ncsbn practice

During the change-of shift-report, the nurse reports that one of the clients is of the Catholic religion and was admitted for the delivery of her ninth child. Which comment made by the nurse indicates a bias against the client?

"All those people tend to indulge in large families." A bias is a tendency, inclination, or prejudice toward or against something or someone. The nurse's comment indicates the bias that people of Catholic faith tend to have large families due to the religion's position on birth control. The other comments are not indicative of a bias by the nurse.

The nurse is caring for a 4-year-old child with a greenstick fracture. The nurse is teaching the parents about the child's fracture. How should the nurse describe this type of fracture?

"Bones of children are more porous than adults', leading to incomplete breaks." Bones in children are generally more porous than adult bones. This allows the pliable bones of growing children to bend, buckle, and break in a "greenstick" manner. A greenstick fracture occurs when a bone is angulated beyond the limits of bending. The compressed side bends and the tension side develops an incomplete fracture. The other statements are not correct.

The nurse is teaching a 65-year-old female client who is newly diagnosed with osteoporosis. Which type of exercise is best for this client?

"Do weight-bearing exercise or resistance activities." Weight-bearing or resistance exercises are best in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes these exercises. Placing weight on bones against gravity helps to promote ossification. Running should be avoided because it can place too much stress on the bone and cause stress fractures. Weight loss might be indicated for osteoarthritis. Although yoga can help with balance and muscle strengthening, it does not directly benefit osteoporosis.

The parent of a 4-month-old infant asks the nurse about how to protect the child from sunburn. Which of these statements is the best advice about sun protection for infants?

"Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats." Infants under 6 months of age should be kept out of the sun or shielded from it. Even on a cloudy day, the infant can be sunburned. A hat and light protective clothing should be worn. Sunscreen is not generally recommended for infants under the age of 6 months; however, the American Academy of Pediatrics states that it can be applied to small areas of the baby's skin that are exposed to the sun (such as the baby's face or the back of the hands).

The nurse is caring for a client who had an extracorporeal shockwave lithotripsy procedure for kidney stones. Which statement by the nurse demonstrates appropriate client teaching?

"Drink at least 3000 to 4000 mL of fluids each day." An extracorporeal shockwave lithotripsy (ESWL) procedure is a non-invasive method for treating stones in the kidney or ureter. It utilizes an energy source which generates a shock wave that is directed at the stone, breaking it up and allowing it to be flushed out of the kidney or ureter. After an ESWL, the client should drink 3 to 4 quarts (3,000 to 4,000 mL) of fluids each day. This extra hydration will aid in the passage of fragments of the broken up renal calculi and help prevent formation of new calculi. The other instructions are not appropriate or required after an ESWL.

The nurse in a primary health care provider's office is talking to a 35-year-old female client about her new diagnosis of uterine fibroids. Which statement by the woman indicates that additional teaching is needed?

"Even if the fibroids do not cause problems, they must still need to be taken out." Fibroids that cause no findings may require only "watchful waiting". The client may just need pelvic exams or ultrasounds periodically to monitor the fibroid growth. Treatment for the symptoms of fibroids (e.g. painful menses and heavy periods) may include oral contraceptives, an intrauterine device (IUD), iron supplements to prevent or treat anemia (due to heavy periods), non-steroidal anti-inflammatory drugs (NSAIDs) for cramps or pain or even short-term hormonal therapy to help shrink the fibroids. Surgical removal using my lobectomy or hysterectomy is usually reserved as a final alternative after other treatment options have failed to provide adequate relief.

A client is started on long-term corticosteroid therapy for an autoimmune disorder. Which statement by the client indicates the need for more teaching by the nurse?

"For 1 week each month I will stop taking the medication." Corticosteroids should never be stopped abruptly, they should always be weaned. To suddenly stop this medication may result in a sudden drop in the blood pressure from a loss in fluid volume associated with adrenal crisis. Clients should be warned not to abruptly stop taking the medication. Corticosteroids can lower the amount of potassium in the body so the client should eat more potassium rich foods. Weight gain is an expected effect of corticosteroid therapy. Clients should regularly keep track of their weight. Generally, corticosteroid medications are taken with breakfast.

A client who lives in an assisted living facility tells the nurse, "I am so depressed. Life isn't worth living anymore." Which statement is the best response by the nurse?

"Have you thought about hurting yourself?" It is most important to determine whether someone who voices thoughts about death is considering suicide (i.e. suicidal ideation). Individuals may provide both behavioral and verbal clues as to the intent of their acts. Behavioral clues include giving away prized possessions, getting financial affairs in order, writing suicide notes and demonstrating a sudden lift in mood. Verbal clues may be both direct and indirect. An example of a direct statement includes, "I want to die." An example of an indirect statement includes, "I don't have anything worth living for anymore". This client's statement indicates suicidal ideation and the client's safety is the highest priority. The nurse should ask the client directly about thoughts or plans to harm themselves. The other responses are not therapeutic and will not help identify if the client is at risk for suicide. The best statement by the nurse follows the nursing process by collecting more data about the client's statement.

The nurse is providing information to a client about propranolol. Which statement by the client indicates the teaching has been effective?

"I can have a heart attack if I stop this medication suddenly." Propranolol is commonly used to treat hypertension, abnormal heart rhythms, heart disease and certain types of tremors. It is in a class of medications called beta blockers. Suddenly discontinuing a beta blocker can cause angina, hypertension, dysrhythmias, or even a myocardial infarction (i.e., heart attack).

The nurse is admitting a male client who is newly diagnosed with a frontal lobe brain tumor. Which statement by the client's spouse would support this diagnosis?

"I find the mood swings hard to deal with." The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in symptoms such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior. The other statements do not pertain to symptoms or changes in behavior typically seen with frontal lobe problems.

The nurse is evaluating self-management of a client who has type 1 diabetes. Which statement made by the client should be of highest concern?

"I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes off!" The client's statement about having a penny in their shoe without realizing it, indicates this client may have peripheral neuropathy. Peripheral neuropathy can lead to lack of sensation in the lower extremities. When clients cannot feel potential tissue injuries (something in their shoe), they are at high risk for impaired skin integrity such as diabetic foot ulcers. The other statements indicate that the client is managing their diabetes appropriately.

The nurse on an inpatient hospital unit answers a call light and enters a client's room. The client expresses anger stating they have been waiting for more than 5 minutes for a blanket. Which is the best response from the nurse?

"I see this is frustrating for you. I have a few minutes so let's talk." The best response from the nurse acknowledges the client's verbalized needs and encourages an open conversation. To say "let's talk" and ask a "why" question is not a therapeutic approach because it does not acknowledge or validate the client's feelings. To apologize and not acknowledge the client's feelings is inappropriate. It is rude for the nurse to tell a client their request could wait a few minutes, and this response does not acknowledge the client's verbalized needs.

The nurse who cares for clients undergoing treatment for cancer might expect clients diagnosed with cancer to make the following statements about their grief.

"I think the tests got mixed up" "I am so mad at everyone for always reminding me that I have it" "If i eat a more balanced diet, I can live longer" "I don't know where to go or what to do" "I will just go on with my life" The phases of loss or the grief process according to Dr. Kubler-Ross are: Denial, Anger, Negotiation/Bargaining, Depression, and Acceptance. The statement "I think the tests got mixed up." indicates denial. The statement "I am so mad at everyone for always reminding me that I have it." indicates anger. The statement "If I eat a more balanced diet, I can live longer." indicates negotiation/bargaining. The statement "I don't know where to go or what to do." indicates depression. The statement "I will just go on with my life." indicates acceptance.

A 15-year-old client has been placed in a cervico-thoraco-lumbo-sacral orthosis or CTLSO brace. Which statement by the client indicates a need for additional teaching?

"I will only have to wear this brace for 6 months." The Milwaukee brace, also known as a cervico-thoraco-lumbo-sacral orthosis or CTLSO, is a back brace used in the treatment of spinal curvatures such as scoliosis or kyphosis in children. It is a full-torso brace that extends from the pelvis to the base of the skull.The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. The client's statement about only having to wear it for 6 months is incorrect and indicates a need for additional teaching. The other statements indicate a correct understanding.

The nurse is teaching a client with chronic renal failure about their medications. The client questions the purpose of taking aluminum hydroxide. How should the nurse respond?

"It decreases your blood's phosphate levels." Aluminum binds to phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidneys. Antacids such as aluminum hydroxide are commonly used in clients with chronic renal failure to decrease serum phosphate levels. Aluminum hydroxide will not increase urine production, control gastric acid secretions or lower serum calcium levels.

The nurse is providing care for a 9-year-old child with cerebral palsy who has recently been admitted for repeated episodes of aspiration pneumonia and weight loss. During a discussion with the child's caregivers, which statement by the nurse demonstrates client advocacy?

"It is possible that we may need to discuss inserting a feeding tube." Deep breathing and coughing exercises may be helpful, but they will not prevent aspiration. The nurse should reinforce manual jaw control and proper positioning during feeding. However, due to repeated episodes of aspiration, it is likely that the client is having significant difficulty controlling the muscles of the tongue/throat and jaw. The nurse needs to discuss the possibility of inserting a feeding tube to prevent future complications associated with repeated aspiration and weight loss.

The nurse is examining a 2-year-old child with a tentative diagnosis of Wilm's tumor. Which statement by the child's parent should the nurse follow-up on?

"My child seems to be urinating less over the past 2 days." Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction. A recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction. Increasing abdominal girth is a common finding with a Wilm's tumor, but does not require immediate intervention by the nurse.

The nurse is talking on the phone with the parent of a 4-year-old child. The child was recently diagnosed with varicella. Which statement by the nurse demonstrates appropriate teaching?

