Princeton Review Remediation

Phlebitis score

0: No complications 1: Erythema, no pain (Remember, 1 thing) 2: Erythema, pain (Remember, 2 things) 3: Erythema, pain, streak formation and palpable venous cord 4. Symptoms from 3 AND purulent drainage

When planning care for a group of clients who are refugees, which is the priority of the nurse? A. Navigating public transportation B. Access to therapy C. Understanding social norms D. Communication barriers

B. Access to therapy Rationale: Clients who are refugees often have left their homes as a result of disaster or under horrific reasons. These clients often experienced traumas, such as torture. The priority for the nurse when planning care is access to therapy. Navigating public transportation, understanding social norms, and communication barriers can impact care, but therapy is the priority.

A nurse receives a prescription to administer oxytocin for induction of labor in a client. Which clinical manifestation indicates an expected response to the medication? A. Absence of uterine bleeding B. Duration of uterine contractions last 50 seconds C. Uterine contractions occur every 1 minute D. Increased uterine tone

B. Duration of uterine contractions last 50 seconds Rationale: Oxytocin is a uterine stimulant used to induce labor and promote effective uterine contractions. Effective contractions occur every 2 to 3 minutes and last 45 to 60 seconds. Absence of uterine bleeding is an expected response postpartum. Uterine contractions that occur every minute do not allow the uterine to rest and regain its tone. Increased uterine tone is an expected response postpartum to avoid hemorrhage.

A nurse is assessing a client who has a puncture wound of the left foot. Which findings would best indicate to the nurse that the client has developed localized osteomyelitis? A. The client reports numbness in the toes of the affected foot. B. The client's skin has erythema over the affected foot. C. The client's skin is non-blanchable around the wound. D. The client reports feeling chills.

B. The client's skin has erythema over the affected foot. Rationale: When assessing a client with a puncture wound of the left foot who is developing localized osteomyelitis the nurse will observe localized erythema and edema over the affected foot. The client will report pain in the affected, numbness in the toes is associated with peripheral vascular disease. Non-blanchable skin would indicate a decrease in perfusion, not infection. The client would report feeling chills if the infection becomes systemic.

The nurse is caring for a client following a lumbar puncture. Which of the following actions should the nurse take? Select all that apply. One, some, or all responses may be correct. A. Encourage the client to increase oral fluids B. Monitor for nausea C. Check sensations in lower extremities D. Keep client in fetal position E. Instruct client to cough and deep breath

A, B, C Rationale: A lumbar puncture is a procedure to aspirate fluid from the cerebral spinal space and to check measure CSF pressures by inserting a needle in the L3-4 or L4-5 interspace. The nurse caring for the client following a lumbar puncture should position the client supine, with the head of the bed flat, monitor for nausea which could be a sign of meningeal irritation, check sensation in lower extremities to assess motor function, and increase the intake of oral fluids. Clients should be instructed to refrain from coughing and deep breathing to prevent increase in intracranial pressure.

The nurse is assessing a client who has renal failure and is exhibiting manifestations of hyperkalemia. Which finding should the nurse expect to observe ? Select all that apply. One, some, or all responses may be correct. A. Irritability B. Irregular pulse C. Abdominal pain D. Vomiting E. Constipation

A, B, C, D Rationale: Hyperkalemia, increase level of potassium, occurs with impaired renal secretion, cellular shift, and increase intake of potassium. For clients at risk for developing hyperkalemia, the nurse should monitor for signs such as irritability, muscle weakness, paresthesia, abdominal pain, diarrhea, vomiting, confusion, and irregular pulse. Constipation is associated with hypokalemia.

The nurse is developing the plan of care for a client who has an acute episode of diverticulitis. Which interventions should the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. A. NG tube insertion and suction B. Admin prescribed IV antibiotics C. Bed rest D. Increase intake of oral fluids E. Obtain blood cultures

A, B, C, E Rationale: During the acute episode of diverticulitis, the client will require management of symptoms, which will include bowel rest with bed rest and NG tube, antibiotics to treat infection, and blood cultures to evaluate if the localized infection has become systemic. During the acute episode the client will be in NPO.

