Uworld Fundamentals

How do you calculate mean arterial pressure?

-multiple diastolic blood pressure by 2, add systolic pressure, and divide the result by 3.

What are the steps for administering ophthalmic ointment?

- perform hand hygiene -tilt the head back, pull the lower lid down, and look upward - squeeze a thin strip of ointment onto the lower eyeliid, from the inner to the outer edge -close the eyes gently for 2-3 minutes after applying the ointment

What are the 6 rights to medication administration?

- the right client -the right medication -the right dose -the right time -the right route -the right documentation

An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client with a right subclavian triple-lumen central venous catheter. Which statement by the graduate nurse indicates understanding of the CVC? -"All 3 lumens come together, so all drugs infused through the CVC must be compatible" -"It is used to provide enteral nutrition to the client who cannot eat" -"Sterile gloves must be worn when administering drugs through the CVC" -"The lumen hub should be cleaned thoroughly with antiseptic prior to drug administration"

-"The lumen hub should be cleaned thoroughly with antiseptic prior to drug administration" --A central line or central venous catheter is inserted by the healthcare provider in a "central" vein and is used to administer fluids, medications, and parenteral nutrition and for hemodynamic monitoring.

Appropriate use of indwelling catheters

--clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients -perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgery -during prolonged immobilization when bedrest is essential -to improve end-of-life comfort -to facilitate healing of an open perineal or sacral wound in continent clients

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? SATA -38 YO with MRSA -42 YO with C-diff -69 YO with pertussis infection - 72 YO with vancomycin-resistance Enterococcus -80 YO with influenze

-38 YO with MRSA -42 YO with C-diff - 72 YO with vancomycin-resistance Enterococcus --Clients with multidrug-resistant organisms, C-diff diarrhea, and scabies require nursing staff to implement contact precautions

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering? -Haloperidol for a client with a fall history who keeps getting out of bed without assistance -Lorazepam for a client who is in alcohol withdrawal and is extremely agitated -Olanzapine for a client with schizophrenia who is exhibiting violent behavior -Propofol for a client who is intubated and receiving mechanical ventilation

-Haloperidol for a client with a fall history who keeps getting out of bed without assistance ---Medications that are standard treatments for specific conditions are not considered chemical restraints. The nurse should question a chemical restraint prescription that may not be medically necessary for a client's safety. Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard treatment for a client with a history of falls who keeps getting out of bed without assistance. The least restrictive method to ensure client safety should be tried first before administering a chemical restraint.

Components for airborne precautions

-N95 respirator or powered air-purifying respirator -negative-pressure isolation room with high-efficiency particuate air filter -as needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield

Components of airborne precautions

-N95 respiratory or powered air-purifying respirator -negative-pressure isolation room with high-efficiency particulate air filter -clean gloves, disposable gown,goggles/face shield as needed

Indications for airborne precautions?

-TB -vericella zoster -herpes zoster -rubeola

Nurses performing negative-pressure wound therapy dressing changes should:

-administer prophylactic analgesics to prevent discomfort -apply a skin protectant to intact skin around the wound to promote an air0tight seal when the adhesive film dressing is placed -ensure negative pressure is present by observing the compression of the foam dressing when the device is turned on

The nurse is providing postmortem care for a client who has died after a long hospitalization. The client had a do-not-resuscitate prescription in place at the time of death, Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home? SATA -allow family members to assist with care -call the medical examiner for an autopsy -gently close the client's eyes -place a pad under the perineum -remove the client's dentures

-allow family members to assist with care -gently close the client's eyes -place a pad under the perineum --postmortem care involves preparing the body for presentation to the family and includes hygiene and positioning.

The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? SATA -cervical cancer -hypertension -ischemic stroke -osteoporosis -skin melanoma

-cervical cancer -hypertension -ischemic stroke ---African Americans have the highest incidence of hypertension in the world as well as increased incidence of stroke and cervical cancer. Whites have a high incidence of osteoporosis and skin cancer.

Steps to drawing up multiple insulins

-clean both vial tops with alcohol swabs -inject air into the NPH insulin vial without touching the needle to the solution -withdraw the needle from the NPH insulin vial and inject air into the regular insulin vial -invert the regular vial and withdraw the regular solution into the syringe -insert the needle into the NPH insulin vial and withdraw the solution

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? -ask the healthcare provider to prescribe a different CCB -consult with the pharmacist to see if an alternate form of the drug is available -open the capsule and sprinkle the medication in a cup of applesauce -warn the client about the dangers of uncontrolled hypertension

-consult with the pharmacist to see if an alternate form of the drug is available ---Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher. Most capsules are created in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill.

Inappropriate use of indwelling urinary catheters

-convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently -for obtaining a urine culture when the client can follow instructions and void voluntarily -postoperatively for prolonged periods when other appropriate indications are not present

What are examples of diagnostics medical errors?

-delay in diagnosis -failure to employ indicates tests -failure to act on results of monitoring

What are the 4 types of medical management errors?

-diagnostic -treatment -preventive -other

What are the most significant manifestations of hyperkalemia?

-disturbances in cardiac conduction -development of potentially life-threatening cardiac dysrhythmias

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first? -assessing the clients' respiratory systems -decontaminating the clients -donning personal protective equipment -providing oxygen by nasal cannula

-donning personal protective equipment --The nurse should always protect other clients, staff, and the healthcare facility first in a chemical contamination. Personal protective equipment should be put on before decontamination. Victims should be decontaminated outside the facility before care is administered

Symptoms of Meniere disease

-episodic attacks of vertigo (associated with N/V), tinnitus, hearing loss, and aural fullness

What are examples of treatment medical errors?

-error in performance of procedure, treatment, dose -avoidable delay

Methods to verify tube placement includes

-imaging (x-ray is standard protocol) -gastric content pH testing (typically used to assess for displacement after initial x-ray verification) -air auscultation (not an evidence-based method for placement verification)

Barriers to self-care include

-knowledge (lack of experience, cognitive abilities) -skills/supplies (lack of dexterity, experience, financial barriers) -motivation (lack of assumed threat to health, denial, hopelessness)

S/S of cardiac tamponade

-muffled heart tones -compression of the heart increases, resulting in hypotension -tachypnea -tachycardia -jugular vein distention -narrowed pulse pressure -presence of pulsus paradoxus

Relative contraindications for MRI

-prosthetic heart valve -metal plate, pin, brain aneurysm clip, or joint prosthesis -implanted device (insulin pump, medication port)

Nursing interventions during a seizure

-protect client's head from injury -place client is rescue position (left lateral) -insert nothing into the mouth -do NOT restrain limbs or torso

What are signs of infections within wounds?

-redness -warmth -purulent drainage

A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and evaluates the fit before discharge from the emergency room. Which assessment finding indicates an incorrect fit? -the elbow is flexed at 90 degrees -the hand is held slightly below elbow level -the sling ends in the middle of the palm with fingers visible -the sling supports the wrist

-the hand is held slightly below elbow level --To ensure proper shoulder sling fit, the nurse should assess for the following: elbow flexion at 90 degrees; hand is held slightly above the level of the elbow; bottom of the sling ends in the middle of the palm with the fingers visible; and the sling supports the wrist joint.

The best way to communicate and obtain information from a client with Alzheimer is to:

-use simple statements and questions -face the client, allowing the client to visualize the speaker's face and help reduce distraction -provide a quiet environment to remove distracting stimuli.

Venipuncture is contraindicated in upper extremities affected by:

-weakness -paralysis -infection -arteriovenous fistula or graft -impaired lymphatic drainage (prior mastectomy)

What is the recommended size of urinary catheter and balloon for an adult male?

16 F

What is the type gauge size and needle length for an intramuscular injection?

18-25 gauge -1-1.5 inches

What is the type gauge size and needle length for a subcutaneous injection?

25-27 --3/8-5/8 inch

Where is the pulmonic valve ausculated?

2nd ICS to the left sternal border

Where is aortic valve ausculated?

2nd ICS to the right sternal border

normal infant respiratory rate

30-60

What drug classification and use is metronidazole

AKA flagyl --antimicrobial --used to treat IBD

TORCH

Toxoplasmosis Other (VZV/parovirus B19) Rubella Cytomegalovirus Herpes Simplex Virus

Which ethnicity has the higher incidence of osteoporosis?

White and Asian Women

Which ethnicity has the higher incidence of melanoma?

White women those over the age of 60

What must a patient with TB (or other airborne transmission diseases) required to wear when leaving their negative-pressure isolation room?

a surgical mask (this contains exhaled respiratory secretions)

Which drugs are best for pain management in a client with immune thrombocytopenic purpura?

acetaminophen opiates

Treatment of Sjogren's syndrome

alleviating symptoms due to no cure being present

define hemianopsia

blindness in half the visual field from eacheye

What happens when hypertonic solutions are infused into the vascular compartment?

body fluids shift from intracellular compartment into extracellular vascular compartment

Aortic stenosis is...

characterized by narrowing of the aortic valve opening, limiting the left ventricles ability to eject blood into the aorta

What is the most reliable indicator for client's pain level?

client's self-report of symptoms

Who is the best client for a nasal cannula?

clients with adequate Tidal volume and normal vital signs. --it is not the best choice for unstable COPD clients with varying tidal volumes.

For which types of clients are non-rebreathing reservoir masks used?

clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis --it can deliver 60-95% oxygen concentrations

What causes electrical alternans?

due to swinging motion of the heart in a fluid-filled pericardial sac

Meniere disease results from...

excess fluid accumulation in the inner ear

What position is appropriate for a lumbar puncture?

fetal position

Multiple tender points is characteristic of...

fibromyalgia

S/S of infant increased work of breathing

flared nostrils and use of accessory muscles

Describe the Venturi Mask

high-flow device that delivers a guaranteed oxygen concentration, regardless of the client's respiratory rate, depth, or tidal volume. --it is the most appropriate oxygen delivery device for a client with rapid changes in inspired oxygen concentration (COPD).

What can repeatedly discarding gastric content cause in a patient?

hypokalemia and metabolic alkalosis

When descending stairs with a cane, the client should

lead with the cane, bring the weaker leg down second, and finally step down with the stronger leg.

Clients at greatest risk for pressure injuries include those with:

limited movement long bone or hip fractures quadriplegia critically ill --clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection

Nephrotic syndrome is characterized by

massive proteinuria and hypoalbuminemia, resulting in edema (commonly seen in abdomen, face, perineum)

Initial management of heat exhaustion includes...

moving the client from the heat to a cooler area and providing a cool, electrolyte-containing sports drink or water.

Which feeding tube has a higher risk for aspiration-- Nasoenteric or nasogastric?

nasoenteric

What can hypertonic formulas sometimes cause?

nausea vomiting diarrhea

What position should a client be placed after a liver biopsy?

on the right side for a minimum of 2 hours. this is to apply pressure and splint the puncture site. after that- supine for 12-14 hours.

Mottling is characterized by...?

patches of pink, pale, and cyanotic skin --indicative of poor perfusion

Lansoprazole is what drug classification?

proton pump inhibitor --used to treat ulcer disease, erosive esophagitis, andgastroesopahgeal reflux disease.

What are the most commonly affected glands with Sjogren's syndrome?

salivary and lacrimal glands

Thickening of the skin is seen with...

scleroderma

What position should the client be placed in when removing a triple-lumen subclavian central venous catheter?

supine position --increases central venous pressure and decreases possibility of air getting into the vessel

Which triple lumen CVC is the largest lumen?

the distal port.

What happens when isotonic solutions are infused into the extracellular vascular compartment?

the isotonic solution remains in the extracellular vascular compartment because no concentration gradient is present

What is the best indicator of adequate rehydration?

urine output

The graduate nurse is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the graduate nurse would cause the supervising nurse to intervene? -"hold a crutch in each hand on both sides when standing up from a chair" -"Move to the edge of the chair before standing and use your unaffected leg to rise" -"Touch the back of your unaffected leg to the chair before preparing to sit" -"use an armrest or seat for assistance when lowering your body into a chair

-"hold a crutch in each hand on both sides when standing up from a chair" --Clients have prescribed crutches after a musculoskeletal injury must understand appropriate device use to facilitate independent ambulation, promote wound healing, and prevent injury. When educating a client to rise from sitting, the nurse instructs the client to hold the hand grips of both crutches in the hand on the affected side, move to the chair's edge, and hold the armrest with the hand on the unaffected side. The client then uses the crutches, armrest, and unaffected leg for support when rising. To sit, the client backs up to the chair and moves both crutches into the hand on the affected side. The client holds the armrest with the other hand and lowers the body.

What angle should subcutaneous injections be administered?

-90 degreesif there are 2 inches of subcutaneous tissue to grasp --45 degrees if only 1 inch of subcutaneous tissue can be grasped

Signs of phlebitis

-erythema -edema -warmth -pain -palpable venous cord

What are symptoms of Middle East respiratory syndrome (MERS)?

-fever -cough -SOA

Procedures to prevent transmission of infection

-meticulous hand hygiene -use of disposable gloves during collection and handling of specimen -proper and immediate transport of specimen to the lab -avoiding placing specimen in clean areas (nursing station)

Nursing priorities when implementing a chemical contamination emergency response plan includes:

-restricting other clients, staff and bystanders from the victims' vicinity to protect non-affected individuals -donning personal protective equipment -decontaminating the clients outside the facility before initiating treatment -assessing and providing treatment of symptoms.

