). When the visual axes are not in alignment, the brain perceives 2 images (diplopia) and suppresses the weaker image to compensate. If left untreated by age 4-6 permanent reduction or loss of visual acuity in the affected eye (amblyopia) can occur. Initial treatments vary depending on the underlying cause. One common treatment is to strengthen the muscles of the weaker eye by wearing a patch over the stronger eye or using special corrective lenses. If nonsurgical methods are unsuccessful, surgical intervention to shorten or reposition an eye muscle for more effective movement may be required. (Option 1) The use of eye drops in the abnormal eye is not an effective treatment for strabismus. Some uncommon treatments of strabismus may include drops in the normal/stronger eye to blur the vision and increase use of the weaker eye. Eye drops are more commonly used to treat glaucoma (Option 2) Monitoring of IOP would be necessary in a client with glaucoma. Strabismus is not associated with abnormal IOP. (Option 4) Surgical repair of strabismus involves changes to the muscles controlling the eye and does not utilize a laser. Laser surgery is an appropriate treatment for refractive errors, such as myopia, hyperopia, or astigmatism. Educational objective: Strabismus is a disorder involving misalignment of the eyes (eg, one eye deviated inward or outward) caused by a congenital or acquired defect of an eye muscle. Treatment of strabismus may include wearing a patch over the stronger eye to develop strength in the weaker eye.

The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin. The child's parent wants to know why this treatment is required. The nurse explains that this therapy is given to: 1. Fight the infection 2. Minimize rash 3. Prevent heart disease 4. Reduce spleen size

3. Prevent heart disease Rationale: Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome, is characterized by >/= 5 days of fever, bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash, and extremity swelling. Coronary artery aneurysms are the most serious potential sequelae in untreated clients, leading to complications such a myocardial infarction and death. Echocardiography is used to monitor these cardiovascular complications. Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent occlusion. KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. However, parents should be cautioned about the risk of Reye Syndrome. Cardiopulmonary resuscitation should also be taught to parents of children with coronary artery aneurysms. (Option 1) KD is a vasculitis of unknown etiology, but it is not an infectious process. Because the child will often have a similar clinical presentation of that of an infection (eg, persistent fever, inflammatory immune response), KD may be mistaken for a bacterial or viral illness. (Option 2) Polymorphous rash of the trunk and extremities is an expected finding in a child with KD. Cool compresses, unscented lotions, and loose-fitting clothing can minimize discomfort. IVIG is not given to control rash. (Option 4) Lymphadenopathy (usually a single palpable anterior cervical node >1.5 cm) and splenomegaly are included in the clinical presentation of KD. IVIG therapy is not indicated to reduce incidence of these findings. Educational objective: IVIG along with aspirin is the recommended initial treatment for Kawasaki disease, with the primary goal of coronary disease prevention.

The nurse is performing an assessment on a neonate shortly after delivery. The nurse is most concerned about which assessment finding? 1. Bilateral rales found on lung auscultation 2. Dullness over bladder found on percussion 3. Ptosis of right eyelid found on facial inspection 4. Single testicle found on genital palpation

3. Ptosis of right eyelid found on facial inspection Rationale: Eyelids should sit above the pupils symmetrically with irises showing. Ptosis (drooping of the eyelid below the level of the pupil) could indicate paralysis of the oculomotor nerve. This finding warrants further investigation. At the time of birth, there should be no cranial nerve abnormalities. (Option 1) Crackles (rales) indicate fluid in the lungs and are expected immediately after birth. Rales will clear as the neonate transitions to extrauterine life. However, wheezes, stridor, or persistence of crackles after the first few hours of birth are abnormal and should be reported. (Option 2) Percussing dullness in the hypogastric area is a normal finding when the bladder is full. The neonate should void spontaneously within a few hours after birth. (Option 4) An undescended testicle (cryptorchidism) at birth is not concerning. most undescended testes descent spontaneously by age 6 months. Educational objective: At the time of birth, there should be no cranial nerve abnormalities. Rales (crackles) indicate fluid in the lungs and will clear as the neonate transitions to extrauterine life. Most undescended testes descend spontaneously by age 6 months.

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis? 1. Impaired social interaction 2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrity

3. Risk for deficient fluid volume Rationale: A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features: -Immobility - the client remains in a fixed stupor of position for long periods •Refuses to move about or engage in activities of daily living •May have brief spurts of excitement or hyperactivity -Remaining mute -Bizarre postures - the client holds the body rigidly in one position -Extreme negativism - the client resists instructions or attempts to be moved -Waxy flexibility - the client's limbs stay in the same position in which which they are placed by another person -Staring -Stereotyped movements, prominent mannerisms, or grimacing Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care. (Option 1) Impaired social interaction is also an appropriate nursing diagnosis in a client with catatonic schizophrenia. However, it is not a priority, especially during the early phases of the disease. (Option 2) The client's mutism makes the diagnosis of impaired verbal communication appropriate, and the nurse should gently encourage this client to talk without undue expectations or pressure. This is not the priority nursing diagnosis. (Option 4) If this client is in a bizarre or fixed posture, there may be a risk for decreased circulation and pressure ulcers. The nurse needs to encourage ambulation and/or provide range-of-motion exercises. Educational objective: Clients with catatonic schizophrenia are unable to meet their own needs for fluids, food, movement, and elimination and need assistance in performing basic activities of daily living, However, a priority nursing diagnosis is deficient fluid volume.