The nurse is reviewing discharge teaching with a client who is postoperative insertion of a permanent pacemaker. Which of the following instructions should the nurse include? Select all that apply. One, some, or all responses may be correct. A. "Count your pulse for 1 minute each morning." B. "Perform range of motion exercises by rotating your arm in a circle." C. "Avoid wearing tight clothes over the insertion site." D. "Request to be scanned with a handheld metal detector when at the airport." E. "Do not have a microwave oven in your home."

A, C, D Rationale: A permanent pacemaker is used to regulate the electrical condition of the heart. Pacemaker is small device placed under the skin with leads threaded into the heart. The nurse should teach a client who is postop from pacemaker placement to count pulse for 1 minute daily to monitor heart rate and evaluate the pacemaker is working. The client will be instructed to avoid lifting arm above waist for at least a week to prevent lead dislodgment. Because the pacemaker can be deactivated by magnets, the client should avoid all body-scanners. Microwaves are safe to use with a pacemaker.

The nurse is caring for a client with Marfan's syndrome who is preoperative for thoracic aortic aneurysm repair. Which manifestation reported by the client would require emergent intervention by the nurse? A. Pain in the middle of the back B. Shortness of breath C. Fatigue D. Nausea

A. Pain in the middle of the back Rationale: A client with a thoracic aneurysm can develop a tear or rupture of the aneurysm, which is a medical emergency. Pain in the middle of the back is the hallmark manifestation of thoracic aneurysm tear. Fatigue and shortness of breath are expected findings with a thoracic aneurysm. Nausea is manifestation of myocardial infarction.

A nurse reviews a prescription to discontinue a nontunneled central venous access device. Which action will the nurse perform to prevent an air embolism? A. Position the patient supine before catheter removal B. Cleanse the insertion site with CHG solution prior to removal C. Instruct the client to take deep breaths during catheter removal D. Apply pressure to insertion site after catheter removal

A. Position the patient supine before catheter removal Rationale: An air embolism is a potential complication of central venous access device removal. Positioning the client supine promotes venous filling and prevents the formation of an air embolus. Cleansing the insertion site with chlorhexidine gluconate (CHG) decreases the risk of infection but does not specifically prevent an air embolism. Instructing the client to take deep breaths during the removal increases the risk of an air embolism. The client should be instructed to bear down (Valsalva maneuver) during removal. Applying pressure to the insertion site after removal prevents hematoma formation and reduces the risk of bleeding.

A nurse is preparing to administer procainamide to a client who takes propranolol for hypertension. Which clinical finding indicates an interaction between these medications? A. Prolonged PR interval on the electrocardiogram B. Blood pressure of 90/50 C. Butterfly-shaped rash on the client's face D. Platelet count of 100,000

A. Prolonged PR interval on the electrocardiogram Rationale: A prolonged PR interval on the electrocardiogram indicates procainamide toxicity. Beta blockers, such as propranolol, increase the risk of procainamide toxicity. A blood pressure of 95/50 mmHg is on the lower side of normal. The nurse should continue to monitor the blood pressure as procainamide and propranolol can have additive hypotensive effects. A butterfly-shaped rash is indicative of systemic lupus syndrome, a complication of procainamide. However, this complication is not due to an interaction between procainamide and propranolol. A platelet count of 100,000/mm³ is indicative of thrombocytopenia, a possible complication of procainamide that usually resolves within a month after initiation of therapy.