Interventions to manage norepinephrine extravasation

-stop infusion immediately and disconnect the IV tubing -use syringe to aspirate the drug from IV catheter and remove while aspirating -elevate extremity above the heart to reduce edema -notify HCP and obtain prescription for phentolamine (Regitine)

What is the type gauge size and needle length for a intradermal injection?

25-27 gauge --1/4-5/8 inch

Where is the Erb's point ausculated?

3rd ICS to the left sternal border

Define pulmonary fibrosis

scarring of lung tissues, causing reduced function, dry cough, and dyspnea. --a progressive complication of scleroderma

What insulins can be mixed with intermediate-acting insulins?

short-acting or rapid-acting.

How should a client be placed during lumbar puncture?

side-lying, with head, back, and knees flexed. A small pillow might be placed between the legs and under the head for comfort and maintain spine in horizontal position.

normal infant heart rate

90-160

Incubation period for MERS

5-6 days --can range from 2-14 days

Where is the tricuspid valve auscultated?

5th ICS to the lower left sternal border

Should you raise your voice when communicating/talking with a hearing impaired client?

NO raising the voice to speak loudly creates a higher pith that is harder to understand

Can a small-barrel syringe be used for enteral feeding tubes?

NO they create too much pressure and rupture the tube

What is Sjogren's syndrome?

a chronic autoimmune disorder in which moisture-producing exocrine glands of the body are attacked by white blood cells.

Early-morning low back stiffness is seen with...

ankylosing spondylitis

What is a high gastric residual volume?

> 500 m:

What drug classification and use is sulfasalazine?

-gastroinestinal anti-inflammatory --treated IBD

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? SATA -" I will apply the prescribed bacitracin ointment after collecting the wound culture" -"I will cleanse the wound by gently flushing it with normal saline" -"I will obtain a sample of the drainage accumulated since the last dressing change" -"I will perform hand hygiene and apply new gloves before obtaining the wound culture" -"I will swab the wound from the outermost margin toward the center"

-" I will apply the prescribed bacitracin ointment after collecting the wound culture" -"I will cleanse the wound by gently flushing it with normal saline" -"I will perform hand hygiene and apply new gloves before obtaining the wound culture" --wound cultures are used to identify microorganisms and select appropriate antibiotics. The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination to prevent misidentification of microorganisms

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse? -"Are you concerned about how the surgery will affect your sexuality" -"if you are concerned about infertility, you could always bank your sperm" -"The cancer is at an early stage. You are going to be fine" -"What have you and your future spouse discussed about your condition?"

-"Are you concerned about how the surgery will affect your sexuality"

The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client who practices traditional Islamic customs. Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity to this client? -"Ask the client's wife if she would like to give the bed bath" -"Do not make eye contact with the client during the bath" -"The client may prefer for you not to talk to him during the bath" -"Touching the head is a sign of disrespect; let the client wash his own face"

-"Ask the client's wife if she would like to give the bed bath" --To provide culturally competent care, it is important for the nurse to realize that in many Arab cultures, a man is not allowed to be alone with a woman other than his wife. It may also be inappropriate for a female healthcare worker to physically care for him; however, in some instances, direct physical care from the opposite sex is allowed if a third party is present.

A 2-year-old who swallowed of adult cough syrup is being discharged from the emergency department. The parents says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer." Which is the best response by the nurse? -"Can you lock your dresser drawer?" -"Make sure all of your medicines have childproof caps" -"That sounds like a safe place" -"You need to keep an eye on your child at all times"

-"Can you lock your dresser drawer?" --The most important strategy to prevent accidental drug overdoses in children is teaching parents and caregivers to keep medicines out of sight, in a locked drawer or cabinet. Parents/caregivers should also be advised to put drugs away after each use

A 55 yer-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? -"Hearing this diagnosis must have been difficult for you. What are your thoughts?" -"we will do everything possible to prevent that from happening" -"Well, we're all going to die sometime" -"You should concentrate on getting better rather than thinking about death"

-"Hearing this diagnosis must have been difficult for you. What are your thoughts?" --The stress of receiving a life-threatening diagnosis often causes clients to feel very vulnerable. There is a tendency to keep feelings and concerns closed off; clients may not be able to express how distressed they fell or find the right words to express feelings and concerns. In asking, "Is this disease going to kill me?", the client is most likely not looking for a direct yes or no answer. This would immediately close off the conversation and create a missed opportunity for a meaningful engagement and communication with the nurse. It is more likely that this question is being asked to provide an opening for further discussion about the meaning of this devastating diagnosis as well as the client's thoughts and feelings.

The nurse teaches safety precautions of home oxygen use in a client with emphysema being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? SATA -"I can apply Vaseline to my nose when my nostrils feel dry from the oxygen" -"I can cook on my gas stove as long as I have a fire extinguisher in the kitchen" -"I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath" -"I should not polish my nails when using my oxygen" -"I should not use a wool blanket on my bed"

-"I can apply Vaseline to my nose when my nostrils feel dry from the oxygen" -"I can cook on my gas stove as long as I have a fire extinguisher in the kitchen" -"I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath" --Safety precautions for home oxygen use include the following: no smoking, electrical devices in good condition and plugs grounded; avoid volatile, flammable products and materials that generate static electricity; staying at least 5-10 feet away from open sources of flame; keeping fire extinguishers readily available; and regularly testing smoke detectors.

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy. Which statement made by the client is critical to report to the healthcare provider before the surgery? -"I didn't take the clopidogrel pill for my heart yesterday or today" -"I know I should stop smoking completely, but at least I didn't have a cigarette yesterday or today" -"I stopped taking my gingko biloba 2 weeks ago even though it really helps relieve leg cramps when I walk" -"I stopped taking naproxen for my arthritis pain 1 week ago and have been taking acetaminophen instead"

-"I didn't take the clopidogrel pill for my heart yesterday or today" --Plavix is an antiplatelet medication that should be discontinued 5-7 days before surgery to decrease the risk for excessive bleeding. The client took this drug 48 hours ago. Therefore, the nurse must notify the HCP. The surgery may be postponed due to the increased risk for intra and postoperative bleeding. All clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems. The client takes gingko biloba to relieve symptoms of intermittent claudication; it was discontinued 2 weeks ago because it can increase the risk for excessive bleeding. NSAIDs such as naproxen should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding. Acetaminophen can be taken to control pain up until surgery

A client with renal failure recently started dialysis and is unable to work due to ongoing health problems. The client's spouse has started working for a cleaning service to replace the lost income. The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis. Which is the most appropriate first response by the nurse? -"How is your spouse's new job going?" -"I notice that you seem frustrated" -"It can take time to adjust to dialysis. We have a support group that can be helpful" -"It's normal to be angry when you can't work any longer"

-"I notice that you seem frustrated" --The client with chronic illness who is unable to work may experience depression, grief, loss, a feeling of inadequacy, or a loss of meaning and purpose in life. It can take time to adjust and accept the new roles, and this stress can increase a person's vulnerability to ongoing health problems. This client has gone from being the main source of income to being someone who is unable to support the family. The client is now dependent on the spouse for financial stability and this is causing a strain. This type of role change can be particularly difficult for men who are used to providing for their families and for anyone who is well-established in a career. The nurse has noticed a change in the client's behavior but has not assessed the client to determine the factors contributing to this change. Assessment is needed before interventions can be planned. An open-ended reflective statement and nonverbal communication expressing acceptance and willingness to listen in the setting of a trusting relationship are appropriate to begin this assessment

The nurse is educating a client recently diagnosed with anaphylatic allergy to latex. Which statement made by the client indicates that the client understood the condition correctly? -"I do not need to worry about my allergy when I am outside of a health care environment" -"I just need to check labels to ensure products do not contain latex and I will be fine" -"I should always carry my Epi-pen in case I have difficulty breathing" -"I should take better care of myself and eat healthy foods like bananas and chestnuts"

-"I should always carry my Epi-pen in case I have difficulty breathing" --Anaphylaxis is a medical emergency and any client with a history of severe allergic reaction should always carry an Epi-Pen. Epinephrine injections is the only option for treating anaphylaxis.

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? SATA -"I should rinse my mouth with water before collecting the sputum" -"I will be careful not to touch the inside of the specimen cup or lid" -"I will inhale deeply a few times and then cough forcefully" -"It is best to collect the sputum mid-day when my secretions are loose" -"It is helpful if I am sitting upright when I collect sputum"

-"I should rinse my mouth with water before collecting the sputum" -"I will be careful not to touch the inside of the specimen cup or lid" -"I will inhale deeply a few times and then cough forcefully" -"It is helpful if I am sitting upright when I collect sputum" ---Collection of a sputum specimen by expectoration is a sterile procedure that requires the client to breathe deeply and cough effectively. The nurse should instruct the client to rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora; to sit upright before specimen collection to promote cough strength during collection; inhale deeply several times, and cough prior to expectorating. The client should avoid touching the inside of the sterile container or lid. Sputum should be collected in the morning to improve sample quality.

The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? SATA -"I use a soft-bristle toothbrush and mild mouth rinse" -"I enjoy walking and wear nonskid footwear for safety" -"I use a safety razor and gentle shaving cream" -"Sometimes I get constipated, so I have been taking docusate" -"When I have a headache, I take over-the-counter ibuprofen"

-"I use a safety razor and gentle shaving cream" -"When I have a headache, I take over-the-counter ibuprofen" ---Clients with immune thrombocytopenicpurpura have low platelet counts and an increased risk of bleeding. Appropriate care for clients with ITP includes safe exercise; using stool softeners, electric razors, and soft-bristle toothbrushes, and avoiding nonsteroidal anti-inflammatory drugs.

The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed? -"I bought a new nightlight for the hallway to the bathroom" -"I feel so much more secure wearing my electronic fall alert device" -"I walk in my stockings at home because it helps to relieve my bunion pain" -"My daughter helped me secure the small, thin rug in my kitchen with strong tape"

-"I walk in my stockings at home because it helps to relieve my bunion pain" --Walking barefoot or while wearing stockings increases the risk of slipping on slick surfaces. Shoes or slippers with non-skid soles should be worn inside and outside of the home.

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse give the client regarding this test? SATA -"A continuous urinary catheter must be inserted for this test and the urine will collect in an attached bag" -"Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use" -"Only daytime urine should be collected in the container as cortisol levels are higher in the morning" -"Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder" -"you will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug"

-"Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use" -"Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder" -"you will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug" ---a 24-hour urine is collected to test for increased cortisol levels when evaluating for Cushing syndrome. The client should be taught to collect the urine in a dark jug issued by the lab, start time and then empty the bladder and discard the 1st urine, and collect all the urine for 24 hours; it is kept in the refrigerator or ice chest with a secure lid. Exactly 24 hours after start time, empty bladder once more into the collection container. Use a dark jug containing a special powder to protect urine from light during collection. The powder helps preserve the urine and adjusts its acidity.

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet. The caregiver states that the child appears to be acting normally. Which response by the nurse is appropriate? -"give syrup of ipecac immediately and proceed to the hospital" -"Please go directly to the nearest emergency department for evaluation" -"Stay home and monitor the child closely for any symptoms" -"You should come immediately to the clinic with the pill bottle"

-"Please go directly to the nearest emergency department for evaluation" --Amitriptyline is a tricyclic antidepressant that can produce cardiac toxicity ad neurological disturbances by altering cholinergic pathways, sodium channels, and calcium channels, causing symptoms such as arteroventricular block, hypotension, cardiac arrest, and seizure. TCAs have a narrow therapeutic index and rapid onset of action, so ingestion of even a small amount may be life-threatening for a toddler. Symptoms of toxicity are usually evident within hours of ingestion, but cardiac failure can develop days after. Neurological and hemodynamic assessments, as well as ECG monitoring in an emergency department setting is recommended.

A home health nurse is visiting a 72 year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond? -"Don't worry. You'll feel better in a few weeks" -"How well are you sleeping at night?" -"These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again" -"You may be experiencing depression. I'll call the healthcare provider and see if we can get a prescription for an antidepressant"

-"These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again" --Clients who have undergone surgery may experience some postoperative cognitive dysfunction. This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder.

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education? -"I can perform the stick on either the medial or lateral side of the outer aspect of the heel" -"Sucrose and a pacifier can help alleviate the infant's pain and stress during the puncture" -"The heel area should be warmed for 3-5 minutes prior to puncture" -"Venipuncture should be reserved only for failed heel sticks because it is more painful"

-"Venipuncture should be reserved only for failed heel sticks because it is more painful" ---To perform a neonatal heel stick, select a location on the medial or lateral side of the outer aspect of the heel to avoid insult to the calcaneus bone. Provide comfort measures, warm the selected puncture site to promote vasodilation, cleanse with alcohol, and puncture using an automatic lancet. An acceptable alternate method of blood collection in the neonate is venipuncture. It is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed.

A client who was placed in restraints appears in the hallway an hour later and states "I'm Houdini. I can get out of anything. There could be trouble now." Which of the following is the best response to this client? -"How are you feeling now?" -"How did you manage to get out of the restraints?" -say nothing but signal to other staff that assistance is needed -"What kind of trouble are you thinking about?"