"Papules, vesicles and crusts will be present at the same time." It is appropriate to teach the parent to expect the different types of varicella (chickenpox) lesions that will be present on the child's body at the same time. Children should not be medicated with aspirin due to the possibility of developing Reye syndrome. A person with chickenpox is contagious for 1 to 2 days before skin lesions appear and remain contagious until all of the lesions have crusted over. Antiviral medications would not relieve itchy skin.

A client has had a positive reaction to a purified protein derivative (PPD) skin test. The client asks the nurse what the test result means. How should the nurse respond?

"This means you have been exposed to tuberculosis" The purified protein derivative (PPD) skin test is used to determine the presence of tuberculosis (TB) antibodies. In an otherwise healthy person, an induration greater than or equal to 15 mm is considered a positive test result. This indicates the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a chest X-ray and a sputum culture will be needed to determine if active TB is present. The sputum cytology test is the only definitive test to confirm a diagnosis of active TB.

The nurse in a pediatrician's office is speaking with the parent of an 8-year-old child who is concerned about the child receiving the annual flu vaccine due to an egg allergy. How should the nurse respond?

"You can schedule an appointment to have the vaccine administered in our office." The Centers for Disease Control and Prevention (CDC) states that people with egg allergies can receive any licensed, recommended age-appropriate influenza (flu) vaccine (IIV, RIV4, or LAIV4) that is otherwise appropriate. People who have a history of severe egg allergy (those who have had any symptom other than hives after exposure to egg) should be vaccinated in a medical setting, supervised by a health care provider who is able to recognize and manage severe allergic reactions. The other responses are not correct.

A nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed. The mother is sitting in a nearby chair. The mother says to the nurse, "take the baby out of here. I do not want it." Which response by the nurse is best?

"You seem upset. Tell me what the pregnancy and birth were like for you."

A client who previously had a stroke refuses to take the daily aspirin prescribed by their health care provider. Which statements should the nurse include in her response to the client? Select all that apply.

-"Do you take your other medications as prescribed by your provider?" -"Can you tell me what concerns you have about the aspirin?" -"Do you experience any nausea when you take the aspirin?" -"Would you like to take the aspirin at another time of day?" Although clients have the right to refuse medications, the nurse should still try to determine the underlying reasons for the client's refusal. Aspirin is a platelet aggregate inhibitor that is often prescribed for clients with cardiovascular disease (CVD) and stroke to prevent another thrombotic event and future stroke. Aspirin can cause gastrointestinal (GI) irritation and should be taken with food. The nurse can increase the client's adherence to their prescribed medication regimen by investigating their reasons for refusal, exploring any misconceptions about the drug and reinforcing the importance of the medication in preventing another stroke. In addition, involving the client in making decisions about when to take the medication can help the client accept the regimen. Stating that the client might die if they do not take the medication is nontherapeutic, inappropriate and violates the client's right to autonomy.

During a yearly health screening, an older female client reports having perimenopausal symptoms including irregular menstrual cycles, mood swings and hot flashes. She requests a more natural approach to manage the symptoms. Which non-pharmacological interventions should the nurse include? Select all that apply.

-"Incorporate more vegetables and legumes in your diet." -"You should drink at least 8-10 glasses of water a day." -"Yoga may help you manage stress and relieve symptoms." -"Use deep breathing exercises when you start having a hot flash." Measures that have been found to be effective in helping manage symptoms of hot flashes include exercise, stress reduction and getting enough sleep at night. Reducing the temperature in the room at night and taking a warm bath or shower before bedtime can help clients get a better night's sleep. Slow abdominal breathing (6-8 breaths per minute) at the onset of hot flashes can help. Other measures that can lessen the number of and severity of hot flashes include yoga, as well as avoiding alcohol, spicy foods and caffeine. Eating a more plant-based diet can also help.

A new task force has been created at a hospital to address a recent increase in client falls. The first meeting is scheduled with members from several departments. Which statements by the nurse leader will increase meeting effectiveness? Select all that apply.

-"Let's discuss when we should meet next and what information we will bring." -"During our meeting today, we will share the information we have on client falls." -"Let's focus on the number of client falls first and then we can talk about staffing." -"Please introduce yourselves and your departments." The leader increases meeting effectiveness by not permitting one person to dominate the discussion, encouraging brainstorming, encouraging others to further develop ideas and helping to engage the team in future discussions. An effective team leader will periodically summarize the information and ensure that all ideas are recorded for all to see (e.g. on a whiteboard) and then follow up with written minutes of the meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand and to demonstrate respect for team members' other commitments.

The nurse asks an unlicensed assistive person (UAP) to help with repositioning of a client in bed. Which actions by the nursing staff support correct ergonomics and safe client handling? Select all that apply.

-Adjust the height of the bed to hip level. -Use a friction-reducing device/sheet underneath the client. -Lower the head of the bed into a flat position. -Coordinate lifting together by counting to three. Adhering to ergonomic principles will help prevent injuries to the nursing staff and/or the client. Raising the bed to hip level, lowering the head of the bed, using a friction-reducing device and coordinating moving at the same time will help with repositioning the client in a safe manner and reducing the risk of injury, such as straining the lower back. Asking a visitor to help and asking the client to hold their breath are not appropriate.

The nurse is caring for a client on a medical-surgical unit who reports difficulty falling asleep and sleeping through the night. The nurse should implement which interventions to promote sleep? Select all that apply.

-Avoiding intake of caffeine products after 4:00 pm -Administering the prescribed diuretic in the morning -Administering a prescribed PRN sleep aid -Assisting client with deep breathing exercises before bedtime Effective interventions for falling asleep and sleeping through the night can include the administration of a PRN sleep aid as a pharmacological intervention and deep breathing exercises before bed as a non-pharmacological intervention to promote relaxation and subsequent sleep. Limiting caffeine intake in the evening may also promote sleep. Administration of diuretics close to bedtime should be avoided as the client may awaken during the night to void when given later in the day. Watching television or computer screens before bedtime can disrupt the sleep cycle, as blue light is known to impair circadian rhythms.

Following a surgical procedure, pneumatic compression devices are applied to both lower extremities of an adult client. The client reports that the device is hot and the client is sweating and itching. Which steps should the nurse take? Select all that apply.

-Collaborate with the primary health care provider for anti-embolism stockings to be worn under the sleeves of the device. -Check for appropriate fit -Confirm pressure setting of 45 mm Hg In any situation in which a client has discomfort associated with a medical device, the nurse should ensure it is applied correctly and functioning safely. The usual safe and effective pressure range is 35-55 mmHg. Explanations to the clients should support their informed decision-making capabilities and should not be phrased to intimidate or remove client autonomy. Applying anti-embolism stockings under the disposable sleeves of the device may help with the sweating and itching.

While being admitted for surgery, a client refuses to sign the surgical consent form. Which nursing actions should the nurse take? Select all that apply.

-Document the client's refusal in the medical record. -Inform the unit charge nurse. -Notify the health care provider. The nurse should document the client's refusal to sign the consent form in the medical record. The nurse is responsible for notifying the charge nurse to keep them informed of the client's decision. The health care provider should be notified so they can discuss the consequences of not having the surgery and potential treatment alternatives with the client. It is not in the nurse's scope to convince a client to have a procedure they have the right to refuse. Unless the client has been deemed incompetent, the nurse should not have anyone sign on their behalf when they have refused treatment because this could create a claim of battery.

The nurse is evaluating the plan of care for a client who has been requesting a daily laxative to aid in having a bowel movement. What additional interventions should the nurse include in the client's plan of care? Select all that apply.

-Request a prescription for psyllium. -Have the client keep a bowel elimination record. -Encourage the client to drink 2 to 3 liters of fluids a day. -Instruct the client to walk at least 30 minutes 3 to 5 times per week. Some clients believe that they are constipated if they do not have a daily bowel movement. This misconception can lead to laxative abuse, causing cathartic colon syndrome, a condition where the colon becomes dilated and atonic (absence of muscle tone). Clients with that condition cannot defecate without the help of a laxative. The nurse should provide additional education (or reinforce education) about interventions to prevent constipation, such as increased intake of dietary fiber and fluids, regular exercise, establishing a regular time to defecate and avoiding delaying defecation and using laxatives. Daily bulk-forming laxatives such as psyllium work like dietary fiber and do not cause dependence. Caffeine should be avoided because it will increase urination, which in turn will reduce fluid volume and harden the stool.

The nurse is preparing to administer a feeding through a percutaneous endoscopic gastrostomy tube. What nursing action is needed before starting the feeding? Select all that apply.

-Verify the length and placement of the tube -Flush the tube with 30 mL of warm water -Elevate the head of the bed 30 to 45 degrees Prior to starting every feeding, the nurse should verify the length and placement of the percutaneous endoscopic gastrostomy (PEG) tube, flush the tube with 30 mL of warm (not hot and not cold) water, and elevate the head of the client's bed at least 30°. The nurse should also verify the presence of bowel sounds before starting the feeding. There is no need to milk the tube unless it is obstructed. Feeding products should be brought to room temperature before administration to prevent gastrointestinal discomfort.