A nurse is assessing a client with cholecystitis. Upon assessment, the client rates the degree of pain a 0/10. Which behavioral response indicates to the nurse that the client may require pain medication? A. The client changes position frequently B. The client is diaphoretic C. The client's blood pressure is 145/90 mmHg D. The client's heart rate is 110 beats/min

A. The client changes position frequently **The question is asking for behavioral response to pain, not physiological** Rationale: Behavioral responses to pain include changes in posture and/or gross motor activities. Although the client rated their pain a 0/10, the nurse identifies frequent position changes as a possible indicator of pain and should re-assess the client. Diaphoresis, hypertension, and tachycardia are physiological, not behavioral, responses to pain.

A nurse is evaluating a client's home for fire safety. Which observation prompts the nurse to intervene? A. The client's bedding is made out of nylon material. B. Emergency numbers are taped to the back of the house phones. C. The smoke alarm batteries were last changed 3 months ago. D. There are 2 fire extinguishers in the home.

A. The client's bedding is made out of nylon material. Rationale: Materials made out of nylon can generate static electricity. The nurse should encourage the client to replace the bedding with items made from cotton. Emergency numbers should be kept within reach, particularly near a phone in case of a fire or other emergency. The batteries in the smoke alarm have been changed within an adequate timeframe. Smoke alarm batteries should be checked and changed every 6 months. Each home should have at least 1 fire extinguisher. Multi-level homes should have a fire extinguisher in each floor.

Which actions by the nurse would be considered a violation of the Health Insurance Portability and Accountability Act (HIPAA)? Select all that apply. One, some, or all responses may be correct. A. The nurse leaves the door of the room open while assisting a client with hygiene care. B. The nurse forces an alert and oriented client back into bed. C. The nurse administers the wrong dose of prescribed medication to a client. D. The nurse uses a client's medical record as a sample for teaching that has client identifiers listed. E. The nurse reports the condition of a client to the physical therapist.

A. The nurse leaves the door of the room open while assisting a client with hygiene care. B. The nurse forces an alert and oriented client back into bed. D. The nurse uses a client's medical record as a sample for teaching that has client identifiers listed. E. The nurse reports the condition of a client to the physical therapist. Rationale: HIPAA is the federal act that protects a client's right to privacy of their healthcare information and records. Leaving the door to the room during hygiene care is a violation of privacy. HIPAA protects clients from unnecessary use of physical restraints, such as forcing an alert and oriented client back into bed. The nurse would need to the client's consent to disclose information to an employer. Using a client's medical record with identifiers is a violation of HIPAA. Administering the wrong medication would be a medical error.

The nurse is planning care for a client with newly diagnosed pernicious anemia. Which intervention should the nurse anticipate for this client? A. Vitamin B12 injection B. Oral iron supplements C. Transfusion of packed RBC D. Dietary consult

A. Vitamin B12 injection Rationale: Pernicious anemia is a cobalamin (vitamin b12) deficiency caused by a lack of intrinsic factor. Intrinsic factor, which is secreted by the gastric mucosa, is required to absorb vitamin B12. When a client lacks intrinsic factor, the client will have a vitamin B12 deficiency, which is treated with vitamin B12 injections. Oral iron supplements are used to treat iron deficiency anemia. A dietary consult would be an intervention for a client with folic acid anemia. A client with anemia due to blood loss will require a transfusion of packed red blood cells.

What is the best method of assessing safe staffing within a hospital?

Asking what the frequency of floating to other units is

A nurse is assigned to triage clients during a disaster response drill. Which client would the nurse identify as requiring immediate attention? A. An alert client with a headache after being struck with a blunt object B. A client with a penetrating injury to the abdomen who has pale mucous membranes C. A client with a deep laceration to the upper arm with decreased range of motion D. A client who sustained a traumatic fall and verbalizes moderate pain to the right hip

B. A client with a penetrating injury to the abdomen who has pale mucous membranes Rationale: A client with a penetrating injury to the abdomen requires immediate attention, particularly if pale mucous membranes are observed. The abdominal cavity contains several vascular organs and rapid hemorrhage is possible. Head trauma is significant. However, the client is alert and there are no other signs of altered consciousness. A deep laceration to an extremity can potentially damage nerves and vessels. The client's ability to perform range of motion, although decreased, indicates an intact neurovascular system. Pain is important to address after a traumatic fall. However, addressing cardiovascular emergencies is the priority.