-"What kind of trouble are you thinking about?" --A client at high risk for violence, self-directed or other-directed, may need to be placed in restraints as a last resort. Frequent monitoring and assessment through observation and use of therapeutic communication techniques will help determine if a client is ready to have restraints removed.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? -"he is critically ill and we are caring for his needs" -"His heart has stopped and we are attempting to revive him" -"I don't know how he is doing but you need to come" -"I will have the healthcare provider talk to you once you arrive"

-"he is critically ill and we are caring for his needs" --beneficence is the ethical principle of doing good. It involves helping to meet the client's emotional needs through understanding. This can involve withholding information at times. Stating that the client is critically ill and is being cared for meets the ethical principle of veracity but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely.

A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate? -"Please try not to worry, you have an excellent surgeion" -"tell me about how you feel about your surgery" -"Why are you considering refusing the surgery?" -"You have the right to make your own decisions and can refuse the surgery

-"tell me about how you feel about your surgery" ---This is the most appropriate statement to encourage the client to express the source of anxiety. Using an open-ended question enables the client to take control of the conversation and direct it to concerns about the surgery. The nurse can then address the specific concerns identified and provide individualized explanations and support.

The nurse is caring for a client who weighs 450 lb 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely? -1-person safely standby with walker -2-person full-body sling lift -2-person standing-assist lift -4-person full-body sling lift

-1-person safely standby with walker --When determining the most appropriate method to transfer a client safely, the nurse should assess whether the client can bear weight and whether the client is cooperative. This client is able to bear weight despite having a heavy body and can cooperate during the transfer. Therefore, such clients should be encouraged to do so as much as they can for themselves, anticipating discharge in the near future. It is appropriate to transfer this client with 1 person standing by for safety. If the client was unable to bear weight fully, more assistance would be needed. The number of caregivers providing assistance during the transfer of a heavier client should be increased to promote safety for the client and staff.

Which client is at the greatest risk for development of hospital-acquired pressure injuries? -25-year-old client with quadriplegia, urosepsis, temperature of 101 F, and white blood cell count of 18,000/mm3 -50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb in a month, prealbumin level <10 mg/dL, and mean arterial pressure of 50 mm Hg -80-year-old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL -87-year-old clients 2 days post open cholecystectomy

-50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb in a month, prealbumin level <10 mg/dL, and mean arterial pressure of 50 mm Hg --Pressure injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone or hip fractures, those with quadriplegia, and the criticall ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk.

The occupation health nurse administers an intradermal tuberculin skin test (TST) to a healthcare worker. The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours? -12 hours -24 hours -36 hours -72 hours

-72 hours --TST is the standard method for conducting TB surveillance of HCWs and involves injection of purified protein derivative solution under the first layer of skin of the forearm ad evaluation of the injection site 48-72 hours later. The healthcare practitioner inspects and palpates the site to determine if a local skin reaction has occurred. Induration indicates a positive test, which means that the individual has been exposed to TB, has developed antibodies, and is infected with TB bacteria. Further testing is needed to determine the presence of latent TB infection or active TB disease. Presence of symptoms, positive sputum culture, and chest x-ray abnormalities confirm active TB

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? -51 YO client who received a permanent pacemaker 48 hours ago -60 YO client who had a myocardial infarction 24 hours ago -74 YO client with stroke and an indwelling urinary catheter for 3 days -75 YO client with dementia and dehydration who is on IV fluids

-74 YO client with stroke and an indwelling urinary catheter for 3 days --A noscomial infection occurs in a hospital or other healthcare setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of healthcare workers to wash their hands, and the overuse of antibiotics. The most common nosocmial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections. The 74 YO client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. Client 4 is at risk due to age and presence of an IV catheter. However, the risk is not at high as the client with the urinary catheter

Which client is most at risk for hospital-acquired methicillin-resistant Staph aureus? -15 YO student athlete in the ER with a fractured femur -46 YO with a large abdominal incision and 2 peripheral IV lines -72 YO who received a permanent pacemaker 24 hours ago -80 YO with COPD who is on a ventilator

-80 YO with COPD who is on a ventilator --Clients at highest risk for hospital-acquired MRSA are older adults and those suppressed immunity, long history of antibiotic use, or invasive tubes or lines. Clients in the ICU are especially at risk for MRSA. the 80 year old client with COPD in the ICU on the ventilator has several of these risk factors. COPD is a chronic illness that can affect the immune system, and clients experience exacerbations that may require frequent antibiotic and corticosteroid use. This client is elderly and also has an invasive tube from the ventilator.

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the HCP? -Blood pressure of 180/100 mm Hg -creatinine of 2 mg/dl -hemoglobin of 9.8 g/dL -platelet count of 120,000/mm3

-Blood pressure of 180/100 mm Hg ---The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication to kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled using antihypertensive medications before performing a kidney biopsy. An elevated serum creatinine level can be expected in a client with probable real disease.

The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? -Continue teaching the client and verify understanding by return demonstration -discuss how important it is for the client to pay attention during the teaching -maintain eye contact during the teaching by following the client's movements -provide written instructions and a private place for the client to learn independently

-Continue teaching the client and verify understanding by return demonstration --Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences. The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration.

The nurse is preparing to administer a unit of packed red blood cells to a 16-year-old with blood loss anemia. The client currently has D5W infusing through a 20-gauge IV catheter. What action should the nurse take? -attach the blood transfusion set to the port closest to the client on the existing IV tubing -discontinue the 20-gauge IV catheter and restart an 18-gauge IV catheter -Discontinue the D5W,flush the IV catheter with normal saline, and start the transfusion -run the blood transfusion as an IV piggyback through the infusion pump

-Discontinue the D5W,flush the IV catheter with normal saline, and start the transfusion --NS is the only fluid that can be given with a blood transfusion. Dextrose solutions may lyse the red blood cells. All other IV solutions and medications may cause precipitation and are incompatible with blood. Blood transfusions should be infused through a dedicated IV line. If a transfusion must be started in an IV catheter currently in use, the nurse should discontinue the infusion and tubing, and then flush the catheter with NS prior to connecting the blood administration tubing. After transfusion, the catheter should be cleared with NS before any other IV fluids are administered.

A nurse prepares a client for knee artheroscopy requiring general anesthesia. Which actions should the nurse complete? SATA -Encourage the client to void prior to surgery -ensure that the client has been on NPO status -place signed informed consents in the client's chart -replace the current 20-gauge IV catheter with an 18-gauge -witness that the correct surgery site is marked by the surgeon

-Encourage the client to void prior to surgery -ensure that the client has been on NPO status -place signed informed consents in the client's chart -witness that the correct surgery site is marked by the surgeon --When preparing a client for surgery, the nurse needs to ensure that informed consent has taken place and signed documents are in the chart. The nurse also witnesses that the correct operative site is marked and verified by the client and ensures that the client is NPO and voids prior to surgery. If an IV line has not been started, an 18-gauge catheter is preferred. However, if a functioning IV line is already present, a 20-gauge is acceptable. Blood products, if needed during surgery, can be transfused through a 20-gauge catheter if necessary.

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the UAP. Which finding by the nurse requires intervention? -UAP has attached a bed alarm to the client's gown and bed -UAP has been making hourly rounds on the client -UAP has lowered the bed and raised all 4 side rails -UAP has placed a fall risk ID bracelet on the client's wrist

-UAP has lowered the bed and raised all 4 side rails --placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate.

The home health nurse is following up with the parent of a Native American infant recently diagnosed with lactose intolerance. In accordance with principles of culturally competent care, what is the most important question for the nurse to ask the parent? -do your other children have this condition? -How long did your infant have diarrhea? -How often are you feeding the infant? -What do you think caused your infant's illness?

-What do you think caused your infant's illness? --When providing culturally competent care, it is most important for the nurse to assess the client's beliefs regarding the cause of current illness. This will facilitate development of a culturally sensitive and appropriate teaching and care plan.

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action? -abdominal thrusts -back blows and chest thrusts -blind sweep of the child's mouth -call 911 for an ambulance

-abdominal thrusts --The Heimlich maneuver is the primary rescue intervention for children over age 1 with a foreign body airway obstruction causing respiratory distress. Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Blind sweeping of a child' mouth should not be attempted

The nurse is caring for a client with scleroderma. Which assessment finding indicates the most serious complication of the disease and requires priority intervention? -abrupt-onset hypertension and headache -blue and cold fingertips -dry cough and exertional dyspnea -heartburn and difficulty swallowing

-abrupt-onset hypertension and headache --Scleroderma is a progressive disease without a cure and treatment is aimed at managing complications. Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure.

Steps to performing wound irrigation

-administer analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect -don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection -fill a 30-60 mL sterile irrigation syringe with the prescribed irrigation solution -attach an 18 or 19-gauge needle or angiocatheter to the syringe and hold 1 inch above the area -use continuous pressure to flush the wound, repeating until drainage is clear -dry the surrounding wound area to prevent skin breakdown and irritation

A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing, Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence? SATA -administer docusate PO daily -administer ondansetron IV PRN for nausea -apply an abdominal binder -implement caloric restriction to promote weight loss -monitor blood sugar to maintain tight glucose control

-administer docusate PO daily -administer ondansetron IV PRN for nausea -apply an abdominal binder -monitor blood sugar to maintain tight glucose control --Dehiscence is a complication of poor wound healing that occurs when the edges of a surgical wound fail to approximate and separate. Dehiscence is associated with factors that impair circulation, tissue oxygenation, and wound healing and with mechanical stress on the wound.

The nurse is preparing to change a negative-pressure wound therapy dressing on a client's pressure ulcer. Which of the following actions are appropriate at this time? SATA -administer prescribed pain medication 30 minutes before the procedure -apply skin protectant to intact skin surrounding the wound -apply the foam dressing to the wound bed using clean technique -cut the foam dressing slightly larger than the size of the wound -ensure that the foam dressing shrinks after the device is turned on

-administer prescribed pain medication 30 minutes before the procedure -apply skin protectant to intact skin surrounding the wound -ensure that the foam dressing shrinks after the device is turned on ---negative pressure wound therapy is used to treat acute and chronic wounds with impaired healing. It promotes wound healing and approximation by using negative pressure to remove fluid, exudate, and infectious organisms and encourages circulation of blood to the wound bed. In negative-pressure wound therapy, a sterile foam dressing is cut to fit in the wound, placed in the wound bed, and then covered with an occlusive dressing to create a seal. A vacuum-assisted closure unit is then connected to creative negative pressure.

Interventions to prevent abdominal wound dehiscence includes:

-administering stool softeners to prevent straining and constipation from postoperative immobility and opioid pain medications -administering antiemetics as needed for nausea to prevent straining that can occur with vomiting -applying a abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing and moving -monitoring blood sugar to maintain tight glycemic control fasting glucose to decrease infection risk and promote wound healing. -splinting the abdomen by holding a pillow or folded blanket against the wound for support when coughing and moving

The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique? SATA -apply suction for no longer than 5-10 seconds -insert catheter with low, intermittent suction applied -set suction higher than 130 mm Hg for thick, copious secretions -wait at least 1 minute between suction passes -withdraw catheter immediately if client begins coughing

-apply suction for no longer than 5-10 seconds -wait at least 1 minute between suction passes --The process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to prevent hypoxia. The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia. In addition, deep, rebreathing should be encouraged. The suction catheter should be no more than half the width of the artificial airway and inserted without suction. The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set at medium pressure as excess pressure will traumatize the mucosa and can cause hypoxia. Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction

The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? SATA -allow the client to refuse food if not feeling hungry -ask if the client is experiencing any pain or nausea -involve the client in meal planing and food selection -plan for loved ones to share mealtimes with the client -provide oral care before and after meals to alleviate dry mouth

-allow the client to refuse food if not feeling hungry -ask if the client is experiencing any pain or nausea -involve the client in meal planing and food selection -plan for loved ones to share mealtimes with the client -provide oral care before and after meals to alleviate dry mouth ----managing anorexia during end-of-life care includes involving the client in meal planning/food selection; including friends/family at meals; offering preferred foods when the client is hungry; providing frequent oral care; administering antiemetics, analgesics, and appetite stimulants, and allowing the client to refuse food or drink.

What support surfaces should be used to prevent pressure ulcers?

-alternating pressure -avoid donut-type devices and synthetic sheepskins -heel protection -mattress -overlay

A client with suspected foot osteomyelitis is scheduled for an MRI. Which findings should the nurse notify the healthcare provider about before the test? SATA -aneurysm clip -cardiac pacemaker -colostomy -retained metal foreign body in eye -transdermal testesterone patch

-aneurysm clip -cardiac pacemaker -retained metal foreign body in eye --Clients must be screened for contraindications before exposure to a magnetic field as it can damage implanted devices or metallic implants. Absolute contraindications can preclude testing, and relative contraindications can post a hazard to the client's devices or implants, affect the quality of the images, or cause discomfort. Other factors that can affect the client's eligibility include inability to remain supine for 30-60 minutes and claustrophobia; however, these concerns are often controllable.