The nurse assesses a pediatric client and finds bruises in various stages of healing on the back and legs. When questioned about the bruises the child begins to cry and states, "Somebody did things to me." Which of the following communications by the nurse is appropriate? Select all that apply. 1. "How long have your parents been doing things to you?" 2. "Tell me about what happened. I promise not to tell anyone." 3. "This is terrible. Whoever did this to you will be sorry." 4. "What happened is not your fault. You are not to blame." 5. "You did the right thing by telling me. You are not in trouble."

4. "What happened is not your fault. You are not to blame." 5. "You did the right thing by telling me. You are not in trouble." Rationale: When speaking with a child about abuse, the nurse should be direct and honest. The nurse should allow the child to disclose the abuse at a comfortable pace, rather than probe for additional information. The nurse should use open-ended questions and avoid leading questions and statements. Guidelines for the interview -Speak with the child in private -Be honest about reporting requirements -Use language appropriate to the child's age -Avoid making assumptions or communicating anger, shock, or disapproval -Reassure the child about not being at fault or in trouble (Options 4 and 5). (Option 1) The nurse should not make assumptions about who abused the child. This could lead to bias or false accusations and/or cause the child to fear revealing the identity of the abuser. (Option 2) "Tell me about what happened" is a correct, open-ended question; however, the nurse is required to report abuse and should communicate this requirement to the child. (Option 3) The nurse should avoid making derogatory statements about the abuser, as this can cause the child feelings or embarrassment or fear and end the conversation. Educational objective: When interviewing a child about abuse, the nurse should affirm that the child is not at fault or in trouble and avoid making assumptions or communicating anger, shock, or disapproval. The nurse should be direct and honest about the requirement to report abuse.

The nurse assesses a pediatric client and finds bruises in various stages of healing on the back and legs. When questioned about the bruises the child begins to cry and states, "Somebody did things to me." Which of the following communications by the nurse is appropriate? Select all that apply. 1. "How long have your parents being doing things to you?" 2. "Tell me about what happened. I promise not to tell anyone." 3. "This is terrible. Whoever did this to you will be sorry." 4. "What happened is not your fault. You are not to blame." 5. "You did the right thing by telling me. You are not in trouble."

4. "What happened is not your fault. You are not to blame." 5. "You did the right thing by telling me. You are not in trouble." Rationale: When speaking with a child about abuse, the nurse should be direct and honest. The nurse should allow the child to disclose the abust at a comfortable pace, rather than probe for additional information. The nurse should use open-ended questions and avoid leading questions and statements. Guidelines for the interview: -Speak with the child in private -Be honest about reporting requirements -Use language appropriate to the child's age -Avoid making assumptions or communicating anger, shock, or disapproval -Rassure the child about not being at fault or in trouble (options 4 and 5) (Option 1) The nurse should not make assumptions about who abused the child. This could lead to bias or false accusations and/or cause the child to fear revealing the identity of the abuser. (Option 2) "Tell me about what happened" is a correct, open-ended question; however, the nurse is required to report abuse and should communicate this requirement to the child. (Option 3) The nurse should avoid making derogatory statements about the abuser, as this can cause the child feelings of

The office nurse receives 4 telephone messages. Which client should the nurse call back first? 1. 28-year-old female client who fell on ice yesterday and has low back pain and spasm 2. 42-year-old male client who developed sharp, burning leg pain radiating from buttock to knee after lifting heavy weights 3. 65-year-old female client 10 days post spinal fusion who has increased persistent back pain and fever of 101.2 F (38.4 C) 4. 70-year-old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back