The unlicensed assistive personnel (UAP) reports to the nurse that the client with diabetes type 2 has a bedside glucose of 65 mg/dL. Which action would be a priority for the nurse? A. Instruct the UAP to give the client a snack of peanut butter and whole milk. B. Assess the client's level of consciousness (LOC). C. Administer prescribed 50mL of dextrose 50% in water (DW50%) D. Encourage the client to drink ½ cup of orange juice

B. Assess the client's level of consciousness (LOC). Rationale: The first action the nurse should take for a client who is experiencing hypoglycemia is to assess the client's LOC, this will determine which intervention to implement. For a client who has a decrease in LOC, the nurse should administer prescribed 50mL of dextrose 50% in water. For the client who is alert and can follow commands, the nurse can encourage the client to drink ½ cup of orange juice. The nurse should assess the client before instructing the UAP to give the client a snack.

A nurse is obtaining the medication history of a client with diabetes mellitus type 2 who takes insulin to manage their disease. The client states their capillary blood glucose has been below normal for the last week. The nurse will question the client regarding the use of which herbal supplement? A. Echinacea B. Black cohosh C. Feverfew D. Ginkgo bilboa

B. Black cohosh Rationale: Black cohosh is an herbal supplement commonly used to treat manifestations of menopause. This supplement increases the risk of hypoglycemia in clients who take medications to treat diabetes mellitus. Echinacea is a supplement commonly used to treat inflammation and stimulate the immune system. There is no known interaction with hypoglycemic agents. Feverfew is commonly used to prevent migraine headaches. Feverfew has a drug interaction with blood thinners, such as warfarin and non-steroidal anti-inflammatory drugs (NSAIDs). Gingko biloba is commonly used to improve memory and peripheral circulation. Gingko biloba has known drug interactions with anti-seizure and anticoagulant medications.

The nurse is monitoring a client with a right pleural effusion who is post thoracentesis 1 hour ago. Which of the following assessment findings would require immediate follow up by the nurse? A. Dullness with percussion B. Muffled breath sounds C. Tenderness in lower back D. Serous drainage at puncture site

B. Muffled breath sounds Rationale: A thoracentesis is the aspiration of fluid by using ultrasound to guide a needle into the pleural space. The nurse should monitor the client for complications of bleeding, such as muffled breath sounds. The client will experience slight tenderness and serous drainage at the puncture site. Clients with a pleural effusion will have dullness with percussion.

The nurse is preparing a client for a paracentesis. Which action would be a priority for the nurse to take before the procedure? A. Auscultate lung sounds B. Palpate bladder for distention C. Verify last BM D. Administer prescribed analgesic

B. Palpate bladder for distention Rationale: A paracentesis is a procedure where the healthcare provider uses an ultrasound guided needle to drain fluid from peritoneal cavity. The nurse should assess for bladder distension to prevent puncture of the bladder during the procedure. Verifying last bowel movement, auscultating lungs, and administering prescribed analgesia are important actions, but not the priority before procedure.

The nurse is planning care for a group of assigned clients. Which client should the nurse implement the sequential compression device? A. Patient post-op day 2 abdominal surgery B. Patient w/ recent stroke and paralysis of the left leg C. Patient with PNA able to sit up in chair for meals D. Patient with GI infection using a bedside commode

B. Patient w/ recent stroke and paralysis of the left leg *Ambulatory vs. non-ambulatory* Sequential compression device is used to promote venous return which will decrease the risk of developing a deep vein thrombosis. The nurse should implement the sequential compression device for the client who has impaired mobility, resulting in the inability to ambulate. The client who had a stroke with paralysis of the left leg is the highest risk for developing a DVT. The client who is postoperative 2 days, the client with pneumonia and the client with gastrointestinal infection are ambulatory.