The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke. The client is dehydrated from multiple episodes of diarrhea. Which interventions should the nurse implement to prevent falls? SATA -apply color-corded, non-slip socks to the client's feet -move the client to a room closer to the nurses' station -place a bedside commode to the right of the client -raise all bed rails before leaving the room -use a bed alarm to alert staff when the client gets up

-apply color-corded, non-slip socks to the client's feet -move the client to a room closer to the nurses' station -place a bedside commode to the right of the client -use a bed alarm to alert staff when the client gets up --Many falls are associated with bathroom urgency/frequency. Fall risk precautions include placing the client in a room near the nurses' station, placing a bedside commode by the client's stronger side, applying nonslip socks, and using a bed alarm.

The nurse is caring for a postoperative client who has D5W/O.45% NS with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? SATA -area around the insertion site feels cool to the touch -client report mild arm discomfort since the infusion was started -edema is observed on the dependent side of the involved arm -intraoperative peripheral IV catheter is placed in the left antecubital region -serous fluid leaks from the site despite secure connections

-area around the insertion site feels cool to the touch -edema is observed on the dependent side of the involved arm -serous fluid leaks from the site despite secure connections ---peripheral IV catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications develop. The nurse should check for signs of infiltration by assessing the insertion site and areas dependent from it. Potassium is a known irritant to veins and discomfort is not a sign of infiltration. Locations where flexion occurs are generally avoided; however, these sites may be required for certain medications or situations.

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? -ask the mother's permission to touch the child's hand -interview the mother about the reason for bringing the child to the clinic -reassure the mother that there is no reason for distress -suggest postponing the examination until the mother calms down

-ask the mother's permission to touch the child's hand --Many Latin Americans believe in "mal de ojo", a cultural belief in an illness thought to be manifested in children by vomiting, fever, and crying. It is believed to be caused when a stranger admires a child without touching the child at the same time or immediately afterward. Asking the mother about the reason for bringing the child to the clinic will not relieve the mother's distress.

Ear irrigation steps

-assess client for contraindications -verify the tympanic membrane is intact and no foreign bodies present -explain the procedure to the client, including possible sensations -place the client ina side-lying or sitting position with the head tilted toward the affected ear. Place a towel an emesis basin under the ear. -verify that the irrigation solution is at body temperature -straighten the ear canal, pulling the pinna up and back for adults or down and back for children less than 3 years of age -irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal. -repeat as tolerated until the ear canal is clear or the prescribed amount is instilled -document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching

Ten minutes after an infusion of packed red blood cells is initiated through a central venous catheter, the client has shortness of breath and slight chest tightness. What initial actions would be appropriate for the nurse to complete? SATA -assess the client's breath sounds -flush the blood IV tubing with normal saline -notify the heathcare provider -remove the CVC -stop the infusion of PRBCs

-assess the client's breath sounds -notify the heathcare provider -stop the infusion of PRBCs --If an adverse blood transfusion reaction is suspected, the first action is to stop the infusion. An infusion of normal saline through a different port for the CVC is typically started. A client assessment and notification of the HCP are also required.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? -ask the client to explain the bruises on the torso -assess the client's general hygiene and nutritional status -report the bruises to the client's health care provide -talk to the client's child about the injuries

-assess the client's general hygiene and nutritional status --The client's injuries are inconsistent with the explanation given in that bumping into furniture could explain bruising on the extremities but does not account for the bruises on the torso. In addition, the bruises are in various stages of healing, which suggests that the injuries occurred over multiple occasions. The nurse's findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse's suspicions and to determine the extent of the abuse. The nurse will assess the client for general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements by the client suggesting neglect. During the assessment and client interview, the nurse will need to maintain a neutral, nonjudgmental attitude to facilitate a trusting nurse-client relationship. Asking the client to explain the bruises on the torso is a "why" type of question, places the client on the defensive, and does not facilitate a trusting nurse-client relationship. Reporting the bruises to the HCP is an appropriate nursing action but is not the priority. The nurse needs additional information. Talking to the client's child and/or other family members may be an appropriate nursing action, but the nurse needs more information.

Client instructions for using a volume-oriented SMI device

-assume a sitting or high Fowler position, which optimizes lung expansion, and exhale normally. -while holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage o air around it -inhale deeply through the mouth until the piston is elevated to the predetermined level of tidal volume. The piston is visible on the device and helps provide motivation -hold the breath for at least 2-3 seconds as this maintains maximal inhalation -exhale slowly to prevent hyperventilation -breathe normally for several breaths before repeating the process -cough at the end of the session to help with secretion expectoration

Steps to ascending the stairs with modified three-point gait

-assume the tripod position and place body weight on the crutches while preparing to move the unaffected leg -place the unaffected leg onto the good step -advance the affected leg and the crutches together up the step -realign the crutches with the unaffected leg on the step before repeating the process.

A nurse is caring for a 3-month-old client with a new trahceostomy. Which findings would indicate a need for suctioning? SATA -audible gurgling -heart rate 105/min -increased irritability -oxygen saturation -respiratory rate 30/min

-audible gurgling -increased irritability -oxygen saturation --Assessment findings that indicate a need for suctioning include: decreased oxygen saturation; altered mental status (irritability, lethargy); increased heart rate (normal infant range: 90-160); increased respiratory rate (normal: 30-60); increased work of breathing (flared nostrils, use of accessory muscles); adventitious breath sounds (crackles, wheezes, rhonchi); pallor, mottled, or cyanotic skin coloring

The nurse should encourage the following healthy sleep habits

-avoid caffeine, nicotine, and alcohol within 4-6 hours of sleep -exercise daily but avoid exercise or strenuous activity within 4-6 hours of sleep -avoid going to bed hungry or eating a heavy meal just before bed -practice relaxation techniques if stress is causing insomnia

The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? SATA -avoid annual influenza vaccination -avoid situations that cause physical and emotional stress -avoid sun exposure and ultraviolet light when possible -notify the healthcare provider if you have fever -use antibiotic soap to cleanse skin rashes

-avoid situations that cause physical and emotional stress -avoid sun exposure and ultraviolet light when possible -notify the healthcare provider if you have fever ---Systemic lupus erythematosus is an autoimmune disorder that results in inflammation and damage to many body parts. Symptoms vary widely among affected individuals, but most experience painful/swollen joints, extreme fatigue, skin rashes, and kidney problems. The symptoms typically appear for periods of time alternating with periods of remission. There is no cure for SLE, but it can be treated with immunosuppressants or immunomodulators. Pneumonia and annual influenza vaccinations are recommended for those with SLE as they are more susceptible to infections. These individuals should avoid contact with sick people and report fever to their healthcare provider. Both physical and emotional stress can exacerbte SLE. Therefore, clients should follow a healthy lifestyle. Balanced exercise with alternating periods of rest is recommended. Sunlight is known to worsen the rash of SLE and should be avoided when possible; protective clothing and sunscreen application are recommended during periods of sun exposure. The rash of SLE should be cleansed only with mild soap. Harsh soap and chemicals should be avoided.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? SATA -avoid the arm on the affected side after a mastectomy -do not make further attempts to draw blood if unsuccessful on first 2 attempts -if necessary to use an arm with IV infusion, draw proximal to infusion point -insert the needle bevel up at a 15-degree angle to the skin -obtain a finger capillary specimen from the middle of the finger pad

-avoid the arm on the affected side after a mastectomy -do not make further attempts to draw blood if unsuccessful on first 2 attempts -insert the needle bevel up at a 15-degree angle to the skin --While performing phlebotomy, clean the site, "fix: or hold the vein taut, and then insert the needle bevel up at a 15-degree angle. Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy should not be used. It places the client at risk for infection and lymphedema.

High fall risk precautions

-bed alarm -high fall risk signs -room close to nurses' station -color-coded socks and wristbands

Which situations would require the nurse to obtain a prescription for physical restraints? SATA -belt restraint used for a confused client who keeps trying to get out of bed but is on bed rest -elbow restraints used temporarily for a toddler while drawing blood -full padded side rails in the raised position for a client during a seizure -long leg immobilizer used for a client with a fractured femur -soft ankle restraint to prevent bleeding at the femoral site following cardiac catheterization

-belt restraint used for a confused client who keeps trying to get out of bed but is on bed rest -soft ankle restraint to prevent bleeding at the femoral site following cardiac catheterization --A physical restrain is a device or method used to immobilize or limit physical mobility or body movement to prevent falls, injury to self or others, or removal of medical devices. The client situation, rather than the device, determines whether it is classified as a restraint, Prescribed orthopedic immobilizers and protective devices used temporarily during routine procedures or examinations are not considered physical restraints and do not require authorization for use from a healthcare provider. Restraints should be used only after less invasive methods have failed and must be discontinued at the earliest time possible once it is safe to do so. The belt restraint is applied at the waist and tied to the bed frame under the mattress with straps using a quick-release knot. It is used to protect a confused or disoriented client who is on bred rest. Although the client can turn, it is considered a restraint because it restricts physical mobility and confines the client to the bed involuntarily. Soft limb restraints immobilize one or more extremities and are used for the prevention of falls or attempted removal of devices. Following aprocedure requiring sedation, clients may require restraints to protect them from disrupting a surgical site or medical device until they are alert enough to follow instructions independently. Limb restraints should be applied loosely enough that 2 fingers can be inserted underneath the secured restraint. The nurse should closely monitor the peripheral neurovascular status and skin integrity of a client's restrained extremity. Elbow restraints used a protective device to temporarily immobilize a child to perform a medical, diagnostic or surgical procedure are not considered a physical restraint. The use of full padded side rails in the raised position for clients during a seizure protects them from immediate injury; these are not considered a restraint. An orthopedic leg immobilizer used to restrict movement and maintain a client's extremity in proper alignment is prescribed for therapeutic purposes and is not considered a restraint.

A client arrives at the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that the client's pulse oximeter reading is inaccurate. Which factors could be contributing to this reading? SATA -black fingernail polish -cold extremities -elevated WBC count -hypotension -peripheral arterial disease

-black fingernail polish -cold extremities -hypotension -peripheral arterial disease ---Any factor that affects light transmission or peripheral blood flow can cause a falsely low reading for oxygen saturation on pulse oximeter. Common causes include dark nail polish, hypotension, low cardiac output, vasoconstriction (hypothermia or vasopressor medications) , and peripheral arterial disease.

The clinic nurse performs an admission assessment on a client diagnosed with systemic lupus erythematosus. Which characteristic cutaneous manifestation of SLE would the nurse most likely assess? -butterfly shaperash -petechiae -pruritus -urticaria

-butterfly shape rash ---The characteristic cutaneous manifestation of SLE is a flat or raised red rash that forms a butterfly shape accross the bridge of the nsoe and cheeks

Absolute contraindications for MRI

-cardiac pacemaker -implantable cardioverter defibrillator -cochlear implant -retained metallic foreign body, especially in organs such as the eye

Which of the following drug administrations should be reported as a practice error? SATA -cephalexin administered; client has hx of anaphylaxis from penicillins -hydromorphone 2 mg administered; client reports pruritus -immunization for 3-month-old administered in ventrogluteal site -oral niacin administered; client has facial flushing -warfarin administered; client at 12 weeks gestation

-cephalexin administered; client has hx of anaphylaxis from penicillins -immunization for 3-month-old administered in ventrogluteal site -warfarin administered; client at 12 weeks gestation ---do not administer warfarin if the client is pregnant. Intramuscular injections are given in the vastus lateralis to children age <7 months. Penicillins and cephalosporins can have across-sensitivity response. Narcotic-induced pruritus is not a true allergy.

The unit implemented a quality improvement program to address client pain relief. Which set of criteria is the best determinant that the goal has been met? -chart audits found clients' self-reported pain scores improved by 10% -number of narcotics used on the unit increased by 20% -positive comments on returned client satisfaction surveys increased by 30% -survey found that 90% of the nurses believed clients had better pain control

-chart audits found clients' self-reported pain scores improved by 10% --Measurements should be objective, rather than subjective. Evidence-based criteria should be used, if applicable. These survey results are objective, restrospective measurements of a positive change.

The client has a dislocated shoulder and the nurse is assisting the healthcare provider with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out "help me" What action should the nurse take first? -administer midazolam per protocol -check the client's pulse oximeter -give more morphine per protocol -open the airway with head tilt-chin lift

-check the client's pulse oximeter ---When there is a new, sudden onset of restlessness/agitation, the nurse should first think about oxygenation or blood glucose. The desired level of sedation is level 3 on the Ramsay Sedation Scale, during which the client is drowsy, but responds to a voice command. If the client is snoring, opening the airway should be considered

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observed urine leaking from the insertion site, past the catheter. What is the nurse's first action? -check the urethral catheter and drainage tubing -irrigate the catheter with 30 mL of sterile NS -notify the HCP -remove and reinsert the next-larger-size catheter

-check the urethral catheter and drainage tubing --The nurse's first action should be to assess for a mechanical obstruction by inspecting the catheter tubing. If these interventions fail, the nurse should then notify the HCP. Irrigation is usually avoided as pus or sediment can be washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to urine flow. If there is a discrepancy in expected urine output compared with fluid intake, a blockage is suspected and a bladder scan is then performed to confirm the presence of urine in the bladder.