The nurse is caring for an older adult client who was admitted to the telemetry unit following a minor surgical procedure. The client's history includes insulin-dependent diabetes and a previous myocardial infarction. The client's telemetry monitor alarms and the rhythm shows asystole. Prioritize the actions the nurse should take from highest priority (top) to lowest priority (bottom). -Obtain a blood glucose level -Initiate emergency response system if indicated -Check level of consciousness -Assess respirations and pulse -Confirm ECG lead placement

-confirm ECG placement -check level of consciousness -assess respirations and pulse -initiate emergency response system if indicated -obtain a blood glucose level Asystole on a rhythm strip may simply be due to a loose or disconnected ECG lead; a quick check to verify all telemetry leads are connected correctly should be done first. Then, the nurse should check for responsiveness, followed by assessing breathing and circulation. These assessments will provide information for the nurse to decide whether the emergency response team is needed. Because stress and changes in food or fluid consumption secondary to surgery increase the risk of hypoglycemia in the person with diabetes, a blood sugar check should be performed.

At the client's request, the nurse performs a fingerstick to test the client's blood glucose and the results are 322 mg/dL. Following the insulin sliding scale orders, the nurse administers 3 units of insulin lispro at 11:00 AM. When does the nurse anticipate the insulin lispro will begin to act?

11:15 am The onset of action for insulin lispro, which is a rapid acting insulin, is 10 to 15 minutes after administration. It was administered at 11:00 AM, so it will begin to act at 11:15 AM.

At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in the labor and delivery unit. Which of these clients should the nurse see first?

A 17-year-old client who is 18 weeks pregnant with a report of no fetal heart tones and coughing up frothy sputum. The 17-year-old client is likely experiencing an actual complication of left-sided heart failure and a possible stillborn birth. The other clients have expected findings, or potential, but not actual, complications. The nurse should see the client who is coughing up frothy sputum first.

An internal disaster has occurred at the hospital. The charge nurse is asked to review acuity of the clients on the unit and determine which clients can and cannot be discharged. Which of these clients should not be discharged?

A 24-year-old client in the second day of treatment for an overdose of acetaminophen. An overdose of acetaminophen requires close observation for several days. Also, the duration of the course of treatment for the oral antidote N-acetylcysteine (NAC) is approximately 72 hours. NAC will protect the liver if given within 8 hours after an acute ingestion. When compared with the other clients, the client who overdosed on acetaminophen is the least stable and should not be discharged.

The charge nurse of a hospital inpatient unit is asked to list the clients who can potentially be discharged. Which one of these clients is most appropriate for discharge?

A 29-year-old client, diagnosed with type 1 diabetes since age 10, admitted 36 hours ago with diabetic ketoacidosis The client with type 1 diabetes is the only client with a chronic condition who has been treated for more than a day and whose condition is the most stable; therefore, this client is most appropriate for discharge. The other clients' conditions are either unstable and/or more acute.

The nurse on a surgery unit is evaluating which client would be appropriate for patient-controlled analgesia (PCA). Which client would not be appropriate for PCA?

A 4-year-old client with intermittent episodes of alertness. The 4-year-old client (preschool-aged) is most likely to have difficulty with the use or understanding of a patient-controlled analgesia (PCA) pump. The preschooler also has a decreased level of consciousness and would not be able to fully benefit from the use of a PCA pump. School age children, ages 6 and up, are better candidates for PCA electronic pumps.

An emergency room nurse is assigned to the triage area of a nearby mass casualty event. Which of these clients should the nurse tag as "Black" or "to be seen last"?

A 45-year-old client with second and third degree burns over 90% of their body Clients that are deemed least likely to survive are tagged "black" or "to be seen last." This increases the ability to provide treatment to victims who have a greater chance of survival. Fractures are treatable with splinting and immobilization. It is a positive sign that the infant is alert and crying. The client with minor bleeding from the nose should be evaluated for head trauma, but appears stable at this time. A client with burns over 90% of their body will experience massive fluid loss and the burn injuries will most likely be fatal. Therefore, this client should receive a black tag or be seen last.

The nurse is working with an unlicensed assistive person (UAP). Which newly admitted client would be most appropriate to assign to the UAP?

A 47-year-old client diagnosed with obsessive-compulsive disorder The unlicensed assistive person (UAP) can be assigned to a client with a chronic condition after an initial assessment is performed by the nurse. The client with obsessive-compulsive disorder (OCD) is most appropriate to assign to the UAP. This client has minimal risk of medical instability. The other clients will require closer monitoring by the nurse due to the potential for medical complications or increased safety concerns.

The nurse working at a community health clinic is screening clients for risk factors of hypertension. Which client is at highest risk for developing hypertension?

A 65-year-old African American male. The incidence of hypertension (HTN) is greater among African Americans than other groups in the United States. Males have higher rates of HTN than females. Increased age also increases the risk for developing HTN. Therefore, the client with all of these risk factors is at highest risk for developing hypertension.

The charge nurse is making assignments for the upcoming shift. Which client would be most appropriate to assign to a licensed practical nurse (LPN)?

A 76-year-old client who has cystitis, and is being treated with an indwelling urinary catheter. The most stable client is the one diagnosed with cystitis. This client, who has predictable outcomes and minimal risk for complications, would be most appropriate to assign to the licensed practical nurse (LPN). The other clients require more complex care, specialized nursing knowledge, and skill or judgment that the registered nurse (RN) should provide.

The nurse is conducting a teaching session for a group of new nurses about types of oxygen delivery systems. Which system provides the most accurate delivery of oxygen?

A Venturi mask The most accurate way to deliver oxygen to a client is through a Venturi or Venti mask. The Venti mask is a high flow device that traps room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered with this system. The maximum amount of oxygen that can be delivered by a Venti mask is approx. 55%.

The nurse is teaching a client with cardiac disease who is taking furosemide and digoxin about foods rich in potassium. Which food choice best indicates the client understands the teaching?

A baked potato A baked potato contains approximately 610 mg of potassium. Apricots, oranges and bananas are also sources of potassium, but because of their size, they are not the highest in potassium. A baked potato is the highest in potassium of the given options and is the best choice.

The nurse from a women's wellness health clinic is temporarily assigned to an adult medical unit. Which of these client assignments would be most appropriate for this nurse?

A client who was in a motor vehicle accident who has an external fixation device on their leg The nurse from the wellness clinic should be assigned to the client with the leg fracture. This client is the most stable and providing care for this client has predictable outcomes. The contraindications in the other clients are: "newly diagnosed," "after a transient ischemic attack (TIA)," and "newly admitted...severe dehydration." All of these clients have a health concern that's less stable than the client who has a stable fracture.

The nurse is caring for a client who underwent a cardiac catheterization 2 hours ago. Which finding would indicate that the client is experiencing a potential complication from the procedure?

Absent pedal pulse in the affected extremity Loss of the pulse in the extremity where the catheterization was performed would indicate a potential severe spasm of the artery or clot formation/occlusion below the site of insertion. It is common for the pulse to be intermittently weaker from the baseline. However, a total loss of the pulse is a medical emergency. The primary health care provider (HCP) should be notified immediately.

A nurse is teaching an 80-year-old client how to use a metered dose inhaler. The nurse is concerned that the client is unable to coordinate the release of the medication during the inhalation phase. Which intervention should improve the delivery of the medication?

Add a spacer device to the inhaler canister. Use of a spacer is especially useful with older adults because it allows more time to inhale and requires less eye-hand coordination. If the client is not using the metered dose inhaler (MDI) properly, the medication can get trapped in the upper airway and lead to dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth.

A client with severe iron-deficiency anemia is prescribed a parenteral form of iron (i.e., iron dextran). Which intervention does the nurse prepare to implement before administering the medication?

Administer a small test dose. The most serious adverse effect of iron dextran is an anaphylactic reaction. Although anaphylactic reactions are rare, their possibility demands that iron dextran be used only when clearly required. To reduce this risk, each dose must be preceded by a small test dose and the client must be closely monitored while receiving the test dose. The nurse should be aware that even the test dose can trigger anaphylactic and other hypersensitivity reactions. In addition, even when the test dose is uneventful, patients can still experience anaphylaxis. The medication does not require informed consent and obtaining the client's vital signs does not prevent an anaphylactic reaction. If the medication is ordered to be administered intramuscularly, the Z-track technique should be used to minimize discomfort, leakage and surface discoloration.

A client diagnosed with an acute anterior myocardial infarction is receiving nitroglycerin and heparin intravenously. The client still reports chest pain. Which action should the nurse take?

Administer intravenous morphine sulfate as ordered. Nitrates are useful for pain control due to their coronary vasodilator effects. The nurse will titrate the intravenous nitroglycerin infusion for chest pain according to standing orders, but if chest pain is unrelieved by the nitroglycerin infusion, the nurse can administer morphine intravenously (IM injections are avoided because they can alter the CPK). Morphine not only relieves pain and reduces anxiety, but also dilates the blood vessels. After giving the pain reliever, the nurse can do a more in-depth assessment of the client (auscultate heart and lung sounds, review ECGs, vital signs and labs).

A client is admitted with severe injuries resulting from an auto accident. The client's vital signs are BP 120/50 mmHg, pulse rate 110 bpm, and respiratory rate of 28 breaths per minute. Which action should the nurse complete first?

Administer oxygen as ordered. Early findings of shock are associated with hypoxia and manifested by a rapid heart rate and rapid respirations. The nurse should use the Airway-Breathing-Circulation approach to prioritize interventions. Therefore, maintaining adequate oxygenation is critical and oxygen should be administered first. The other interventions are secondary to oxygen therapy.

The nurse is caring for a toddler who is diagnosed with an infection and whose temperature is 103°F (39.4°C). Which intervention would be most effective in lowering the child's temperature and promoting comfort?

Administer the prescribed antipyretic medication. A fever is not a primary illness. It is a physiologic mechanism the body uses to fight an infection. Although tepid sponge baths can lower the body temperature, they can distress febrile children (as evidenced by crying, shivering and goosebumps). Antipyretics can not only reduce the fever in the child, but they can also improve comfort and decrease irritability.