A nurse is evaluating laboratory data of a client who received 2 units of fresh frozen plasma. Which value will the nurse review as an indication of therapy effectiveness? A. Hgb B. Prothrombin time C. Albumin level D. Platelet count

B. Prothrombin time Rationale: Fresh frozen plasma (FFP) is administered for the replacement of coagulation factors. Prothrombin time provides a measure of blood clotting time and is one of the lab values used to assess effectiveness of FFP administration. The hemoglobin level is used to assess the effectiveness of packed red blood cell administration. Albumin level is used to evaluate the administration of albumin, a blood product. Fresh frozen plasma is not administered specifically for platelet deficiencies. Decreased platelet levels are treated with platelet concentrates.

A nurse is providing care to a client who reports constipation for the last 5 days. Upon assessment, the client suddenly has projectile vomiting with a fecal odor. Which acute condition does the nurse suspect? A. Colon intussesception B. Small bowel obstruction C. Gastrointestinal perforation D. Large intestinal volvulus

B. Small bowel obstruction **PROJECTILE VOMITING** Rationale: Projectile vomiting with a fecal odor is characteristic of a small bowel obstruction. Pressure within the bowel causes a back up of intestinal contents, resulting in emesis with a fecal odor. Colon intussusception occurs when a part of the large bowel folds into an adjacent section. Pain and rectal bleeding are characteristic signs of this condition. Gastrointestinal perforation is characterized by sudden, intense pain with subsequent signs of sepsis. A volvulus occurs when a part of the intestine twists. Symptoms related to large intestinal conditions do not produce emesis with a fecal odor.

The nurse is caring for a client with a lower extremity fracture who is on bed rest. The client states, "I need to go home so I can take care of my family." Which response by the nurse demonstrates the therapeutic communication technique of focusing? A. "You feel responsible for taking care of your family?" B. "It must be frustrating to be unable to care for your family." C. "Can you tell me more about your concerns for your family?" D. "When your family was here, they seemed fine."

C. "Can you tell me more about your concerns for your family?" Rationale: Focusing communication technique centers the conversation on specific factors or concepts, such as concern about family. Clarifying restates the client's statement to ensure correct understanding. Empathy is verbalizing an understanding of the client's feelings. Sharing observations is when the nurse comments on what was observed.

A nurse is evaluating a client's understanding on the use of a hearing aid. Which client statement indicates further teaching is required? A. "The hearing aid amplifies sound but it does not interpret speech." B. "I should clean the ear mold with soap and water." C. "The volume should be set on the highest level so I can hear properly." D. "I will remove the batteries when I am not using the hearing aid."

C. "The volume should be set on the highest level so I can hear properly." Rationale: The nurse should clarify the volume settings on a hearing aid. The volume on a hearing aid should be set to the lowest setting that allows the client to hear without unnecessary background feedback. A hearing aid amplifies sound but it will not assist the client with interpretation of words and speech patterns. The use of soap and water is the correct method to clean the ear mold. The hearing aid itself should be kept dry. The batteries should be removed when the hearing aid is not in use to avoid corrosion and decrease battery usage.

The nurse is assessing a client who has hyperthyroidism and notes the client's heart rate is 150 and oral temperature is 101.3F (38.5C). The nurse suspects the client is experiencing thyroid storm. Which action should the nurse take first? A. Administer prescribed IV dextrose fluids B. Administer prescribed propranolol C. Apply a hypothermic blanket D. Reduce environmental stimuli

C. Apply a hypothermic blanket Rationale: Thyroid storm, or acute thyrotoxicosis, is a systemic syndrome due to excessive amounts of thyroid hormones in circulation and is considered a medical emergency. The client will experience hyperthermia, severe tachycardia, and seizures. The first action of the first is to decrease core temperature by applying a hypothermic blanket. Then, the nurse will decrease heart rate with propranolol, decrease dehydration with prescribed IV dextrose fluids, and prevent seizures with reduction of environmental stimuli.