The nurse is planning teachnig for a client newly diagnosed with Sjogren's syndrome. Which measures will the nurse include in the teaching plan? SATA -chewing sugar-free gum or using artificial saliva -scheduling regular dental examinations -showering with lukewarm water and avoiding harsh soaps -using over-the-counter decongestants to alleviate nasal symptoms -using over-the-counter lubricants to ease vaginal dryness

-chewing sugar-free gum or using artificial saliva -scheduling regular dental examinations -showering with lukewarm water and avoiding harsh soaps -using over-the-counter lubricants to ease vaginal dryness ---Clients with Sjogren's syndrome need measures to combat the effects of damaged moisture-producing glands. These include eye drops, sugar-free candy or artificial saliva, vaginal lubricants, frequent dental examinations, lukewarm showers with mild soap, and avoiding decongestants.

The triage nurse has one isolation room left in the emergency department. Which priority client should be assigned to this room? -child with chickenpox for the past 14 days; all lesions are crusted and dried -child with impetigo who has been on antibiotics for 3 days -child with leg rash secondary to poison ivy exposure -child with suspected pertussis who has paroxysms of coughing

-child with suspected pertussis who has paroxysms of coughing ---paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection. Pertusis is a highly contagious disease and requires droplet precautions. It can be deadly if contracted in infancy before vaccination is started. Chickenpox is no longer contagious after the lesions have crusted and dried, but this process can take as long as 3 weeks. Impetigo is no longer contagious after 24 hours of antibiotics. Poison ivy rash is not considered contagious

A 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound. Which actions by the new nurse would require the experienced nurse to intervene? SATA -administers the prescribed analgesic 30 minutes before irrigating the wound -cleanses the wound from the most to the least contaminated area -obtains a 10-mL syringe and a 27-gauge needle -reviews the child's most recent immunization record -uses continuous pressure to irrigate and repeats until drainage is clear

-cleanses the wound from the most to the least contaminated area -obtains a 10-mL syringe and a 27-gauge needle --Before an open wound is closed, irrigation is performed to wash out debris and bacteria to ensure appropriate wound healing. This is important for wounds obtained in an outdoor environment as contamination with soil or dirt greatly increases the risk of infection. Immunization history is reviewed to determine tetanus vaccination status. Typically, a tetanus vaccination is administered if the client has not had one within the last 5-10 years, depending on the contamination level of the wound.

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? SATA -client admitted with white blood cell count of 28,000 mm3 and dies from sepsis -client receives 1 mg morphine instead of prescribed 0.5 mg morphine -client refuses pneumonia vaccination and contracts pneumonia -nurse did not report client's new hemoglobin result of 6 g/dl to oncoming nurse -provider was not notified of client's positive blood culture results

-client receives 1 mg morphine instead of prescribed 0.5 mg morphine -nurse did not report client's new hemoglobin result of 6 g/dl to oncoming nurse -provider was not notified of client's positive blood culture results --Adverse events are injuries caused by medical management rather than a client's underlying condition. Types of errors include diagnostic, treatment, preventive, and failure of communication, equipment, or other systems.

The nurse reviews the most current laboratory results of assigned clients. Which result should the nurse report to the healthcare provider immediately? -client who has cellulitis of the leg with a white blood cell count of 13,000/mm3 -client who has chronic kidney injury with a hematocrit of 28% and hemoglobin of 9 g/dL -client who has type 2 diabetes mellitus with a 2-hour postpranial serum glucose of 165 mg/dL -client who is 1 month post kidney transplant with a urinalysis showing WBC's and bacteria

-client who is 1 month post kidney transplant with a urinalysis showing WBC's and bacteria ---Clients who have undergone kidney (or organ) transplantation are prescribed immunosuppressant drugs to help prevent organ rejection and are therefore at increased risk for developing infection. The nurse should notify the HCP immediately of any signs or symptoms of an infection. Cellulitis is a bacterial infection that causes inflammation of the subcutaneous tissues. An increased WBC count would be expected in this client. Clients with chronic kidney injury have a decreased level of the hormone erythropoietin, resulting in decreased erythrocyte production. Decreased hematocrit and hemoglobin levels would be expected. An elevated postprandial serum glucose would be expected in a client with type 2 diabetees mellitus, so notifying the HCP is not necessary.

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume of 80 mL. Which action should the nurse perform next? -collect gastric pH measurement -delay feeding for atleast 1 hour -discard the gastric residual -return residual and administer feeding

-collect gastric pH measurement --Before administering intermittent enteral feedings, the nurse must verify tube placement, such as with x-ray confirmation or gastric pH measurement. Ensuring that the top of the feeding tube is correctly placed in the stomach or small intestine is essential because administration of enteral feeding through a misplaced tube may result in life-threatening aspiration. Gastric residual volume is one indicator of how well the client is tolerating enteral feedings. High GRV may indicate delayed gastric emptying and poor intestinal motility, which is traditionally considered a risk factor for aspiration. The nurse should follow facility policy or contact the HCP to determine if feedings should be delayed for high GR or other symptoms of intolerance.

The male client had a hemiclectomy. The client is refusing to wear the prescribed sequential compression devices. What is most important for the nurse to communicate to the client? -an appropriate form must be signed, verifying refusal -complications, including death, could result -the client will be billed for the equipment regardless -the surgeon will be informed of the refusal

-complications, including death, could result --Just as there is informed consent, there is informed refusal. The client should be made aware of all the possible complications when making a decision, and this should be documented. The nurse should try to work with the client to get at least partial compliance when it is in the client's best interest.

The nurse is feeding a confused client via a small-bore nasoenteric tube. The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark. After immediately stopping the feeding, which action is appropriate for the nurse to take next? -advance the tube to the original exit mark, check gastric aspirate pH, and resume feeding -contact the HCP to request a prescription for hand mitts -contact the HCP to request an x-ray to verify tube placement -reinsert the guide wire and advance the tube to its original exit mark

-contact HCP to request an x-ray to verify tube placement --A feeding tube is marked with indelible ink at the exit site (nare). If the external length of the tube changes, the nurse should contact the HCP and request a prescription for a repeat x-ray to determine tube location before resuming administration of enteral feedings and medications. Even if bedside methods to determine placement are used (gastric aspirate pH and appearance) advancing the tube to the original marking does not guarantee correct placement. Tube feedings should not be resumed after tube dislodgment without x-ray verification. A prescription for hand mitts to keep a confused client from disrupting enteral nutrition may be appropriate if other less restrictive interventions are ineffective or unavailable. Once removed, the guide wire should never be reinserted while the tube is in place as it can protrude and damage both the tube and the client's mucosa

The nurse reviews the serum laboratory results of a client who was seen in the clinic 2 days ago for worsening joint pain from a flare of systemic lupus erythematosus. Which result is of greatest concern and prompts the nurse to notify the healthcare provider? -creatinine of 1.8 mg/dL -elevated erythrocyte sedimentation rate -positive antinuclear antibody titer -white blood cell count of 3,600/mm3

-creatinine of 1.8 mg/dL --increased creatinine, BUN, and abnormal urinalysis can indicate the presence of lupus nephritis, a potentially serous complication of SLE. Early recognition and aggressive immunosuppressive treatment are essential to preserve renal function and prevent irreversible kidney damage. An elevated erythrocyte sedimentation rate can indicate the presence of an active inflammatory process and would be expected in a client with an inflammatory disease such as SLE, especially during a disease flare. A positive antinuclear antibody titer indicates the presence of AAs, which the body produces against it own DNA and nuclear material. This would be expected in a client diagnosed with SLE. Anemia, mild leukopenia, and thrombocytopenia are often present in SLE

The nurse observes a client who is postoperative left total knee replacement use a cane. Which action by the client indicates an understanding of the correc technique when walking down the stairs? -descends with the cane on the step first, followed by the left leg, and then the right leg -descends with the cane on the first step, followed by the right leg, and then the left leg -descends with the left leg on the step first, followed by the cane, and then the right leg -descends with the right leg on the first step, followed by the left leg, and then the cane

-descends with the cane on the step first, followed by the left leg, and then the right leg --To prevent falls when descending the stairs using a cane, the client should lead with the cane, follow with the weaker leg, and then step down with the stronger leg.

What are some examples of hypertonic solutions?

-dextrose 5% and 0.9% NaCl -5% dextrose and lactated ringer -colloid solutions (dextran, albumin

What are some signs of aspiration pneumonia?

-diminished or adventitious lung sounds (crackles, wheezing) -dyspnea -productive cough

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? SATA -dimming the lights at night -increasing the level of continuous IV sedation during nighttime hours -leaving the television on for diversion at night -opening the window blinds/shades in the morning -scheduling interventions and activities during the day when possible -turning off equipment alarms in the client's room at night

-dimming the lights at night -opening the window blinds/shades in the morning -scheduling interventions and activities during the day when possible --it is important to maintain the client's normal circadian rhythms in the ICU. Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, providing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium. Continuous IV sedation, if indicated, should be given at the lowest dose adequate for pain management. Unless the client is awake and chooses to have the television turned on, this extra stimulus is disruptive to sleep. Turning the alarms off in the client's room would pose a risk to safety, as the nurse may not be alerted to a change in condition or equipment failure. If possible, alarm parameters should be adjusted according to the client's routine to prevent unnecessary awakening.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? SATA -do not leave the tourniquet on more than 1 minutes while looking for a vein -draw the specimen while the skin is still wet with the alcohol prep -if pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes -use a highly visible vein on the ventral side of the client's wrist -vigorously shake the specimen tube to mix obtained blood with anticoagulant solution

-do not leave the tourniquet on more than 1 minutes while looking for a vein -if pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes ---When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of write (due to risk for nerve injury and risk of arterial access), position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

nursing considerations after seizure

-document timing and symptoms -remain with client -perform neurological assessment -assess for physical injury

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesion. Which of the following actions are appropriate to include in the plan of care? SATA -don gown, gloves, and N95 respirator when entering the client's room -ensure that pregnant staff members are not assigned to care for this client -place single-use, disposable thermometer and stethoscope in the room -place the client in a private room with negative air pressure -request discontinuation of isolation precautions once all lesions are dry and crusted.

-don gown, gloves, and N95 respirator when entering the client's room -ensure that pregnant staff members are not assigned to care for this client -place single-use, disposable thermometer and stethoscope in the room -place the client in a private room with negative air pressure -request discontinuation of isolation precautions once all lesions are dry and crusted. Varicella-zoster virus is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation and contact isolation until vesicles have crusted.

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection? -antecubital fossa -dorsal surface of hand -dorsum of foot -lateral surface of wrist

-dorsal surface of hand --Clients most at risk for catheter-related bloodstream infections are those with compromised immune systems; therefore, this client is at high risk. The IV site chosen for catheter insertion can influence the infection risk. The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed. The antecubital fossa is commonly selected in emergency situations due to its size and ease of cannulation but is problem prone for longer-term needs as it is in the bend of the elbow. Bending of the arm can move the catheter, causing irritation at the insertion site and increasing infection risk. The foot is not typically accessed in adults without a specific healthcare provider prescription. It is occasionally used in emergency situations; however,veins in the legs and feet may have decreased venous return, and complications can lead to thrombophlebitis or deep vein thrombosis. The radial vein is present on the later side of the wrist but is in close proximity to several nerves, which could cause severe pain or nerve damage.

Symptoms of Sjogren's syndrome

-dry skin and rashes -chronic dry cough -vaginal dryness and painful intercourse

Clinical manifestations of heat exhaustion

-elevated body temperature -intravascular volume depletion -electrolyte imbalances -dizziness -weakness -fatigue -sweating -flushing -nausea -tachycardia -muscle cramping

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections? SATA -cleanse periurethral area with antiseptics every shift -ensure each client has a separate container to empty collection bag -keep catheter bag below the level of the bladder -routinely irrigate the catheter with antimicrobial solution -use sterile technique when collecting a urine specimen

-ensure each client has a separate container to empty collection bag -keep catheter bag below the level of the bladder -use sterile technique when collecting a urine specimen --Routine catheter care to prevent healthcare catheter-associated UTIs includes routine hand hygiene, cleansing the perineal area with soap and water routinely, keeping the catheter bag below the bladder and off the ground, keeping the catheter and tubing free of kinks and facilitating urine into the bag, and using sterile technique when collecting urine specimens.

Strategies that can help reduce falls in the home environment

-exercising regularly for 30 minutes 3 times/week (increase strength, balance, coordination, and flexibility) -maintaining a well-lit, clutter-free environment -using grab bars and non-ski bath mats in the bathroom -wearing shoes/slippers with non-skid soles both inside and outside of the home -periodically reviewing medications and side effects with a pharmacist and HCP -getting regular vision exams -wearing an electronic fall alert device.

Tasks performed for postmortem care

-maintain standard or isolation precautions in place at the time of death -gently close the client's eyes -remove tubes and dressings per policy, unless an autopsy or organ harvest is pending -straighten and wash the body and change the linens. Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased -leave dentures in place, or replace if removed, to maintain the shape of the face -place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters -place a pillow under the head to prevent blood from pooling and discoloring the face -remove equipment and soiled linens from the room -give client's belongings to a family member or send with the body.

A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? -explain to the family that this is a normal physiological response to dying -explore the family's thoughts and concerns about the client's refusal of food -recommend a feeding tube -tell the family that "force feeding" the client could cause the client to choke on the food.