4. 70-year-old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back Rationale: An abdominal aortic aneurysm (AAA) is a blood-filled bulge in the abdominal aorta caused by weakening in the vessel wall due to increased pressure. Risk factors include male sex, age >65, coronary artery and peripheral vascular disease, hypertension, and family and smoking history. AAA dissection (blood leakage into a vessel tear) or rupture may manifest as acute-onset abdominal pain reradiating to the back and is typically associated with symptoms of hemorrhagic shock (eg, decreased systolic pressure; increased, weak pulses; pallor). This client's symptoms could indicate impending rupture, which can lead to life-threatening vascular hemorrhage. (Option 1) This client's pain is most likely musculoskeletal in origin and due to a lumbosacral strain. Although assessment and treatment (eg, nonsteroidal anti-inflammatory drugs, muscle relaxants) are necessary, this is not a life-threatening condition. (Option 2) This client's pain is most likely radicular (irritation of the sciatic nerve) in origin). Although neurovascular evaluation for a herniated disk (L5-S1) is necessary, this is not a life-threatening condition (Option 3) This client's pain and fever can be associated with a postoperative infection in the bone and surrounding tissue (osteomyelitis). Although diagnosis and treatment with prescribed antibiotics are crucial to prevent sepsis, a potential massive hemorrhage is a higher priority. Educational Objective: Clients with atherosclerotic vascular disease in one system (eg, stoke, peripheral vascular disease) are more like to have an undiagnosed, underlying atherosclerotic vascular disease in other areas (eg, coronary disease, aortic aneurysm). Evaluation and treatment of a suspected abdominal aortic aneurysm dissection or rupture are critical as a vascular bleed is potentially life threatening.

Medication prescription Albuterol and ipratropium: nebulize every 4 hours as needed Levofloxacin: 750 mg IV, once daily Methylprednisolone: 40 mg IV, every 8 hours Enoxaparin: 40 mg subcutaneously, once daily A 75-year-old client is hospitalized with chronic obstructive pulmonary disease (COPD) exacerbation. The health care provider (HCP) initiates noninvasive positive airway pressure ventilation (NIPPV) with a bilevel positive airway pressure (BIPAP) device, Prescribed medications are shown in the exhibit. Which parameter is most important for the nurse to monitor frequently in this client? 1. Blood glucose level 2. Capillary refill time 3. Extreme swelling 4. Mental status

4. Mental status Rationale: An exacerbation of COPD is characterized by the acute worsening of a client's baseline symptoms (eg, dyspnea, cough, sputum color and production). NIPPV is often prescribed short-term to support gas exchange in clients who have moderate to severe COPD exacerbations and acidosis (pH < 7.3) or hypercapnia (PaCO2 >45 mmHg). NIPPV can prevent the need for tracheal intubation and is administered until the underlying cause of the ventilatory failure is reversed with pharmacologic therapy (eg, corticosteroids, bronchodilators, antibiotics). BIPAP involves the use of a mechanical device and facemask in a conscious client who is breathing spontaneously. BIPAP delivers oxygen to the lungs and then removes carbon dioxide (CO2). CO2 retention causes mental status changes. If the client becomes drowsy or confused, it is likely that more CO2 is being retained than what BIPAP can remove; this should be reported to the HCP. Arterial blood gas evaluation should be obtained to determine CO2 level and BIPAP effectiveness. Altered mental status poses the greatest threat to a client's survival as it can lead to decreased protective reflexes (eg, gag, swallow, cough), periods of apnea, and airway compromise (Option 4). (Option 1) The nurse should monitor the blood glucose level because the client was prescribed the corticosteroid methylprednisolone (Solu-Medrol), which can cause hyperglycemia, especially in client with diabetes mellitus. However, blood glucose is not the most important parameter to monitor frequently in this client. (Option 2) Capillary refill time is indicated to assess poor perfusion states, and a value of >3 seconds (delayed refill time) is seen in conditions such as dehydration, shock, and peripheral vascular disease. (Option 3) Unilateral swelling is concerning for deep venous thrombosis (DVT) in a hospitalized client. Bilateral swelling indicates volume overload or venous stasis. This client was started on enoxaparin (blood thinner) to prevent DVT. Volume overload is unlikely as the client is not receiving IV fluids. Educational objective: In a client with COPD exacerbation, it is most important for the nurse to monitor mental health status frequently and report changes such as restlessness, decrease level of consciousness, somnolence, difficult arousal, and confusion to the HCP. These signs may indicate increased CO2 retention and worsening hypercapnia, which would necessitate an immediate change in therapy.

A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure? 1. Epidural anesthesia 2. Hydrotherapy 3. IV narcotics 4. Pudendal nerve block

4. Pudendal nerve block Rationale: A pudendal nerve block infiltrates local anesthesia (ie, lidocaine) into the areas surrounding the pudendal nerves that innervate the lower vagina, perineum, and vulva. When birth is imminent, a pudendal block provides the best pain relief with the least maternal/newborn side effects and could be administered quickly by the health care provider. It does not relieve contraction pain but does relieve perennial pressure when administered in the late second stage of labor (Option 4). In clients without an epidural, pudendal blocks may be used in preparation for forceps-assisted birth or laceration repair. (Option 1) An epidural can be administered in the first or early second stage of labor but may not be a feasible option in late second stage when birth is imminent. A multiparous client may give birth before the epidural can be administered or before the epidural takes adequate effect (20-30 minutes). (Option 2) Some clients forgo pharmacological pain relief during labor and instead utilize nonpharmacological techniques (eg, hydrotherapy, relaxation breathing). However, this client specifically requests pain relief, and nonpharmacological techniques would likely be ineffective considering birth is imminent. (Option 3) IV narcotics cross the placenta and can cause neonatal respiratory depression when administered close to birth. Therefore, these are not generally administered in the second stage of labor. Educational objective: A pudendal nerve block can provide pain relief for clients experiencing perineal pressure in the late second stage of labor. It may also be used in preparation for forceps-assisted birth or laceration repair in clients without an epidural. It does not provide relief of contraction pain.