The nurse is caring for a client who is postoperative two hours coronary artery bypass graft. The nurse notes that the client's central venous pressure monitoring is increased. Which of the following actions should the nurse take? A. Check chest tube for kinks B. Increase the prescribed IV fluids C. Auscultate lung sounds D. Administer prescribed dopamine

C. Auscultate lung sounds Rationale: A client who is post CABG is at risk for fluid volume overload and fluid volume deficit. Fluid volume overload can occur with post op heart failure. Central venous pressure measures volume, increasing pressures indicates fluid volume overload. The nurse should assess the client's lung sounds to evaluate if the client is experiencing heart failure. A decrease in central venous pressure would indicate fluid volume deficit, so the nurse would assess for signs of bleeding or administer prescribed dopamine.

The nurse is caring for a client on a continuous infusion of propofol who appears to be agitated and has been trying to reach for the endotracheal tube. The infusion has been titrated to keep the client lightly sedated. The nurse will monitor for what effect? A. Improved respiratory effort B. Reduced oxygen saturation C. Decreased blood pressure D. Increased paralytic effect

C. Decreased blood pressure Rationale: Propofol is an intravenous anesthetic commonly used in the ICU for sedation while on mechanical ventilation. It produces amnesia, euphoria, and hypnosis, but is not a paralytic. Because the client is ventilated, the titration of this medication to increase sedation should not decrease the oxygen saturation. Because of the depression of the central nervous system, it will reduce the respiratory effort of the client. Propofol reduces both blood pressure and cardiac output, which can be treated with fluids and vasopressors.

When assessing a patient who requires assistance with ambulation, which is a priority question? A. Who do you live with? B. What equipment will you need? C. Does your home have a second floor? D. What type of flooring do you have in your home?

C. Does your home have a second floor? When planning a safe discharge, the nurse should assess the client's home environment for safety issues. For a client who requires assistance with ambulation, the nurse should assess if the client has factors that could increase the risk of falls or injury, such as stairs. It is important to know who lives with the client but is not the priority. It is the responsibility of the nurse to evaluate what equipment the client will need.

The nurse is caring for a client with a stage 3 pressure injury. Which of the following findings would require immediate follow up? A. Urine output >40mL/hr B. Hyperactive bowel sounds C. Increase in lactic acid level to 2.5mmol/L D. Bounding pulses

C. Increase in lactic acid level to 2.5mmol/L A client with a pressure injury is at risk for infection. Sepsis, which is a systemic response to an infection, results in organ and tissue insufficiency. A client who is developing sepsis will have an increased lactic acid level, decrease urine output, weak thready pulses, and hypoactive bowel sounds.

Upon review of the client's electronic medical record, the nurse notes a medication has been documented as given during the previous shift. When the nurse opens a secure client drawer on the mobile computer workstation, an unopened dose of the medication is found. How does the nurse best address this situation? A. Edit the documentation and mark as not given. B. Remove the medication from the drawer and return it to the medication room. C. Inform the unit manager and fill out an incident report D. Ask the client if the medication was given and document the response.

C. Inform the unit manager and fill out an incident report Rationale: A medication that is documented as given but found to be unopened should be reported, as this is considered false documentation. The nurse should also fill out an incident report and inform the unit manager of the finding. The nurse should not edit the documentation. The nurse is unaware of what occurred during the shift. Returning the medication to the medication room is not sufficient to address the incident. Unsafe practices should be reported as per facility protocol. Asking the client if the medication was given can provide clarification of medication administration. However, the nurse should allow the unit manager to investigate the incident.