A nurse is assessing the health status of several clients at a community health event. The nurse should conduct a mental status examination on which clients?

All clients participating in the event. A mental status assessment is a critical part of baseline information and should be a part of every screening. This assessment serves as a screening tool for the nurse to assess for mental status abnormalities. The tool evaluates the client's behavioral and cognitive functioning.

The nurse working in a community clinic is administering an influenza vaccine. Which is the appropriate IM injection site on an adult client?

An influenza (or flu) vaccine is less than 1 mL of fluid, so it is acceptable to administer this injection in the deltoid muscle. The deltoid muscle of the upper arm is a site that is easily accessible in public settings where mass vaccinations are administered.

A 3-year-old client has just returned from surgery for application of a hip spica cast. Which nursing action should the nurse implement?

Apply waterproof plastic tape to the cast around the genital area. The most important aspects of caring for the cast is to keep it clean and dry. Shortly after returning from surgery, waterproof plastic tape should be applied around the genital area to prevent soiling of the cast. The child should be turned every 2 hours to help facilitate drying, from side to side and front to back, with the head elevated at all times. If a crossbar is used to stabilize the legs, it should not be used to turn the child (it may break off). After the cast has completely dried, if it becomes damp, it can be either exposed to air or a hairdryer (set to cool) can be used to help dry the cast.

A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. Which action should be the nurse's priority?

Assess for dyspnea or stridor. Due to the location of the burns, the client is at risk for the development of upper airway edema and subsequent respiratory distress. The other options are correct, but the priority is to assess breathing and manage the airway. The client with any signs of airway injury may need be intubated.

The nurse is caring for a client following a right lower lung lobectomy. During the assessment of the chest drainage unit, the nurse notices bubbling in the water-seal chamber. What is the first action the nurse should take?

Assess the chest tube dressing, tubing and drainage system. The first action the nurse should take is to thoroughly check the dressing, tubing and drainage system. Intermittent bubbling in the water seal chamber right after surgery usually indicates an air leak from the pleural space. This is a common finding and should resolve as the lung re-expands. Continuous bubbling usually means a leak in the chest drainage unit such as a loose connection or a leak around the insertion site. Other nursing actions will include assessing the color and amount of the drainage and auscultating the lungs. After the initial post-operative period, the nurse will assist the client to change positions, cough and deep breathe to help re-expand the lung and promote fluid drainage.

A 67-year-old client is admitted to the telemetry unit with substernal chest pressure that radiates to the jaw. The client's diagnosis is an acute myocardial infarction. To monitor the client, the nurse should give priority to which assessment?

Assess the client's cardiac output. In the immediate post- myocardial infarction (MI) period, altered cardiac output is a potential problem. An area of myocardial tissue has been damaged by a lack of blood flow and oxygenation, increasing the risk for decreased cardiac output, dysrhythmias and heart failure. Findings would include low blood pressure, tachycardia, low urine output, unrelieved or worsening chest pain, and shortness of breath. Nursing assessments and interventions should be directed toward promoting myocardial tissue perfusion and oxygenation. The other assessments are also relevant, but monitoring cardiac output is the priority.

The client is scheduled for a coronary artery bypass procedure. When conducting pre-operative teaching with the client, which action should the nurse perform first?

Assess the client's learning style. The first step in the teaching process consist of assessing how the client learns best. That way, the nurse increases success of the teaching by delivering the education in a format that the client understands and prefers. Therefore, the nurse should first assess the client's preferred learning style (e.g., reading a handout or watching a video).

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease. The client reports persistent dyspnea. Which action should the nurse take?

Assist the client with pursed-lip breathing. The nurse should assist the client with pursed-lip breathing. Pursed-lip breathing during periods of dyspnea in clients with chronic obstructive pulmonary disease (COPD) helps to control the rate and depth of respirations. This will also help to prevent alveolar collapse and improve oxygenation. The other actions are not appropriate for this client.

The nurse is completing a head-to-toe assessment on a client. The nurse notes a pulsating mass in the client's periumbilical area. Which assessment is appropriate for the nurse to perform?

Auscultate The nurse should auscultate the mass. If the finding of a bruit is present, this could confirm the presence of an abdominal aortic aneurysm. The mass should not be palpated or percussed because of the risk of rupture.

A client who is two days post abdominal surgery has the following vital signs: blood pressure of 120/70 mm Hg, heart rate of 110 bpm, respiratory rate of 26 breaths per minute and a temperature of 100.4°F (38°C). The client suddenly develops severe shortness of breath, cyanosis and pallor. Which assessment is the priority?

Auscultate the lungs for diminished breath sounds. This client could be experiencing a complication from surgery, such as a pulmonary embolism (PE). A PE occurs as a result of a piece of a clot from the veins in the leg that has broken off and traveled to the lungs. The breath sounds will most likely be diminished or absent in the lung where the embolus lodged, thus a respiratory assessment is the priority.

The nurse manager informs the nursing staff that the clinical nurse specialist will be conducting a research study about staff attitudes toward client care. All staff are invited to participate in the study, if they wish. This type of research participation affirms which ethical principle?

Autonomy The principle of autonomy means individuals must be free to make independent decisions about participation in research without coercion from others. Anonymity means the person's identity is not revealed. Beneficence is the state or quality of being kind, charitable, beneficial or a charitable act. Justice relates to fairness.

The nurse is teaching a client who has coronary artery disease about nutrition. What information should the nurse include?

Avoid large and heavy meals. Eating large, heavy meals can pull blood away from the heart to aid in the digestion process. This may result in angina for clients with coronary artery disease (CAD). This is important information to emphasize to the client with CAD. The other modifications are not appropriate or required with CAD.

The nurse working in an intensive care unit is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment for this client?

Blood pressure Nitroglycerin (NTG) is a vasodilator used to promote myocardial tissue perfusion and relieve chest pain associated with coronary artery occlusion. The systemic vasodilation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure should be evaluated every 15 minutes until stable, and then every 30 minutes to every hour thereafter. Clients receiving IV nitroglycerin should also be placed on continuous ECG monitoring. NTG is not known to affect neurologic status, urine output or heart rate.

Which finding should alert the nurse to the possible presence of a cataract in a client?

Blurred vision and reduced color perception As the lens becomes opaque and less able to refract light appropriately, the client will experience blurred vision and a reduced ability to distinguish among different colors. The development of a cataract does not typically cause loss of peripheral or central vision and visual acuity, nor does it result in aching of the eye or eyelids.

The nurse is caring for a child who was diagnosed with coarctation of the aorta. Which finding should the nurse expect when assessing the child?

Bounding pulses in the arms Coarctation of the aorta, which is a narrowing or constriction of the descending aorta, causes increased blood flow to the upper extremities, resulting in a bounding pulse in the arms. Cardinal signs include resting systolic hypertension, absent or diminished femoral and pedal pulses and a widened pulse pressure.

Two members of the interdisciplinary team are arguing about the plan of care for a client. Which strategy could be used to de-escalate the situation?

Bring the communication focus back to the client. Bringing the subject of the communication back to the client refocuses attention on the client's care, instead of the manner of communication. It is an effective de-escalation strategy because it is an example of effective communication and collaboration. The other options are non-productive and may even make the situation worse.

A client with a spinal cord injury at the T-2 level reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, piloerection, facial flushing, congested nasal passages and a heart rate of 50 bpm. What is the priority action?

Check the client for bladder distention or kinking of the urinary catheter. The client is exhibiting manifestations of autonomic dysreflexia, also called hyperreflexia, seen with a spinal cord injury (SCI), typically above the T6 level. It is most often caused by a noxious stimulus below the level of the injury such as a full bladder, an enema or bowel movement, fecal impaction, changing of an indwelling catheter and a vaginal or rectal examination. The stimulus creates an exaggerated response of the sympathetic nervous system that can be a life-threatening event. Therefore, the priority action is to identify and relieve the cause of the response.

A child is treated with succimer for lead poisoning. Which of these assessments is the priority?

Check the client's complete blood count with differential. Succimer is used in the management of lead or other heavy metal poisoning. Although it is generally well-tolerated and has a relatively low toxicity, it may cause neutropenia. Succimer therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1,200/mm3. The normal range for an ANC is 1.5 to 8.0 (1,500 to 8,000/mm3). Therefore, the assessment priority in this scenario is checking the complete blood count (CBC) with differential which includes an ANC value.

The nurse is caring for a client with a nasogastric tube and is preparing to administer an enteral feeding through the tube. Which is the best method to confirm correct tube placement prior to beginning the feeding?

Check the pH level of the aspirated contents. Once the initial placement of the tube has been confirmed by X-ray, the nurse should check the pH of the aspirated contents before administering medications or enteral feeding solutions. A properly placed nasogastric tube will contain aspirate with an acidic pH. This is the best method for the nurse to check the tube placement. If tube placement is in doubt, an order for an X-ray should be obtained.

The nurse is teaching a group of adolescents about sexually-transmitted infections. Which should the nurse emphasize as the most common sexually-transmitted infection?

Chlamydia Chlamydia is the most frequently reported bacterial sexually-transmitted infection in the United States. This infection has subtle symptoms so an infected person is less likely to seek medical attention and more likely to unknowingly infect others. Prevention is similar to safe sex practices taught to prevent any sexually-transmitted infection including abstinence and the use of condoms during intercourse.

The nurse is completing a health history of a client diagnosed with Alzheimer's disease. The nurse reviews a list of the client's medications and supplements routinely taken at home. Which treatment should be a cause for concern by the nurse?