The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to "reach the itch." What is the nurse's priority action? 1. Offer the client a straw to reach the itch instead of a lead pencil 2. Perform a peripheral neurovascular check of the casted extremity 3. Pour a generous amount of baby powder or corn starch in the cast to reach the itch 4. Review appropriate itch relief technique using the cool setting of a hair dryer

4. Review appropriate itch relief technique using the cool setting of a hair dryer Rationale: To relieve itching underneath a casted area, clients should use the cool setting of a hair dryer to direct air under the cast. Clients should never place any object, lotions, or powders in or around the casted area as skin irritation, may occur. Signs and symptoms of infection (eg, sores, purulent drainage, foul odors) and persistent itching should be reported to the health care provider. (Options 1 and 3) Nothing should be placed inside the case due to the risk for injury and infection. (Option 2) The skin of the casted extremity should be assessed as the client could have damaged it by inserting a pointed object. Regular neurovascular checks should be performed on a client with a new cast as the client is at risk for compartment syndrome. However, there is no indication of peripheral vascular impairment (eg, changes in extremity color, temperature, or pules) or peripheral neurologic impairment (eg, loss of sensory or motor function) of the casted extremity; therefore, this is not the priority at this time. Educational objective: The client should be taught that nothing should be placed in a cast. Attempting to reach an itch with any instrument (eg, pencil, coat hanger) or applying powder or lotion may cause skin breakdown and infection. Cool air from a hairdryer may alleviate the itch.

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? 1. Ask another nurse to help 2. Delegate the task to unlicensed assistive personnel 3. Premedicate the client for pain 4. Verify the client's activity prescription

4. Verify the client's activity prescription Rationale: A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall. (Option 1) A client who had knee surgery will likely be unable to bear any weight on the affected limb. Depending on the client's size, it may be prudent for the nurse to get additional help. This could be requested after the activity prescription has been verified. (Option 2) Assistance with ambulation is often delegated to unlicensed assistive personnel (UAP); however, the nurse should verify the prescription first. It would also be prudent to have the UAP assist the nurse as this is the client's first time up after surgery. (Option 3) The nurse should assess the client's pain level before providing pain medication. Educational objective: The nurse should verify activity prescriptions before getting clients out of bed after surgery or a procedure. The nurse should be present when these clients begin ambulating and may need assistance from another nurse or unlicensed assistive personnel.

The nurse is calculating IV fluid resuscitation for a client weighing 85 kg with visible partial-thickness burns covering 40% of the body. Using the Parkland formula, how many liters of IV fluid resuscitation are needed during the first 8 hours?

6.8 L Parkland formula protocol 24-hr fluid requirement calculation 4 mL x body weight (kg) x total body surface area burned (%) First 8-hr fluid administration 50% total fluid requirement Remaining 16-hr fluid administration 50% total fluid requirement Burn injuries are caused by direct tissue damage from exposure to caustic (eg, thermal, chemical, electrical) sources. This initial tissue injury, combined with the systemic inflammatory response, causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. This intravascular loss often leads to hypovolemic shock in clients with extensive burns and requires emergency fluid resuscitation for client survival. The Parkland formula is an IV fluid resuscitation protocol used to calculate the fluid replacement needed in the first 24 hours after a burn injury. Half of the calculated fluid volume is administered during the first 8 hours after injury, when the greatest amount of intravascular volume loss occurs. The following steps should be used to calculate the volume needed for infusion during the first 8 hours. 1. Calculate the total volume needed for infusion for 24 hours. 4 mL x weight (kg) x TBSA burned = total infusion volume 4 mL x 85 kg x 40% TBSA = 13,600 L 2. Calculate the volume needed for infusion during the first 8 hours 24-hr infusion volume/2 13,600/2 = 6800 mL 3. Convert mL to L (6800 mL/1) (L/1000 mL) = 6.8 L Educational objective: The Parkland formula (4 mL x weight [kg[ x body surface area burned [%]) is used to calculate the amount of IV fluid required for a burn victim during the initial 24 hours after injury. Half of the calculated volume is administered within the first 8 hours.