The nurse is monitoring a client who is postoperative 6 days following a single-lung transplantation. Which of the following findings should the nurse report to the healthcare provider immediately? A. Client reports incisional pain B. Diminished breath sounds C. O2 desat with ambulation D. Serosanguinous drainage observed on dressing

C. O2 desat with ambulation Rationale: The client who is postoperative single-lung transplantation is at risk for acute rejection which can occur in the first 10 days. The nurse should monitor the client for oxygen desaturation, low grade fever, dyspnea with exertion, and a dry cough. The other options are normal findings following lung surgery.

The nurse is caring for a client with a history of chronic pain who is admitted to the hospital for acute pneumonia. The client regularly takes a long-acting opioid that is not listed on the medication administration record (MAR). The client is reporting pain and requesting this medication. What action by the nurse is appropriate? A. Inform the client that long-acting opioids are not administered in the hospital setting B. Tell the client that the medication is not ordered because of the risk of respiratory depression C. Recommend to the healthcare provider that this medication be prescribed D. Attempt to reduce the client's pain with non-pharmacologic approaches

C. Recommend to the healthcare provider that this medication be prescribed Rationale: Abstinence from opioids after chronic use produces a withdrawal syndrome. Long-acting opiates such as oxycodone XR (oxycontin) are associated with more severe withdrawal symptoms. This client has been using this medication, so the risk of respiratory depression is less than with an opiate naïve individual. These medications are administered in the hospital setting, with close monitoring of the respiratory status. The client with chronic pain may respond to non-pharmacologic pain management, but the risk for withdrawal is the nurse's priority.

A nurse is providing care to a client with a prescription for a low-residue diet. Which food items does the nurse expect to see on the client's meal tray? A. Dried apricots and celery B. Creamed corn and swiss chard C. Scrambled eggs and ripe bananas D. Banana nut bread and brussel sprouts

C. Scrambled eggs and ripe bananas Rationale: Foods with low residue (food waste) are low in fiber and fat. Low-residue foods are easily digested and prevent intestinal blockages. Scrambled eggs and ripe bananas are considered low-residue foods. All other food options contain high amounts of fiber, skin, seeds, or other products that are difficult to digest.

A nurse is performing tracheostomy care for a client. Which action should the nurse take? A. Use clean technique. B. Clean the inner cannula with mild soap and water. C. Secure new tracheostomy ties before removing the old ones. D. Apply suction when inserting the catheter.

C. Secure new tracheostomy ties before removing the old ones. Rationale: When performing tracheostomy care, the nurse will use sterile technique and clean the outer cannula with sterile water. The nurse should secure the new tracheostomy ties before removing the old ties to prevent dislodgement of the inner cannula. When suctioning, the nurse should only suction when removing the suction catheter.

A nurse is preparing a sterile field prior to performing wound care. Which action would prompt the nurse to restart the procedure? A. Sterile forceps fall from the package onto the floor. B. The nurse touches the drape with bare hands ¼ inch from the outer edge. C. The client accidentally tips a cup of water onto the drape. D. Sterile solution is poured onto a sterile container from 1 inch above the sterile field.

C. The client accidentally tips a cup of water onto the drape. Rationale: Water that comes into contact with the drape will soak through to the sterile items, causing contamination. The nurse must restart the procedure to ensure all items are sterile. Any sterile items that fall off the sterile field can be replaced individually. The sterile field can be maintained if no contamination has occurred. The nurse can touch the drape with bare hands within 1 inch along the borders. Sterile solutions should be poured onto a container from 1 to 2 inches above the sterile field.

The nurse is monitoring a client following an esophagogastroduodenoscopy (EGD). Which finding should the nurse immediately report to the healthcare provider? A. The client's voice is hoarse when speaking. B. The client has hypoactive bowel sounds. C. The client reports difficulty with swallowing. D. The client reports nausea.