Coconut oil Donepezil, rivastigmine, and galantamine are most commonly used in the treatment of Alzheimer's disease (AD). Complementary and integrative therapies use to treat AD include Gingko biloba (a plant extract) and omega-3 fatty acids. While there isn't sufficient research to support using these treatments, continued use won't necessarily be harmful. However, coconut oil, which is a source of caprylic acid, is a concern. While there has been limited research on Katasyn (an experimental drug containing caprylic acid), there is no scientific evidence that coconut oil is safe and effective or prevents cognitive decline.

The nurse is reviewing a new prescription for a client with conjunctivitis that reads: Administer ciprofloxacin solution 1 gtt OD Q4H. Which action should the nurse take next?

Contact the prescriber to clarify and rewrite the order. Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every". Although "gtt" is not on the official "Do Not Use List", it is best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous workaround. The next action the nurse should take is to call the primary health care provider (HCP) who prescribed the medication and clarify the order.

The nurse is preparing a client for discharge following inpatient treatment for pulmonary tuberculosis. Which instruction should be given to the client?

Continue taking medications as prescribed. Early cessation of treatment may lead to development of drug-resistant tuberculosis (TB). Active TB is usually treated with a combination of four different antibiotics (Isoniazid, rifampin, ethambutol and pyrazinamide) and can now take anywhere from 6-12 months to completely kill the bacteria. As with any antibiotics, clients should continue to take medications even after they begin to feel better. There is no reason to avoid contact with children, pregnant women or immunosuppressed persons once discharged from the hospital as long as the client is adhering to medication schedules. Isoniazid should be taken on an empty stomach; ethambutol can be taken with food to avoid stomach upset. If taken with TB medications, aluminum hydroxide will interfere with absorption of these medications.

The nurse in the postanesthesia care unit is caring for a client who is recovering from a left lower lobectomy. The client has a chest tube in place. While repositioning the client during the first post-op check, the nurse notices 75 mL of a dark red fluid flowing into the collection chamber of the chest drainage system. What action should the nurse take?

Continue to monitor the rate of the drainage. Following a lobectomy, it is not unusual for blood to collect in the chest and be released into the chest drainage system when the client changes positions. This is most common in the immediate, post-operative phase. The dark color of the blood indicates it is likely old blood and there is not active bleeding inside of the chest. Sanguineous drainage should be expected within the initial 24 hours post-op, progressing to serosanguineous, and then to a serous type. If the drainage exceeds approximately 100 mL in one hour, then the nurse should call the surgeon. In this case, the nurse should continue to monitor the rate of the drainage.

The nurse is caring for a child diagnosed with Kawasaki disease. The nurse should monitor the child for which potential complication?

Coronary artery aneurysm Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis), affects the mucous membranes, lymph nodes, walls of the blood vessels and the heart. It can cause inflammation of the arteries, especially the coronary arteries of the heart, which can lead to aneurysms and possible myocardial infarction in the child. The other complications are not typically seen with Kawasaki disease.

The nurse is teaching a client about effective stress management techniques prior to a surgical procedure. Which technique should the nurse recommend for this client?

Deep breathing Deep breathing is a reliable and valid method for stress reduction and can be taught and reinforced in a short period of time preoperatively. The other approaches require more time and repetition over time for maximum effectiveness.

The nurse is providing discharge teaching to a client who has had a total hip arthroplasty performed. Which instruction should the nurse include?

Do not cross your legs at the ankles or knees. Clients who underwent a hip arthroplasty or replacement are at risk for dislocating the new hip joint if certain precautions are not followed. The risk will vary, depending on the surgical approach (anterior vs. posterior). To prevent a post-surgical hip dislocation, the nurse should instruct the client to prevent hip flexion beyond 90 degrees or hip hyperextension. Furthermore, it is generally recommended to keep the legs slightly abducted and avoid adduction such as crossing the legs. The other instructions are not appropriate or required following a hip arthroplasty.

The nurse is teaching a community class about human immunodeficiency virus (HIV) prevention. Which behavior increases the risk for HIV infection?

Engaging in unprotected sexual encounters. Because human immunodeficiency (HIV) is spread through exposure to blood and bodily fluids, unprotected intercourse and shared drug paraphernalia such as needles remain the highest risks for acquiring HIV. The other activities are not at-risk behaviors for HIV.

The nurse smells smoke and notices a small fire in a non-client storage area. The alarm system begins to sound. Which action should the nurse take next?

Extinguish the fire using an ABC fire extinguisher. A fire in any health care facility presents great potential for harm. In this situation, there are no clients in imminent danger and the alarm has been activated. The nurse should attempt to extinguish the fire using an appropriate fire extinguisher. The ABC type is appropriate for all types of fires. Backing out of the room and closing the door may allow the fire to burn out of control. Using a blanket is not appropriate at this time. If the fire is manageable, the nurse should attempt to extinguish it and not wait for the fire department to arrive.

A client who is taking isoniazid for tuberculosis asks the nurse about the possible side effects of this medication. The nurse informs the client to report which side effect of this medication to the primary health care provider (HCP)?

Extremity tingling and numbness Peripheral neuropathy is a common side effect of isoniazid and other anti-tubercular medications. Extremity tingling and numbness should be reported to the primary health care provider (HCP). Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid use.

The nurse is planning a family care conference for a client who will be returning home with new medical needs. Which of these aspects of the discharge planning evaluation should receive priority consideration?

Family's understanding of the client's health care needs Family members must be willing and able to provide the required care at the times needed and understand the client's health care needs before the client is discharged home. The discharge planning evaluation will take into account a wide variety of information, such as the home environment, and the availability of community-based services (such as support groups, hospice, or medical equipment and related supplies, etc.) Family members should understand the financial implications of discharge, including health insurance and prescription coverage.

The nurse is caring for a client with breast cancer who received chemotherapy one week ago. Which finding is the priority to report to the health care provider?

Fever and chills Chemotherapy causes myelo or bone marrow suppression, resulting in neutropenia, the reduction in neutrophils (white blood cells) that fight off infections. Neutropenic, i.e., immunocompromised, clients are at an increased risk for infection, sepsis and septic shock and the nurse has to be extra vigilant in monitoring for early signs of infection. A fever and chills are indicative of a possible infection and take priority to be reported to the HCP. The other findings are also important to note and should be addressed by the nurse after notifying the HCP of the fever and chills.

The respiratory therapist arrives to draw blood from a client for an arterial blood gas analysis. What should the nurse understand about the collection procedure?

Firm pressure should be applied over the puncture site for at least 5 minutes after the sample is drawn.

The nurse is preparing to administer an albuterol nebulizer treatment to an 11-year-old child with asthma. Which assessment finding should be brought to the health care provider's attention prior to administering the medication?

Heart rate of 116 bpm One of the more common adverse effects of beta-adrenergic medications, such as albuterol, is an increase in heart rate. Normal resting heart rate for children 10-years-old and older is the same as adults: 60 to 100 bpm. The nurse should report the heart rate to the health care provider prior to administering the medication.

The nurse is caring for a client who has cystic fibrosis. The nurse would expect the client to be prescribed which type of diet?

High fat, high-calorie Cystic Fibrosis (CF) affects the cells that produce mucus, sweat and digestive juices. Clients with CF need a high-energy diet that includes high-fat and high-calorie foods, extra fiber to prevent intestinal blockage, and extra salt (especially during hot weather). Clients with CF are at risk for osteoporosis and need good intake of calcium and dairy products. There are no recommended gluten restrictions for clients with CF.

The nurse receives an order to administer intravenous gentamicin to a client. For which finding should the nurse contact the health care provider to clarify the order?

High serum creatinine Gentamicin is an aminoglycoside antibiotic that is excreted primarily by the kidneys. If there is reduced renal function as evidenced by the elevated serum creatinine level, the client is at greater risk for drug toxicity and further renal damage.

The client is having an intravenous pyelogram procedure. After the contrast material is injected, which client reaction should be acted upon by the nurse immediately?

Hives with severe itching all over the body. Hives over the body with severe itching is a sign of anaphylaxis and should be acted upon with the administration of epinephrine immediately. The other reactions are considered normal after the dye injection. Prior to any dye injection procedure clients should be informed that these symptoms may occur.

A hospitalized 8-month-old infant is receiving digoxin to treat Tetralogy of Fallot. Prior to administering the next dose of the medication, the parent reports that the baby vomited one time, just after breakfast. The infant's heart rate is 92 bpm. What action should the nurse take?

Hold the medication and notify the primary health care provider. Toxic side effects of digoxin include bradycardia, dysrhythmia, nausea, vomiting, anorexia, dizziness, headache, weakness and fatigue. It isn't typically necessary to hold the medication for infants and children if there is only one episode of vomiting. However, it is appropriate to hold the medication and notify the primary health care provider (HCP) of the vomiting episode and the lower than normal heart rate. A digoxin level may need to be drawn. The normal resting heart rate for infants 1 to 11 months old is 100 to 160 bpm.

The nurse is conducting teaching with a family whose newborn infant was diagnosed with hypothyroidism. Which point is important for the nurse to emphasize during the teaching?

Hormone replacement therapy will prevent complications. It is important to emphasize that early identification (ideally before 13 days old) and continued treatment with levothyroxine thyroid hormone replacement will correct hypothyroidism in newborns and prevent future problems. If undetected and untreated, hypothyroidism can result in poor growth, weight gain, slow heart rate, low blood pressure and babies who are unusually quiet. An untreated child will be at risk for permanent brain damage and intellectual disabilities. Approximately one in every 4,000 babies is born with hypothyroidism. Congenital hypothyroidism can be caused by a variety of factors, only some of which are genetic.

A home health nurse is teaching the parents of a pediatric client with acute spasmodic croup. Which interventions are most important to include?