-explore the family's thoughts and concerns about the client's refusal of food --It is very common for family members to become distressed when a terminally ill loved one refuses food. The nurse needs to explore theirs fears and concerns and help them identify other ways to express how they care. The nurse should also provide education about the effect of food and water during all stages of the illness.

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? -facilitate immediate removal of people from the area -inform the client that the client cannot act that way -pull the fire alarm to get additional immediate help -state that the nurse can see the client is upset

-facilitate immediate removal of people from the area --When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area, and security should be called immediately.

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection? -femoral line inserted in emergency department post cardiac arrest 48 hours ago -internal jugular line inserted 6 days ago in operating room -peripherally inserted central catheter line with one lumen occluded that was placed 2 weeks ago -subclavian line with slight redness at anchor suture sites inserted in intensive care unit 72 hours ago.

-femoral line inserted in emergency department post cardiac arrest 48 hours ago --In adult clients, central venous access sites in the upper body are preferred to minimize the risk of infection. Access sites in the inguinal area are easily contaminated by urine or feces, and it is difficult to palce an occlusive dressing over these sites. A central venous cathter should be placed where aseptic technique can be applied. The site should be assessed daily for signs/symptoms of infection. The duration of CVC placement should be based on clinical need and judgment that there is no evidence of infection. Peripherally inserted central catheter lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter.

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter. The nurse should call the primary health care provider for clarification prior to implementation when recognizing that which prescription is an error? -administer intravenous total parenteral nutrition at 50 mL/hr -change occlusive central line dressing every 7 days -flush unused lumens of the CVC with 1,000 units heparin every 12 hours -use distal port of CVC to monitor central venous pressure

-flush unused lumens of the CVC with 1,000 units heparin every 12 hours --Most CVC lumens require anticoagulation in the form of a heparin flush to maintain patency and prevent clotting when not in use. The nurse should check the institution's protocol and the HCP prescription to determine the correct dose. Doses of 2-3mL containing 10 units/mL are the standard of care for flushing a CVC. Doses of 1,000-10,000 units are given for cases of venous thromboembolisml therefore, this prescription is an error and should be clarified by the nurse. The CDC recommend that a single-dose vial or prefilled syringe be used to reduce infection risk. Heparin is a high-alert medication.

The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time? -ask the client when a spiritual leader or clergy member is coming to visit -document the response and notify the healthcare provider and perioperative team -follow up with the client regarding the nature of the spiritual or religious practices -notify the hospital chaplain and tell the client that the chaplain will come by to assist

-follow up with the client regarding the nature of the spiritual or religious practices --Spiritually and religious beliefs are often integral parts of a client's life and can be therapeutic in the management of illness. Some studies have found that clients who engage in regular spiritual or religious practices have shorter recovery times, better coping mechanisms, and improved health outcomes. Spiritual, cultural, or religious needs should be accommodated within the plan of care. During the nursing process, the nurse should first assess the client's needs to best address them. By following up with the client regarding the questionnaire and asking about the specific nature of spiritual needs or religious practices, the nurse can effectively assist the client and create an appropriate plan of care.

Steps for performing the procedure for a client with a disposable inner cannula

-gather supplies to the bedside, then place client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation and prevent aspiration of secretions -don personal protective equipment to maintain universal precautions. Ausculate lungs and suction secretions if necessary -remove soiled dressing and also remove clean gloves -don sterile gloves; remove old disposable cannula and replace with a new one. -clean around stoma with sterile water or saline, dry and replace sterile gauze pad to remove dried secretions, and dry around stoma well to limit the growth of microorganisms.

The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first? 1. Face shield/goggles 2. Gloves 3. Gown 4. Mask/respirator

-gloves ---The proper removal of personal protective equipment limits self-contamination. Gloves should be removed first and promptly after use to prevent contamination of other items or noncontaminated materials

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome. Which personal protective equipment will the nurse use when providing care to this client? -gloves and gown -gloves and mask -gown and N95 respirator -gown, gloves, N95 respirator, and eye protection

-gown, gloves, N95 respirator, and eye protection --MERS is a viral respiratory illness caused by the coronavirus. Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those affected. The incubation period is 5-6 days but can range from 2-14 days. How the virus spreads is not fully understood, but it is thought to spread via respiratory secretions. Because it has easily spread to those who care for infected persons, the CDC recommends the use of standard, contact, and airborne precautions with eye protection when caring for clients with MERS.

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? SATA -gown -goggles or face shield -hand washing -N95 particulate respirator -surgical mask

-hand washing -N95 particulate respirator --Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting. Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if TB is extrapulmonary with draining lesions. For client care involving airborne precautions, a class N95 or higher respirator must be used in lieu of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated for barrier protection for droplet splashing and filtration of large respiratory particles only. Clients should be given surgical masks during their transportation.

For medical procedures, the nurse should ensure that the client....

-has empty bladder and is in high Fowler's or sitting position for paracentesis -trandelenburg on left side for suspected air embolism -has arm raised above the head on the affected side for chest tube insertion -lies on right side (2+ hrs) and supine (12-14 hrs) after liver biopsy -side-lying with head, back, and knees flexed for lumbar puncture.

The nurse in the oral surgery clinic reviews a client's medical record prior to surgery. Which will the nurse immediately report to the oral surgeon? SATA -client is on a calorie-restricted diet for obesity -creatinine is 1.3 mg/dL -history of congenital heart disease -international normalized ratio of 2.5 -presence of prosthetic valve

-history of congenital heart disease -international normalized ratio of 2.5 -presence of prosthetic valve --Clients with a history of congenital heart disease and those with prosthetic valves are at risk for developing infective endocarditis, an infection of the endothelial lining of the heart, with oral surgery and certain procedures. These clients should receive prophylatic antibiotic therapy prior to any such procedure or surgery. Clients on warfarin therapy due to the presence of prosthetic valves or for other reasons will have a therapeutically elevated international normalized ratio to inhibit blood clot formation. However, this will place these clients at risk for excessive bleeding during surgical procedures.

Steps for administering a continuous enteral feeding

-identify the client using 2 identifiers and explain the procedure to the client. Perform hand hygiene and apply clean gloves -elevate the HOB > 30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspration -validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measruement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation -check gastric residual volume -flush the tube with 30 mL of water after checking residual volume, every 4-6 hrs during feeding, and before/after medication administration -administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump.

to prevent air embolism when discontinuing a CVC, the nurse should:

-instruct the client to lie in a supine position to increase CVP and decrease the possibility of air getting into the vessel -instruct client to bear down or exhale. NEVER inhale -apply air-occlusive dressing to help prevent a delayed air embolism. =pull the line cautiously and never pull harder if there is resistance

The school nurse is speaking with the parent of a fourth grade student about a bedbug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. Which is the best action by the nurse? -instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags -instruct the teacher of the child's classroom to use an insecticide spray -send letters home to all of the children's parents informing them about the finding -send the child home and prohibit school attendance until the infestation has been resolved.

-instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags ---Although full-blown bed bug infestations are uncommon in a school setting, a bed bug brought in on the clothing or possessions of one student could easily "hitch" a ride to another student's home and cause an outbreak there. The most important measure to prevent bed bugs from infesting other students' homes is to prevent the bugs from entering the school in the first place. Laundering clothing in hot water and using the highest temperature setting on a dryer will kill any bed bugs attached to clothes. The clothing should then be stored in tightly sealed plastic bags to prevent additional infestation.

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? SATA -ensuring the client wears a N95 respirator at all times -keeping the door the client's room closed at all times -maintaining a log of everyone in and out of the client's room -removing both pairs of gloves before removing gown and mask -restricting visitors from entering the client's room

-keeping the door the client's room closed at all times -maintaining a log of everyone in and out of the client's room -restricting visitors from entering the client's room --Ebola is an extremely disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions. The client is placed in a single-client airborne isolation room with the door closed. Visitors are prohibited unless absolutely necessary for the client's well-being. For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms. Procedures and use of sharps/needles are limited whenever possible. There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial.

Interventions to promote safety when using crutches in the home includes:

-keeping the environment free of clutter and remove scatter rugs to reduce fall risk -look forward and not down at the feet, when walking to maintain an upright position -use a small backpack, fanny back, or shoulder bag to hold small personal items -wear rubber or non-skid slippers/shoes without laces -rest crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip hazard -keep crutch rubber tips dry and replace them if worn to prevent slipping.

The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? SATA -history of angioedema with lisinopril -history of epilepsy -known allergy to avocados and bananas -known allergy to shellfish -lip swelling when blowing up balloons

-known allergy to avocados and bananas -lip swelling when blowing up balloons --Latex allergy is an exaggerated immune reaction to exposure to latex-containing products. Risk factors include swelling, hives, or itching after exposure to common latex-containing products; certain food allergies (banana, avocado, tomato) and a history of multiple latex exposures.

A client recovering at home following a left total knee replacement 7 days ago is using a can to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for further instruction? -faces forward when going up and down the stairs -holds the cane with the right hand -leads with left leg,follows next with cane, and finally right leg when going up the stairs -places full weigh on left leg when going down the stairs

-leads with left leg,follows next with cane, and finally right leg when going up the stairs --Clients who have had total knee replacement surgery can typically bear full weight by the time of discharge. To reduce the risk of falls, the client should hold the cane on the stronger side and face forward when going up and down the stairs, To ascend the stairs, the client should first step up with the stronger leg, next bear weight on that leg and move the cane, and finally step up with the weaker leg.

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the charge nurse handle the situation? -call security to escort the family member to the waiting room have the family member stand or sit in an area that is not in the staff's way -inform the family member that relatives are not allowed in rooms during emergency situations -let the family member stay and assign a staff person to explain what is happening

-let the family member stay and assign a staff person to explain what is happening --The nurse should support a family member who wants to present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place.

A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? SATA -locate and remove any medication patches -locate possible medical alert band or necklace -remove rings and jewelry and lock in a secure location -remove tampon and replace with menstrual pad -take out contacts if no presence of eye trauma

-locate possible medical alert band or necklace -remove rings and jewelry and lock in a secure location -remove tampon and replace with menstrual pad -take out contacts if no presence of eye trauma --The unconscious client requires a thorough head-to-toe assessment on admission to assess for foreign objects, devices, or belongings that have potential for harm. Medication patches should not be removed without first consulting the healthcare provider. Clients are often prescribed transdermal patches for chronic conditions. Removing and discarding a medication patch without additional information may harm the client.

The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? SATA -keeps hearing aids clean by rinsing them with water -lowers television volume when talking with nurse -places hearing aids on food tray when not in use -turns volume completely down prior to insertion of aid into the ear -verifies that battery compartment is closed before insertion

-lowers television volume when talking with nurse -turns volume completely down prior to insertion of aid into the ear -verifies that battery compartment is closed before insertion --The nurse should ensure that clients with hearing aids understand proper hearing aid use and care. Principles of hearing aid care include: turning volume off and ensuring the battery compartment is shut before insertion; minimizing background noise; cleaning the aids with a soft cloth; keeping the aids in a safe, dry place; and not immersing them in water

The nurse recognizes that which factors place a client at increased risk for falls? SATA -age of 50 -diagnosis of ovarian cancer -lying pulse 80/min, standing pulse 110/min -osteoarthritis of knees -takes carbidopa/levodopa -uses a cane to ambulate

-lying pulse 80/min, standing pulse 110/min -osteoarthritis of knees -takes carbidopa/levodopa -uses a cane to ambulate ----Falls risk does not increase until ages greater than 65-75.

The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies? -blistered with a garlic scent near the wrists -circular bruised blemishes on the back -markings appearing to be human bites on the arms -well-like linear lesions on the back

-markings appearing to be human bites on the arms --The culturally competent nurse is aware that some alternative medicine practices of nondominant cultures in North America can present with dermatologic findings. Markings that appear to be human bites would require further follow-up as these are not common in alternative medicine. Although nurses should be aware of various cultural practices, any marks consistent with child abuse should be reported to the appropriate authorities

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus? -check for variation in amplitude of QRS complexes on the electrocardiogram strip -compare apical and radial pulses for an deficit -measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle -multiple diastolic blood pressure by 2, add systolic pressure, and divide the result by 3.

-measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle --Muffled heart tones in a client with pericardial effusion can indiciate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. additional signs and symptoms of tamponade include tachycardia, jugular venous distention, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration.

The nurse plans to start an IV line on a female client hospitalized with pneumonia. The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for the client's IV line? -basilic vein of the left forearm -cephalic vein in the right antecubital space -median vein of the right forearm -radial vein of the left wrist

-median vein of the right forearm --The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected arm. The nurse must avoid an needlesticks, IV insertions, or blood pressure measurements in the affected arm. The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best because the client has a left-sided mastectomy. Other dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection.