C. The client reports difficulty with swallowing. Rationale: An EGD is a procedure that uses a flexible, fiberoptic scope to visualize the esophagus, stomach, and upper duodenum. Following the EGD, the nurse should monitor the client for signs of perforation, such as pain, difficulty swallowing, and vomiting blood. The client should be instructed to expect a hoarse voice and sore throat for several days following the procedure. Nausea is common after an EGD.

A nurse is providing discharge instructions on medication administration to a client prescribed ipratropium via a metered-dose inhaler. What will the nurse include in the teaching? A. "Hold your breath for 3 to 5 seconds after pressing the inhaler." B. "Avoid shaking the inhaler prior to administration." C. "Press the inhaler after you breathe out completely." D. "You may place the inhaler 1 to 2 inches away from your mouth during administration."

D. "You may place the inhaler 1 to 2 inches away from your mouth during administration." Rationale: Positioning the inhaler 1 to 2 inches away from the mouth is an acceptable way to administer the medication. The client may also be instructed to place their lips around the mouthpiece for administration. The nurse should instruct the client to hold their breath for 10 seconds to allow the medication to reach the lungs. Shaking the inhaler ensures the medication is mixed properly before administration. The inhaler should be pressed at the start of inhalation to ensure the medication is absorbed properly.

A nurse is preparing to perform an ear irrigation on a client. Which precaution will the nurse take to prevent acute otitis externa? A. Ensuring proper control of the irrigation syringe B. Inspecting the auditory canal prior to the procedure C. Using a sterile irrigation solution D. Drying the outer ear canal with a cotton ball

D. Drying the outer ear canal with a cotton ball Rationale: Acute otitis externa is an ear infection caused by retained moisture. Drying the outer ear canal with a cotton ball ensures any remaining irrigation fluid is removed. Proper control of the irrigation syringe prevents damage to lining of the ear canal. Inspection of the auditory canal verifies ear structures are intact. However, this does not prevent a possible infection. The irrigation solution to be used will be prescribed by the healthcare provider. Not all ear solutions are sterile.

The nurse is caring for a client with an active gastrointestinal bleed. Which action should the nurse take first? A. Auscultate bowel sounds B. Insert indwelling catheter C. Obtain blood type and culture for cross match D. Insert large bore peripheral IV

D. Insert large bore peripheral IV Rationale: When caring for a client with active GI bleed, the first action the nurse should take is to establish large bore IV to infuse fluids to prevent hypovolemic shock. Then, the nurse will assess bowel sounds, insert an indwelling urinary catheter, and obtain blood for type and cross match.

A nurse is setting up the sterile field for an indwelling catheter insertion. As the nurse applies the sterile gloves, the client verbalizes they forgot to mention a past allergy to latex. Which action does the nurse take?

Instructs the client to use the call bell to call another nurse. Rationale: The client is able to assist the nurse by using the call bell to call another nurse. The nurse can request a different set of sterile gloves from the other nurse to avoid contaminating the sterile field or discarding the equipment. Every allergy should be considered significant. The nurse must eliminate any chance of exposure. Discarding the entire kit is not necessary. The nurse can request another nurse to obtain alternative sterile gloves and still maintain a sterile field. The procedure requires sterile technique. Clean gloves can increase the risk of contamination and infection.

The nurse is triaging a new client on the labor and delivery unit who states "I haven't felt the baby move in eight hours." Which of the following actions should the nurse take first? A. Start an intravenous oxytocin infusion B. Provide the client with a high carbohydrate snack C. Gather the client's complete health history D. Place a fetal heart monitor on the client's abdomen

Rationale: If there are concerns about fetal wellbeing (in this case, decreased fetal movement) the priority action is to assess the fetal heart rate. The client's plan of care greatly depends on the findings of this assessment. The nurse will gather a health history, and may provide food/drink to the client, but not until the fetal heart rate pattern has been established. At this time, there are not indications for the use of oxytocin.

To implement practice change, a nurse should present the change with....

Shared governance group This is a framework for nurses in direct care to create and maintain the optimal nursing practice setting through actively participating in decision making