Humidified air with an increase in oral fluids The most important aspects of home care for a child diagnosed with acute spasmodic croup are humidified air and increased oral fluids. Humidified air helps reduce vocal cord swelling. Taking the child out into the cool night air for 10 to 15 minutes can also reduce nighttime symptoms. Adequate systemic hydration aids mucociliary clearance by keeping secretions thin and easy to remove with minimal coughing effort.

A new nurse is asking about stoma care for a client with a new ostomy. Which type of ostomy poses the highest risk for skin breakdown?

Ileostomy Ileostomy output, which is from the small intestine, is of a continuous, liquid nature. This output contains gastric and enzymatic agents that when present on skin can denude the skin in a few hours. Because of the caustic nature of this stoma output, adequate peristomal skin protection must be delivered to prevent skin breakdown. With a transverse colostomy the stool is of a somewhat mushy and soft nature. With a sigmoid colostomy the output is formed with an intermittent output. An ileal conduit is a urinary diversion with the ureters being brought out to the abdominal wall.

The nurse on a telemetry unit is assessing orthostatic vital signs on a client with cardiomyopathy. The client's systolic blood pressure decreased from 145 to 110 mmHg between the supine and upright positions. The client's heart rate increased from 72 to 96 bpm during that time. The client reports feeling lightheaded when standing up. Which action should the nurse implement?

Increase the client's PO fluid intake for the next 2 hours. The client is experiencing postural hypotension. Postural hypotension is a decrease in systolic blood pressure of at least 15 mmHg, accompanied by an increase in heart rate of 15 to 20 beats above the baseline with a change of position from supine to upright. This is often accompanied by lightheadedness. Fluid replacement is appropriate, and must be instituted very cautiously. The client with cardiomyopathy will also be sensitive to changes in fluid status and fluid overload may develop rapidly with aggressive rehydration. After the client increases fluid intake for one to two hours, the client should be reassessed for resolution of the postural hypotension.

A woman who is 5 days postpartum and has a history of pregnancy-induced hypertension, calls the hospital triage nurse hotline to ask for advice. She states, "I have had the worst pounding headache for the past two days. Since this afternoon, everything I look at appears blurred. Nothing I have taken helps." What action should the nurse take?

Instruct the client to call 911 to be brought to the nearest emergency room. The woman is describing symptoms related to pregnancy-induced hypertension (PIH) that appears to be progressing to preeclampsia/eclampsia. PIH may progress to preeclampsia and eclampsia prior to, during, or up to 10 days after delivery. This places the woman at risk for seizure activity which is a medical emergency. The client should call 911 to be brought immediately to the closest emergency room (ER).

A pregnant client at 34 weeks gestation is diagnosed with a pulmonary embolism. Which of these medications should the nurse plan to administer?

Intravenous heparin Clients diagnosed with pulmonary embolism (PE), whether pregnant or not, are initially treated with intravenous unfractionated heparin. Alternatively, low molecular weight heparin such as enoxaparin can be used to treat women who are pregnant. Warfarin should never be given during pregnancy due to its teratogenic effects. Although aspirin has anticoagulant properties, low-dose aspirin therapy (81 mg) is more often used prophylactically, not for the treatment of a PE.

A group of nurse managers is tasked with making several important staffing decisions. Which statement describes the advantage of using a decision grid to make decisions?

It is both a visual and a quantitative method of decision-making. A decision grid allows the group to visually examine alternatives and evaluate them quantitatively or more objectively. It does not necessarily make the decision-making faster or interpretation easier. There are other tools available to aid in decision-making by a group.

A client with schizophrenia is admitted to a mental health center with acute paranoia. The client tells the nurse: "I am a government official being followed by spies." Upon further questioning, the client states: "My warnings must be heeded to prevent nuclear war." Which action is most appropriate for the nurse to take?

Listen quietly without comments. The client's comments demonstrate grandiose ideas or delusions of grandeur. The most appropriate action is to calmly listen and avoid being pulled into the client's delusional thinking. At some point, validation of the present situation will need to be done. Confrontation would be an inappropriate action and non-therapeutic.

A community health nurse has been caring for a woman who is 22 weeks pregnant and has a history of morbid obesity, asthma and hypertension. Which of these lab reports should be communicated to the primary health care provider immediately?

Magnesium 0.8 mEq/L and Creatinine 3 mg/dL The lab reports of highest concern are the magnesium and creatinine. The magnesium level is low and the creatinine level is high, indicating acute renal failure, most likely related to gestational hypertension or preeclampsia. Hypomagnesemia can lead to seizure activity. These lab reports should be communicated to the primary health care provider (HCP) immediately.

The parents of a 5-month-old infant report that the infant has "vomited 9 times in the past six hours." Which complication should the nurse monitor the infant for?

Metabolic alkalosis Vomiting results in a loss of acid from the stomach. Prolonged vomiting results in excess loss of acid and leads to metabolic alkalosis. Manifestations of metabolic alkalosis include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.

The emergency room nurse is evaluating a client with injuries sustained from domestic partner violence. The nurse should understand that after an acute battering incident, the batterer is most likely to respond to the client's injuries by taking which action?

Minimize the episode with an underestimation of the injuries. Many batterers lack an understanding of the effects of their behavior on the person who was battered. Batterers use excessive minimization. They typically are in a state of denial about the situation, their behaviors or their intent. The other actions are not typically seen from the batterer in a domestic/partner violence incident.

The nurse is caring for a client who is diagnosed with Hodgkin's disease and is scheduled for radiation therapy to the whole body. The nurse would expect the client to experience which side effect?

Nausea As a result of radiation therapy, which is at the lymph nodes throughout the body, nausea often results (radiation sickness). Night sweats are an expected finding with Hodgkin's disease. These clients are not likely to have a high fever because the lymphatic or immune system is not fully functional. Neutropenia is a side effect of chemotherapy.

The nurse is assessing a 4-year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and appears to be having severe pain. The foot on the affected extremity is pale, cool to touch and the pulse is barely palpable. What action should the nurse take?

Notify the primary health care provider. The pain and absence of a pulse suggests compartment syndrome. This condition occurs when there is a buildup of pressure within the muscles. This pressure decreases blood flow and can cause muscle, tissue, and nerve damage. Compartment syndrome is a medical emergency. Delaying treatment can lead to permanent damage to the extremity. Therefore, the nurse should contact the primary health care provider (HCP) immediately.

An inpatient client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." Which action should the nurse take?

Obtain more details of the client's claim of abuse by a nurse. The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, assessment before interventions and before documenting or reporting the complaint.

The nurse in an intensive care unit is reviewing the laboratory results for several clients. Which laboratory result indicates that the client has a partially compensated metabolic acidosis?

PaCO2 of 30 mmHg With metabolic acidosis, the nurse should expect to see a low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L). Compensation means that the body is trying to get the pH back to a normal range of 7.35 to 7.45. A pure metabolic acidosis will elicit a compensatory response by the lungs in form of a decrease in PaCO2 (normal range is 35 to 45 mm Hg). Therefore, the PaCO2 level of 30 mm Hg indicates a partially compensated metabolic acidosis. A pH of 7.48 indicates an alkalosis and the chloride level does not pertain to the acid-base imbalance or compensation.

An 80-year-old client arrives in the emergency room after a fall at home. The client has several large skin abrasions. Which action should the nurse perform first?

Perform a head-to-toe assessment. The nurse should first perform a head-to-toe assessment to see if other body systems were affected by the fall. After that initial assessment, the nurse should perform the other actions. The nurse would then document information collected during the assessment, such as any injuries.

The nurse is assigned to a client who is newly diagnosed with active tuberculosis. Which intervention is the priority?

Place the client in a private, negative pressure room. A client with active tuberculosis should be hospitalized in a negative pressure room, i.e., airborne precautions, to prevent spread of the disease. Placing the client on on airborne precautions is the priority because this bacteria can be suspended in the air for long periods of time and may be carried for long distances on air currents, infecting others.

The parents of a 4 year-old boy have just been informed that their son has a congenital neurologic disorder that is terminal. The nurse should anticipate the parents' reaction to fall into which crisis phase?

Pre-crisis phase A crisis is a sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. The development of a crisis situation follows a relatively predictable course. Stages in a crisis go from the pre-crisis phase (phase 1) , to the impact phase (phase 2), then the crisis phase (phase 3), and finally the resolution phase (phase 4). The time frame of recent bad news places the parents in phase 1. In this phase, an individual is exposed to a precipitating stressor, resulting in increased anxiety and employment of previous problem-solving techniques.

A client who has been receiving chemotherapy through a central venous access device (CVAD) at home, is admitted to the intensive care unit with a diagnosis of septicemia. Which nursing intervention is the priority?

Prepare the client for insertion of a new CVAD. Many cases of sepsis occur in immunocompromised clients and clients with chronic and debilitating diseases. Since it is likely that the existing CVAD is the source of the blood stream infection, it should be removed and the tip sent for culture and sensitivity testing. The nurse should anticipate this action and the priority is to prepare the client for insertion of a new CVAD. The other interventions are not indicated or appropriate for this client.

The home health nurse is planning a care conference for the family of a 2-year-old child with cerebral palsy. Which goal should the nurse suggest to the family?

Promote the child's optimal development. The primary goal of nursing care for the child is to promote the child's optimal development. The child should be supported and encouraged to learn and grow to their fullest potential. Self-care and toileting may not be appropriate goals for the child due to the cerebral palsy. It is premature to discuss if the child should be placed in a long-term care facility.

Today's prothrombin time for a client receiving warfarin is 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action?

Recognize that this is a therapeutic level. For the client on warfarin therapy, this prothrombin level is within the therapeutic range. Therapeutic levels for warfarin are usually one and a half to two times the normal level.