Proper hearing aid use and care includes

-minimize distracting sounds during conversation to enhance effectiveness -turn the volume off prior to insertion, then gradually turn up the volume to a comfortable level -to adjust to the new hearing aids, initially wear them for a short time and gradually increase length of wear time -do not wear the hearing aids when using hair dryers or heat lamps -regularly check that the battery compartment is clean, the batteries are inserted correctly, and the compartment is shut before insertion -remove the battery at night and when the aid is not in use to extend battery life

Special techniques to utilize when caring for a patient with dysphagia includes:

-modification of food consistency (pureed, mechanically altered, soft) -thickened liquids -having client sit upright at 90-degree angle -placing food on the stronger side of the mouth to aid in bolus formation -tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take? -document the test results on the preoperative checklist -notify the healthcare provider about the test results -place the printed ECG in the front of the chart -report the results to the surgical nurse to tell the surgeon

-notify the healthcare provider about the test results --this is a high-risk client and the acute, new, significant finding needs further evaluation and possible intervention before undergoing the stress of surgery. In addition, clients with a long history of diabetes often have associated neuropathy and may not experience the chest pain typical of myocardial infarction, known as silent MI. As a result, the nurse must ensure that the healthcare provider is made aware of this client's new findings in a timely manner

What can cause leakage of urine from the insertion site of an indwelling urinary catheter?

-obstruction (clots/sediment) -kinking/compression of catheter tubing -bladder spasms -improper catheter siz

Wound cultures are obtained through:

-perform hand hygiene and apply clean gloves. -remove the old dressing. remove and discard gloves -perform hand hygiene and apply sterile gloves -assess wound bed. Cleanse wound bed and surrounding skin with NS -remove and discard gloves. perform hand hygiene and apply clean gloves. -gently swab the wound bed with a sterile swab from the wound center toward the outer margin. -avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora -place swab in sterile specimen container; avoid touching the swab to the outside of the container -apply prescribed topical medication after obtaining cultures to prevent interference with microorganism identification -apply new dressing -remove and discard gloves and perform hand hygiene. -label specimen and document the procedure

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? SATA -ask a family member about the client's preferences for room arrangement -offer the client an elbow to hold, and walk a half-step ahead for guidance -say"goodbye" when leaving the room to help orient the client -speak slowly and slightly louder so the client can understand -use a clock-face pattern to explain food arrangement on the client's meal tray

-offer the client an elbow to hold, and walk a half-step ahead for guidance -say"goodbye" when leaving the room to help orient the client -use a clock-face pattern to explain food arrangement on the client's meal tray ---When caring for a client who is blind, the nurse should create a safe therapeutic environment and foster client independence by orienting the client to the surroundings, announcing room entry and exit, guiding the client by offering an elbow and walking slightly in front, using a clock-face description to orient the client to the location of objects, and asking the client directly about preferences.

Standard fall risk precautions

-orientation to room and call light -call light within reach -bed in lowest position -uncluttered room -nonslip socks or shoes -well-lit room -belongings within reach

Standard fall risk precautions includes

-orientation to room and call light -call light within reach -bed in lowest position -uncluttered room -nonslip socks/shoes -well-lit room -belongings within reach

s/s of extravasation

-pain -blanching -swelling -redness

The nurse is caring for an elderly client after hips replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate? -administer the prescribed as-needed milk of magnesia -ask dietary services to add more fruits and vegetables to the client's tray -notify the healthcare provider -perform a focused abdominal assessment

-perform a focused abdominal assessment ---Constipation may be a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client and then use measures that promote normal bowel function. The HCP is contacted if the focused abdominal assessment indicates a potential complication, such as postoperative ileus,

The general steps for preparing the sterile field for a wet-to-damp dressing change:

-perform hand hygiene -open a sterile gauze package that has a partially sealed edge with ungloved hands by grasping both sides of the edge, one with each hand, and pull them apart while being careful not to contaminate the gauze. -hold the inverted opened gauze package 6 inches above the waterproof sterile field so it does not touch the field, and then drop the gauze dressing onto the sterile field -place the sterile dressings on the sterile field 2 inches from the edge; the 1 inch margin at each edge is considered unsterile because it is in contact with unsterile surfaces -use sterile NSS from a recapped bottle that was opened <24 hours ago

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure? SATA -discard the first 6-10 mL of blood drawn from the line -flush the line with sterile normal saline before and after collection -perform hand hygiene -place the specimen in a biohazard bag -scrub the catheter hub with antiseptic prior to use

-perform hand hygiene -place the specimen in a biohazard bag -scrub the catheter hub with antiseptic prior to use --Blood and bodily fluids are considered hazardous materials and must be placed in containers identifying them as biohazards. This alerts staff to take the necessary precautions to prevent infection transmission when handling the specimen. An appropriate antiseptic scrub of the catheter hub prior to use inhibits microorganism entry and prevents transmission of infection to the client. When drawing a blood specimen from a central line, the nurse should discard the first blood drawn to prevent an inaccurate lab result, but this will not prevent the transmission of infection. Flushing the line prior to specimen collection will clear any previous infusions and assist in checking patency. It is important to flush the line after collection to remove blood and prevent clotting. Neither action prevents infection transmission.

Steps for inserting a NG tube for gastric decompression includes:

-perform hand hygiene and apply clean gloves -place client in high Fowler's position -assess nares and oral cavity and select naris -measure and mark the tube -curve 4-6 inches tube around index finger and release -lubricate end of tube with water-soluble jelly -instruct client to extend neck back slightly -gently insert tube just past nasopharynx, aiming tip downward -rotate tube slightly if resistance is met, allowing rest periods for client -continue insertion until just above oropharynx -ask client to flex head forward and swallow small sips of water -advance tube to marked point -verify tube placement and anchor.

Correct clean catch collection method for a female client

-perform hand hygiene and open the specimen container, leaving the sterile side of the collection lid positioned upward to prevent contamination -spread the labia using the index finger and the thumb of the nondominant hand so that the specimen cup can be held with the dominant hand -cleanse the vulva in a front-to-back motion with provided antiseptic wipes, using a new towelette with each wipe to prevent contamination -initiate the urinary stream to flush any remaining microorganisms from the urethral meatus before passing the container into the stream for the collection of 30-60 mL of urine -remove the specimen container from the stream before the urinary flow ends and the labia are released to prevent contamination -replace the sterile cap without contaminating it and repeat hand hygiene

Steps for suctioning the tracheostomy tube

-place client in semi-fowler position, if not contraindicated, to prevent hypoxemia and microatelectasis -preoxygenate with 100% oxygen to prevent hypoxia and microatelectasis -insert the catheter gently the length of the airway without applying suction to prevent mucosal tissue damage. -withdraw the catheter slightly if resistance is felt at the carina to prevent mucosal tissue damage -apply intermittent suction while rotating the suction catheter during withdrawal to prevent mucosal tissue damage. Limit suction time to 5-10 seconds with each suction pass to prevent mucosal tissue damage and limit hypoxia.

The procedure for measurement of pulsus paradoxus:

-place client insemirecumbent position -have client breath normally -determine SBP using manual BP cuff -inflate BP cuff to at least 20 mm Hg above the previously measured SBP -deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure -continue to slowlu deflate the cuff until you hear sounds throughout inspiration and expiration; note the pressure -determine the difference between the two measurements in steps 5 and 6; this equals the amount of paradox -the difference is normally <10 mm Hg, but the difference > 10 mm Hg may indicate the presence of cardiac tamponade.

A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection techniques is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick? -apply adhesive urine collection bag around the genital areas and wait for the child to void -intermittently catheterize the child every morning to avoid contaminating the specimen -place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick -place urine dipstick in the child's diaper overnight and check result in the morning

-place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick ---Children with nephrotic syndrome often require daily urinalysis to monitor for proteinuria. Urine collection bags or dipsticks in the diaper risk breakdown of edematous skin. To collect a nonsterile urine specimen from a child in diapers, the nurse can place cotton balls in a dry diaper and later squeeze urine onto a dipstick.

The nurse has unlicensed assistive personnel caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse? -assist the client in ambulating to the bathroom -dim the room lights -place the bed in low position with all side rails up -turn off the television

-place the bed in low position with all side rails up --Safety is a priority for the client experiencing an acute attach of Meniere disease. Fall precautions include placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating. Vertigo can be minimize by staying in a quiet, dark room without a television or flickering lights.

Contact precautions includes:

-placing client in private room or cohorting clients with the same infection -using dedicated equipment -wearing gloves when entering room -perform proper hand hygiene before exiting room -wearing gown with client contact and removing before leaving room -place door notice for visitors -having client leave room only for essential clinical reasons

Which of these are correct nursing actions related to client positioning? SATA -position client in high Fowler's for a paracentesis related to end-stage cirrhosis -position client on left side after liver biopsy -position client on side with head, back, and knees flexed after lumbar puncture -position client Trendelenburg on left side if air embolism is suspected -position client with arm raised above head for chest tube placement

-position client in high Fowler's for a paracentesis related to end-stage cirrhosis -position client Trendelenburg on left side if air embolism is suspected -position client with arm raised above head for chest tube placement ---Abdominal paracentesis is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease. The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture. In the event of an air embolus, the head of the bed should be lowered and the client should be positioned on the left side; this will cause the air to rise to the right atrium. The healthcare provider should be notified immediately and the nurse should remain with the client. Chest tube insertion should be performed with the client's arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm.

Steps for indwelling urinary catheter insertion for the female client

-position the client supine with knees flexed and hips slightly externally rotated -perform hand hygiene and open a sterile catheterization kit -apply sterile gloves and place a sterile drape underneath the client's buttocks -remove the protective covering from the catheter, lubricate the catheter tip, and pour antiseptic solution over cotton balls or swab sticks while maintaining sterility of gloves and sterile field -use the nondominant hand to gently spread the labia.The nondominant hand is now contaminated. -use the dominant hand to cleanse the labia and urinary meatus with antiseptic-soaked cotton balls or swab sticks. Cleanse in an anteroposterior direction. Use a new swab for each swipe to avoid transferring bacteria between areas. Cleanse the labia majora first, then the labia minora, and lastly the urinary meatus -use the dominant hand to insert the catheter until urine return is visualized in the tubing and then advance it an additional -hold the catheter in place with the nondominant hand, and then use the dominant hand to inflate the balloon

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic and the telemetry monitor indicates sinus rhythm. Which of the following critical values is most likely due to laboratory error? -blood urea nitrogen of 60 mg/dL -creatinine of 4.0mg/dL -potassium of 7.0 mEq/L -sodium of 155 mEq/L

-potassium of 7.0 mEq/L --With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L in any client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L would normally constitute a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. An assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the HCP. In this case, it is likely a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnanted hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching, and use of a larger gauge needle for the sample.

A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action? -holds the package 6 inches above the sterile field and drops the sterile gauze onto the field -opens the sterile gauze package with ungloved hands -places the sterile gauze dressings within 2 inches from the edge of the sterile drape -pours sterile normal saline solution into a sterile basin from a bottle opened 30 hours ago

-pours sterile normal saline solution into a sterile basin from a bottle opened 30 hours ago ---the sterility of an opened bottle of sterile saline cannot be guaranteed. Some institutions policies permit recapped bottles of solution to be reused within 24 hours of opening, and some require disposal of the remaining solution. Therefore, the nurse should intervene when the student uses sterile saline from a bottle that was opened >24 hours ago.

The nurse cares for a client with an exacerbation of inflammatory bowel disease. The client tells the nurse about being infected with TB 10 years ago, but never being medicated. Which prescription is of concern and prompts the nurse to notify the healthcare provider? -lansoprazole -metronidazole -prednisone -sulfasalazine

-prednisone ---A client with latent TB infection has a positive TST, is symptomatic, and cannot transmit the disease to others. Malignancy, immunosuppressant medications (prednisone), chemotherapy, and prolonged debilitating disease can convert LTBI to active disease.

The general steps for chest tube removal

-premedicate the client with analgesic 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal. -provide the HCP with sterile suture removal equipment -place the client in the Semi-Fowler position or on unaffected side to promote comfort and facilitate access for tube removal -instruct client to breath in, hold it, and bear down while the tube is removed to decrease the risk for a pneumothorax. -apply a sterile airtight occlusive dressing to the chest tube site immediately to prevent air from entering the pleural space -perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame

A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse? -administers hydromorphone 1 mg to a client who rates pain at 7 on a 1 to 10 scale -notifies physician of occasional premature ventricular beats in a client with myocardial infarction -positions a postoperative pneumonectomy client on the affected side -prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia

-prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia --Treatment of hypokalemia may require an IV infusion of potassium chloride. The infusion rate should not exceed 10 mEq/hr. Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. The charge nurse would need to intervene if the new nurse was attempting to administer IVPB KCL via gravity infusion instead of a pump. With the complete removal of the lung in a pneumonectomy, the client should be positioned on the surgical side to promote adequate expansion and ventilation of the remaining lung.

The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing interventions is the highest priority for this client? -consult with the wound care nurse specialist -insert a rectal tube to contain the feces -provide perianal skin care with barrier cream -use incontinence briefs to protect the skin

-provide perianal skin care with barrier cream --Disruptions of motor function and/or sensory function can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infections, and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick moisture barrier product to the skin. Clean, dry linens and clothing should be provided.

The healthcare provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take? -administer the medication and monitor client frequently -ask a nursing colleague if this drug amount is used -check hydromorphone dose that the client had previously -question the prescription with the prescriber

-question the prescription with the prescriber --When a medication prescription is outside the safety range, the nurse must question/clarify the prescription with the prescriber and not administer the drug automatically.