The nurse is assessing a 1-day-old newborn infant. The nurse notices that the infant's breasts are enlarged bilaterally with a thin, white discharge. Which action by the nurse is appropriate?

Record the findings, noting they are normal. Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days to weeks after birth. This is a result of circulating maternal hormones after birth. This typically resolves on its own in the first few weeks after birth.

There is an order for a 25-year-old client, who is unresponsive after suffering a traumatic brain injury, to be transferred from the hospital to a long-term care facility today. Which staff member should the charge nurse assign to care for this client?

Registered nurse (RN) The Registered Nurse (RN) is responsible for facilitating continuity of care for clients and their families during the transfer from one health care setting to another. The transfer to a long-term care facility often requires referrals and coordinating information from many different providers about treatments, therapies and medications. The charge nurse should assign this client to a RN.

The home health nurse is preparing for a home visit of a new client. Which action is most important to ensure the safety of the nurse during the visit?

Remain alert and leave if cues suggest the home is not safe. Nurses need to assess and manage safety risks and have ongoing clinical supervision and support when making home visits. The most important action a nurse can take to ensure safety during a home visit is to always remain alert and to leave if there are any cues that the home is not safe. Proper safety should begin with a thorough assessment of the client's home to identify potential risks, such as pets (a commonly assessed hazard), drug use and weapons. The nurse should also develop a plan to eliminate the risks and understand that there is always the option to end a visit early if the environment does not seem safe. Carrying a phone, using a buddy system, learning about the client prior to the visit can also help mitigate risks.

The nurse is planning care for a newly admitted 78-year-old client who is diagnosed with severe dehydration. Which task would be appropriate for the nurse to assign to an unlicensed assistive person (UAP)?

Report hourly outputs of less than 30 mL/hr within 15 minutes of the check. When assigning tasks to an unlicensed assistive person (UAP), the nurse must communicate clearly about each delegated task with specific instructions on what must be reported and when. Because the nurse is responsible for all care-related decisions, only routine tasks should be assigned to UAPs because such tasks do not require clinical judgment and decision-making. Measuring hourly urine output and reporting the amount to the nurse is an appropriate task to delegate to a UAP.

The nurse has been caring for the same client for 5 days. The client has been exhibiting manipulative behaviors. The nurse becomes aware of feeling reluctant to interact and care for the client. Which action should the nurse take?

Report the feelings of reluctance to an objective peer or supervisor. The nurse who experiences stress in a professional relationship with a client can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of reactions that can influence the nurse-client relationship in positive and negative ways.

The nurse at a hypertension clinic has been teaching adult clients about modifiable risk factors. Which client response would best indicate that the teaching was effective?

Reported behavioral changes If the clients alter behaviors such as smoking, drinking alcohol and stress management, these changes suggest that learning has occurred. Additionally, physical assessments, observed behaviors and laboratory data (e.g., blood tests) may confirm risk reduction.

The nurse receives change-of-shift report on an 80-year-old client diagnosed with middle-stage Alzheimer's disease. Which information should be of highest concern?

Reports of increased confusion, agitation and withdrawal. Infections and pain can quickly exacerbate common symptoms of Alzheimer's disease, including confusion, agitation or withdrawal. A urinary tract infection (UTI) is one of the most common causes of sudden behavior changes in older clients. Because a UTI can quickly progress to urosepsis, the neurologic changes are of highest concern.

A parent asks about expected motor skill development for their 3-year-old child. Which activity is considered a typical motor skill for that age?

Riding a tricycle 3-year-old children are developing gross motor skills that require large muscle movement. While there will always be some variation between children, movement milestones typically include peddling a tricycle, standing on one foot for a few seconds, walking backwards and jumping with both feet. The other activities listed require more coordination and fine motor skills that are more typical for older children.

As a client is being discharged following resolution of a spontaneous pneumothorax, the client tells the nurse, "I'm going on a beach vacation next week." The nurse should instruct the client to avoid which activity?

Scuba diving The nurse would strongly emphasize the need for the client with a history of spontaneous pneumothorax problems to avoid high altitudes, flying in an unpressurized (open) aircraft and scuba diving. The negative pressure associated with diving could cause the lung to collapse again.

The nurse is reviewing the lab results of a full term, 30-hour-old newborn infant. The nurse knows that the first-time mother is Rh negative. Which of these findings is the priority to report to the health care provider?

Serum bilirubin of 11 mg/dL Jaundice is a common condition in newborns. But for a full-term infant who is 30 hours-old, a total serum bilirubin level of 11 mg/dL is high, indicating the possibility of hemolysis due to Rh incompatibility. The concern about hyperbilirubinemia is increased because the mother is Rh negative. Therefore, that finding is the priority finding to report to the health care provider. The other findings are either normal (hematocrit) or not as important at this time.

A nurse is reviewing laboratory results for a client diagnosed with acute renal failure. Which result should be reported to the primary health care provider immediately?

Serum potassium of 6 mEq/L Although all of these findings are abnormal, the elevated potassium level is a life-threatening finding and must be reported immediately. Serious consequences of hyperkalemia include heart block, asystole and life-threatening ventricular dysrhythmias. Anemia (approximate hemoglobin less than 13 g/dL in men or less than 12 mg/dL in women) is common with kidney disease. Blood urea nitrogen (BUN) is expected to be increased in acute renal failure (7 to 30 mg/dL is considered normal).

The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis. Which finding is consistent with this diagnosis?

Shallow respirations Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. In ALS, upper and lower motor neurons degenerate and stop sending messages to muscles. All muscles eventually weaken and atrophy, including the muscles needed to maintain effective respirations. People eventually lose their ability to speak, eat, move and breathe. The other findings are not typically seen with ALS.

A nurse in an obstetrics clinic is taking a health history from a 40-year-old woman in the first trimester of pregnancy. Which information from the health history requires priority follow-up from the nurse?

She has been taking an ACE inhibitor for her blood pressure for the past 2 years. A report by the client that she has been taking medications in the first trimester of pregnancy should be the priority to follow-up on. ACE inhibitors are pregnancy category X, as they may cause teratogenic effects on the developing fetus and increase the risk of birth defects. The nurse should notify the primary health care provider (HCP) of this pertinent information. Folic acid is recommended to take during pregnancy to aid in fetal neurological development. While the family history of diabetes and tuberculosis are important to note, the priority is the ACE inhibitor that the client is taking because it may be affecting fetal development.

A community health nurse is speaking to a group of community members about alternative therapies. What is the focus of chiropractic treatment?

Spinal column manipulation The theory underlying chiropractic treatment is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the misalignment (subluxation).

The nurse is assessing a client who just returned to the medical surgical unit after a segmental lung resection surgery. During the assessment, the client is coughing and clearing their throat. What is the first action the nurse should take?

Suction excessive tracheobronchial secretions. This type of surgery involves removing a bronco-vascular segment of a lung lobe. It is typically used to remove small, peripheral lung tumors. Surgical manipulation during this procedure, along with anesthesia, and increased mucus production can lead to airway obstruction, which is why the nurse may need to suction the client if there are excessive secretions. The first action the nurse should take is to suction the excessive secretions. Since this client just returned from surgery, it is not the time to ask the client to turn, cough and deep breathe. Vital signs and oxygen saturation are important data to gather, but clearing the client's airway by suctioning needs to be done first.

A nurse in a rural community uses telehealth to provide care and education to clients in remote locations. What are the perceived benefits of using telehealth?

Telehealth removes the time and distance barriers from the delivery of care. Telehealth is the use of technology to deliver health care, health information or health education at a distance. People in rural areas and homebound clients can communicate with primary health care providers via telephone, email or video consultation, thereby removing the barriers of time and distance for access to care.

The nurse is caring for a client diagnosed with anemia and confusion. Which task could the nurse assign to an unlicensed assistive person (UAP)?

Test a stool sample for occult blood and report the results Unlicensed assistive personnel or persons (UAP) perform routine tasks that have known or expected outcomes because these tasks typically do not require nursing judgment or decision-making. Any nursing intervention that requires independent, specialized nursing knowledge, skill or judgment cannot be assigned to UAP.

The community health nurse is planning a teaching session for a family with children about safety and risk-reduction in their home. What information is most important to obtain prior to the session to ensure the teaching is effective?

The ages of the children in the home. Although all of the information is important for the nurse to consider, the ages and developmental levels of the children are the most important considerations for anticipatory guidance associated with safety, and should be given priority when developing a teaching plan. With this information, the nurse can individualize the teaching session to meet the specific needs and risks of the children in the home.

The nurse is using the new Ballard score to perform an assessment to determine the gestational age of a newborn infant. The total score can range from -10 to 50. The infant's score is near 50. What is a reasonable interpretation of this result?

The baby is post-term. Birth weight and gestational age are important indicators of a newborn's health and are used to identify any potential problems. A full-term pregnancy is usually 40 weeks. It's important to assess when gestational age is uncertain or the infant is smaller or larger than expected. The New Ballard scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments. The total score may range from -10 to 50. Premature babies have lower scores. Higher scores correlate with post-term maturity. Fetal distress during labor tends to result in lower scores.

The nurse in a behavioral health inpatient unit is observing a female client who has been diagnosed with obsessive-compulsive disorder. Which behavior supports this diagnosis?

The client is seen washing her hands every 15 minutes. Washing her hands every 15 minutes indicates compulsive behaviors seen with obsessive compulsive disorder (OCD). OCD is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions). Affected individuals are often unable to stop the compulsive behaviors. The other behaviors are not typically seen with OCD. Verbalizes suspicions reflect a paranoid thought process seen with delusional disorders, such as schizophrenia or schizoaffective disorder. Repetitive involuntary movements are side effects seen with certain antipsychotic medications.

The nurse is caring for a client with a diagnosis of cirrhosis of the liver and ascites. What should the nurse emphasize to the unlicensed assistive personnel (UAP) about providing care for this client?

The client should ambulate as tolerated, resting in bed with legs elevated between walks. Encourage alternating periods of ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client to gradually increase the duration and frequency of walks.

A client is admitted to an ambulatory surgery center and underwent a right inguinal orchiectomy. Which goal is the priority before the client should be discharged home?

The client's postoperative pain is well-managed. An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer (testicular, prostate, or cancer of the male breast). Due to the location of the incision, pain management is the priority. Most men will be able to eat regularly when they get home. They should at least tolerate liquids before discharge. The client should be able to walk without assistance prior to discharge. Psychological counseling may be needed as part of long-term aftercare; however, this is not the priority prior to discharge.

The nurse is conducting a teaching session to new nurses about the principles of pain management. Which principle is most important when assessing a client's pain level?

The client's self-report is their actual pain level. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but the most important consideration when assessing a client's pain is their self-report.

The parents of a 7-year-old child tell the nurse that their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents?

The ethical sense and feelings of justice are developing. The child is developing a sense of justice and a desire to do what is right. At age 7, children are increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment. This age group, 6-12 years of age, is called the school-aged group.

The nurse is caring for a primigravida client who is in active labor. Which assessment finding may be an early indication that the client is developing a complication of the labor process?

The fetal heart rate has been around 180 bpm for several minutes. The finding that indicates a possible complication of the labor process is the fetal heart rate of 180 bpm for several minutes. The normal fetal heart rate is typically somewhere between 120 and 160 bpm. Although the heart rate will fluctuate during labor and between contractions, prolonged fetal tachycardia can be an early sign of hypoxia.

The nurse is providing discharge teaching to the parents of a 15-month-old child diagnosed with Kawasaki disease. The child received intravenous immunoglobulin therapy during the hospitalization. Which information should the nurse include?

The measles, mumps and rubella vaccine should be delayed. Discharge instructions for a child with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis), should include the information that immunoglobulin therapy may interfere with the body's ability to form appropriate amounts of antibodies. Therefore, live or attenuated (weakened) immunizations should be delayed. The measles, mumps, and rubella (MMR) vaccine contains three live attenuated viruses and should be delayed until the child's immune system recovers from this treatment.

The nurse witnesses a client having a seizure. Which observation is important to note to determine the type of seizure?

The sequence and types of muscle movement. All behaviors observed during and after the seizure need to be reported and recorded. However, accurate descriptions of seizure activity and a system for recording and reporting activity is essential to seizure management. For example, during the seizure event, the nurse needs to observe the client's facial expression, muscle tone, movements (e.g. jerking or twitching) the parts of the body involved, and any automatic or repeated movement (e.g. lipsmacking, chewing, swallowing).

The nurse is evaluating a stage III pressure ulcer. Which assessment finding would indicate that the prescribed treatment is working?

The size of the wound is decreasing A wound that is decreasing in size is healing. "Slough" is yellow, tan or green tissue that is not healing. Soft and denuded tissue in the periwound area indicate tissue breakdown due to excessive moisture from wound drainage. Curled or rolled wound edges (epibole) prevents epithelial cells from migrating to close the wound, preventing the wound from healing.

An 18-month-old child is awaiting a renal transplant. When reviewing the child's health history, the nurse notes that the child has not had the first measles, mumps, rubella (MMR) immunization. Which action should the nurse take?

The vaccine should be given now, before the transplant. The measles, mumps and rubella (MMR) vaccine is a live virus vaccine, and should be given at this time, pre-transplant. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the child's compromised immune system.

A client diagnosed with testicular cancer has undergone a unilateral orchiectomy. The client expresses fears about his prognosis. What should the nurse understand about this type of cancer?

This cancer has a five-year survival rate of 90% or greater with early diagnosis and treatment. With aggressive treatment and early detection/diagnosis the cure rate is generally 90% or greater. The other options are incorrect information. After unilateral orchiectomy, the remaining testicle can produce adequate sperm for fertility and impotence is unlikely.

The clinic nurse is assisting with medical billing. The nurse uses the Diagnosis Related Group (DRG) manual for which purpose?

To determine reimbursement for a medical diagnosis. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other insurance companies often use it as a standard for determining payment. The nurse uses this manual to determine reimbursement for medical diagnoses.

A community health nurse is teaching a new parent group about primary prevention of lead poisoning in children. Which intervention should the nurse include?

Use bottled water to add to any formula concentrate or powder. 117of171 Ref # 1966 A community health nurse is teaching a new parent group about primary prevention of lead poisoning in children. Which intervention should the nurse include? Request chelation therapy from the child's pediatrician. Monitor the child for developmental delays. Boil tap water for 10 minutes prior to adding to formula or food. Incorrect Use bottled water to add to any formula concentrate or powder. Correct Response Submit Lead exposure to children can result from multiple sources and can cause irreversible and life-long health effects. No safe blood lead level in children has been identified. Even low levels of lead in blood have been shown to affect IQ, ability to pay attention and academic achievement. Lead-contaminated water continues to pose a risk for many communities in the United States. Drinking water may become contaminated by lead from old lead pipes or the lead solder used in sealing the water pipes in older communities, building and homes. To reduce the risk of lead poisoning in infants in communities at risk for lead-contaminated water, a preventative intervention is to use bottled water to prepare formula from concentrate or powder. Boiling water will kill bacteria in water but does not remove the lead. Developmental delays are an outcome of lead poisoning, not a preventative measure. Chelation therapy is a treatment option for children diagnosed with high serum levels of lead; it is not a preventative treatment.

The nurse on an inpatient medical unit is caring for a client who is in the advanced stage of multiple myeloma. Which intervention should the nurse include in the plan of care?

Use careful repositioning techniques. Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. This disease may also harm other tissues and organs, especially the kidneys. This type of cancer causes hypercalcemia, renal failure, anemia, and bone damage. Because multiple myeloma can cause erosion of bone mass and fractures, extra care should be taken when moving or positioning a client due to the risk of pathological fractures.

The nurse is caring for a woman in active labor. An internal fetal heart rate monitoring wire is in place. Which fetal heart rate pattern indicates a possible complication of labor?

Variable decelerations A deceleration in fetal heart rate (FHR) may be benign or abnormal. Variable decelerations in FHR are often indicative of an interruption in the fetal oxygen supply due to umbilical cord compression. This is a complication that should be reported to the health care provider immediately.

A client has been admitted to an inpatient behavioral health unit for severe depression and suicidal threats. The client has been placed on suicide precautions. The nurse should be aware that the danger of the client attempting suicide is greatest during what period of time?

When the client's mood or energy level improves. The risk for suicide is often increased when there is an improvement in mood and energy level. This can occur when the client is being treated and receiving new or increased doses of antidepressants. The medications can make the client feel less ambivalent and give the client the energy to carry through with the threat for suicide

A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) has died. Which transmission-based precautions should be used when performing postmortem care?

contact precautions MRSA is transmitted by contact and MRSA bacteria remain alive for up to 3 days after a client dies. Therefore, contact precautions must still be used, including the use of a gown and gloves. The body should also be labeled as MRSA contaminated so the funeral home staff can protect themselves as well.

The nurse is caring for a client who received 2 units of packed red blood cells after an episode of gastrointestinal bleeding. Which laboratory value should the nurse monitor closely?

hematocrit The hematocrit is an indirect measurement of red blood cells (RBCs) number and volume. It is used as a rapid measurement of RBC count. It is used to determine the degree of anemia in a client and evaluate effectiveness of treatment such as a blood transfusion. It is performed in combination with a hemoglobin level, commonly referred to as an 'H&H'. A follow-up hemoglobin and hematocrit should be checked around 4 to 6 hours after the transfusion is completed.

A newborn baby that was delivered at home without a birth attendant is admitted to the hospital for observation. The baby's initial temperature is 95° F (35° C). The nurse should recognize that the newborn is at risk for which complication?

hypoxemia This newborn has hypothermia and it at risk for cold stress. This can cause a variety of physiologic stresses including increased oxygen consumption and reduced partial pressure of oxygen in arterial blood or PaO2, i.e., hypoxemia. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97°F (36°C). Normal core body temperature for newborns is 97.7° F-99.3° F (36.5° C-37.3° C)

The nurse on a critical care unit is admitting a client who is experiencing a hypertensive urgency or crisis. Which assessment is the priority?

orientation The organ most susceptible to damage in hypertensive crisis is the brain, due to the high risk for rupture of cerebral blood vessels leading to a stroke or hemorrhage. Therefore, a neurologic assessment that should include orientation and level of consciousness is the priority for this client.

The nurse is planning care for a 2-year-old hospitalized child. Which issue will produce the most stress at this age?

separation anxiety Toddlers experience separation from their parents as a major stressor. Separation anxiety peaks in the toddler years and will produce the most stress at this age.

A nurse is teaching a group of adults about modifiable risk factors for cardiovascular disease. Which risk factor is most important to include?

smoking cessation Smoking cessation is a priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time, but the priority modifiable cardiac risk factor is smoking.

A client is transported to the emergency department after a motor vehicle accident. When assessing the client 30 minutes after arrival, the nurse notes several physical changes. Which finding requires immediate attention?

tracheal deviation Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build, collapsing the lung and shifting the mediastinum to the opposite side. This obstructs venous return to the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency, requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the pressure. The other findings are most likely related to the potential pneumothorax.