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which action by the graduate nurse indicate that more education is needed? SATA -flushing the line before and after each medication administration -pausing the parenteral nutrition prior to drawing blood from a different port -reinforcing a torn peripherally inserted central catheter line dressing with tape -scrubbing the port with alcohol for 5 seconds before use -taking the client's blood pressure in the left arm

-reinforcing a torn peripherally inserted central catheter line dressing with tape -scrubbing the port with alcohol for 5 seconds before use ---Peripherally inserted central catheter lines provide central venous access for clients who require long-term medication administration or infusion of noxious substances. Maintaining the line integrity with aseptic technique and routine care is important for continued use and prevent of central line-associated bloodstream infections. Dressings that no longer occlude the insertion site must be changed immediately. Loose corners may be temporarily reinforced with tape. The nurse should scrub the hub with alcohol or chlorhexidine for 10-15 seconds.

nursing interventions before a seizure

-remove potential sources of injury -place padding -keep oxygen at the bedside -assess therapeutic level of antiepileptic drugs -identify seizure triggers

What are the steps to administering ophthalmic medications?

-remove secretions from the eyelid by wiping from the inner to outer canthus -pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac -apply pressure to the lacrimal duct if medication has systemic effects (beta blockers, timolo maleate)

The registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube. Which action by the graduate nurse requires intervention by the registered nurse? -asking the client to take small sips of water during insertion -marking the tube at the exit point from the naris -removing the stylet before the x-ray is performed -stopping insertion of the tube while the client is coughing

-removing the stylet before the x-ray is performed ---After placing a new, small-bore nasoenteric feeding tube, the nurse should obtain an x-ray to verify tube placement and should leave the styletin place until tube placement is verified. The nurse should never reinsert a stylet into a nasoenteric tube. The nurse should stop advancing when the client is inhaling or coughing to avoid inserting the tube into the airway and then continue advancing when the client is able to swallow again.

A client is being discharged after having a coronary artery bypass (CABG) X 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? SATA -report any itching, tingling, or numbness around your incisions -report any redness, swelling, warmth, or drainage from your incisions -soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion -wash incisions daily with soap and water in the shower and gently pat them dry -wear an elastic compression hose on your legs and elevate them while sitting

-report any redness, swelling, warmth, or drainage from your incisions -wash incisions daily with soap and water in the shower and gently pat them dry -wear an elastic compression hose on your legs and elevate them while sitting ---The nurse should instruct the client with chest and leg incisions from CABG to wash them daily with soap ad water in the shower. In addition, the client must b instructed not to apply any powders or lotions to the incisions, to report any redness, swelling or increase in drainage, and to wear an elastic compression hose on the legs.

A 3-month-old client infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? -document a description of the injury -question the mother about where the infant sleeps -report the injury per facility protocol -separate the mother from the infant

-report the injury per facility protocol --The parent's account of this injury is inconsistent with the developmental milestones of a 3-month-old infant, as the muscles required for rolling over do not develop until age 4-5 months. Additionally, spiral femur fractures indicate that pressure was applied to the leg in opposite directions, which is unlikely accidental injury in a nonambulatory child. Fractures in young children, especially non-ambulatory infants, are always of concern and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities following facility protocol as required by law. After reporting suspected maltreatment, the nurse should: facilitate a complete physical evaluation, document facts and observations objectively, using medical terms when possible. Include the history provided by the parent or caregiver and the time period from inury occurrence to evaluation, and perform a review of child-care practices with the caregiver.

The nurse is caring for a client with C.Diff. Which of the following infection control measures by the nurse are appropriate? SATA -applies sterile gloves before performing client care -ensures surgical masks are worn by staff in the client's room -request that the client be assigned to a single-client room -uses alcohol-based sanitizers for hand hygiene -wears a single-use, disposable gown during client care

-request that the client be assigned to a single-client room -wears a single-use, disposable gown during client care ---C. Diff is a highly infectious bacteria requiring contact isolation precautions, including a single-client room assignment if available, disposable gowns and clean gloves, and hand hygiene with soap and water. Surgical masks are not necessary unless performing client care with the possibility of body fluid splashing

The nurse is obtaining orthostatic vital signs on a client admitted for dehydration. The nurse measures the client's blood pressure and pulse using the left brachial site with the client lying supine and then sitting. Which action by the nurse is appropriate. Blood Pressure: Supine = 153/83; sitting= 119/70 Heart Rate: Supine = 70/min; Sitting = 95/min -assist the client to a standing position and measure a third set of vital signs -place the client in reverse Trendelenburg position and take an apical pulse -reassess the client's blood pressure in the supine position using the popliteal site -return the client to a recumbent position and notify the healthcare provider.

-return the client to a recumbent position and notify the healthcare provider. ---Orthostatic vital signs involve measuring the client's blood pressure and heart rate in the supine, sitting, and standing position. Each measurement should be obtained after maintaining each position for 2 minutes. IF any position change produces decreased systolic BP >20 mm Hg, decreased diastolic BP >10 mm Hg, and/or increased pulse >20/min from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the healthcare provider. It is unsafe to assist the client to a standing position after identifying orthostatic hypotension, as a syncopal event may occur and the client may fall.

Proper position for lumbar puncture

-side-lying with knees drawn up and head flexed -sitting up and bent forward over a bedside table

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube. The client is receiving a hypertonic formula. What is the best nursing action? -dilute the formula with water -discontinue the tube feeding -send a stool sample to the lab for culture and sensitivity -slow the rate of administration of the feeding

-slow the rate of administration of the feeding ---Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their higher osmolality, hypertonic formulas sometimes cause N/V or diarrhea, especially during the initiation of total enteral nutrition. The gastrointestinal tract will pull fluid from the surrounding intra and extravascular compartments to dilute the formula, making it similar to body fluid osmolality. This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, N/V. Slowing down the rate of administration of total enteral nutrition will usually alleviate these problems. The feeding can gradually progress to the established goal rate.

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor? -step behind client with arms around waist, squat using the quadriceps, and lower client to the floor -step in front of client, brace knees and feet against the client's, and assist to the floor gently -step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor -step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor

-step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor --To prevent injury to the nurse and the client if the client is falling, the nurse uses good body mechanics to try to break the fall and guide the client to the floor if necessary. These nursing actions can help prevent injury if a client is falling while the nurse is assisting with ambulation; steps slightly behind the client with feet wide apart and knees bent; place arms under the axillae or around the client's waist; place one leg behind the other and extend the front leg; and let the client slide down the extended leg to the floor

Routine care of peripherally inserted central catheter lines includes:

-sterile dressing changes every 48 hours with a gauge dressing OR every 7 days with a transparent semipermeable dressing. --dressing changes if dressing is loose/torn, soiled, or damp -flushing the line before and after medication administration and per facility protocol -performing blood pressure and venipuncture on opposite arm -pausing infusing medications before drawing blood from the PICC to prevent false interpretation of the client's serum levels.

If signs of a transfusion reaction occur, the nurse should:

-stop the transfusion immediately -using new tubing, infuse normal saline to keep the vein open -continue to monitor hemodynamic status and notify the healthcare provider and blood bank -administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids -collect a urine specimen to be assessed for a hemolytic reaction -document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis.

Management of anaphylatic shock includes:

-stopping infusion causing the reaction and call for help -ensure patent airway -administer oxygen via high-flow non-rebreather mask (prepare for intubation) -give epinephrine intramuscularly. -maintain blood pressure with normal saline IV fluids -administer adjunctive therapies (bronchodilators, antihistamines, corticosteroids) -continue to reassess vital signs for any changes

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? -the axillary pads are torn and show signs of wear -the client has a 30 degree bend at the elbow when walking -the crutches and injured foot are moved simultaneously in a 3-point gait -there is a 3 finger-width space noted between the axilla and axillary pads

-the axillary pads are torn and show signs of wear --Proper crutch fit includes a 3-4 finger-width space between the axillary pad and axilla and a handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body weight on the hands and arms, not the axillae. Wear and tear on the crutch pads many indicate improper use or fit. Clients progress from 3-point gait to 2-point gait and then 4-point gait as rehabilitation continues.

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most important? -the client has acute urinary retention -the client is confused and incontinent -the client is elderly and at risk for falls -the client is receiving intravenous diuretics

-the client has acute urinary retention --The use of indwelling urinary catheters should be minimized during hospitalization. Appropriate use includes urinary obstruction or retention, some perioperative circumstances, required prolonged immobilization, end-of-life comfort, and facilitating healing of an open perineal or sacral wound. Indwelling urinary catheters should not be used for convenience or as a substitute for nursing care

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing healthcare provider? -the client ate a full breakfast that morning -the client has an implantable cardioverter defibrillator -the client is allergic to povidone-iodine -the client took all prescribed cardiac medications before arriving.

-the client has an implantable cardioverter defibrillator --Radio waves and a magnetic field are used to view soft tissue during MRI. This test is especially useful in diagnosing tumors, disc disease, asvascular necrosis, ligament tears, cartilage tears, and osteomyeltis. MRIs can have open or closed chambers. The client should be advised that the procedure is painless but the machine will make loud tapping noises and may cause claustrophobia in some clients inside a closed chamber. MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of the MRI can damage the ICD or interfere with its function. MRI is a noninvasive test that does not require anesthesia. The client is not required to have nothing by mouth and can take medications as normally indicated. The client is not required to have nothing by mouth and can take medications as normally indicated. No betadine is used during an MRI; gadolinium contrast is used

The elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? -the client has been admitted to the facility without the client's consent -the client is becoming delirious and should be assessed for infection -the client is concerned that someone might steal possessions -the client wants to take care of business before imminent death

-the client wants to take care of business before imminent death --This client with advanced renal failure who decides not to start dialysis treatments may have only a few weeks to live. Toxins will build up in the body and soon lead to increased weakness and cognitive decline. This client knows there is a limited time left to live and wants to ensure that possessions will be taken care of appropriately after the client's death.

An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next? -contact the national database to see if the client has a healthcare proxy -contact the police to help identify the client and locate family members -obtain a court order for the client's surgical procedure -transport the client to the operating room under implied consent

-transport the client to the operating room under implied consent --Implied consent in emergency situations includes the following criteria (there is an emergency; treatment is required to protect the client's health; it is impractical to obtain consent; it is believed that the client would want treatment if able to consent) In this case, it would be assumed that the client would want life-saving surgery; the healthcare provider should proceed.

Indications for airborne precautions

-tuberculosis -varicella zoster -herpes zoster -rubeola (measles)

The nurse helps the healthcare provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort? -fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them -lying on the affected side with head of the bed elevated to 30-45 degrees -prone with head turned to the affected side and arms over the head, supported by a pillow -upright leaning forward over the bedside table, with arms supported on pillows

-upright leaning forward over the bedside table, with arms supported on pillows --During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort. --if unable to sit, the client can be positioned lying on the UNaffected side, not the affected side.

Key teaching to reduce the client's risk of bleeding with immune thrombocytopenic purpura.

-use soft-bristle toothbrushes, gentle flossing, and nonalcoholic mouthwashes to prevent periodontal disease and gingival bleeding -avoid activities that may cause trauma. -wear footwear -take prescribed stool softeners and laxatives as needed to prevent hard stools and straining -use electric razors to reduce the risk of nicking the skin -avoid nonsteroidal anti-inflammatory drugs.

Steps to prevent infections in clients with urinary catheters include:

-wash hands thoroughly and regularly -perform routine perineal hygiene with soap and water each shift and after bowel movements -keep drainage system off the floor or contaminated surfaces -keep the catheter bag below the level of the bladder -ensure eachclient has a separate, clean container to empty collection bag and measure urine -use sterile technique when collecting a urine specimen -facilitate drainage of urine from tube to bad to prevent pooling of urine in the tube or backflow into the bladder -avoid prolonged kinking, clamping, or obstruction of the catheter tubing -encourage oral fluid intake in clients who are awake and if not contraindicated -secure the catheter in accordance with hospital policy -inspect the catheter and tubing for integrity, secure connections, and possible kinks

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take? -have the client remove the existing dressing while the nurse prepares sterile supplies -wear clean gloves for removal and application of a new dressing -wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing -wear sterile gloves, gown, and goggles to remove the soiled existing dressing

-wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing --The existing dressing is already contaminated so clean gloves can be worn to remove and discard it. Surgical wounds should be re-dressed using aseptic technique, which would require sterile gloves and sterile dressing supplies. The nurse should carefully remove the soiled dressing to avoid shedding an microorganisms into the air and expose the wound for minimal time to avoid additional contamination.

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much. I can't do it." What is the first action by the nurse? 1. Administer an analgesic 2. Assess the child's level of pain using a numeric rating scale 3. Come back later in the day 4. Tell the child, "Get up and walk if you want to go home soon."

2. Assess the child's level of pain using a numeric rating scale --When a client is in pain, assessment is the first necessary nursing action. The pain assessment helps to determine the appropriate relief measure and serves as a baseline for evaluating the effectiveness of the chosen pharmacological or non-pharmacological measure. A numeric pain scale can be used with most children who can count and understand the concept of numbers, generally at around age 5. The scale uses a straight line with divisions marked in units from 0-10.

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? 1. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning 2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning 3. Discard urine and container, have client void, add urine to new container, and then restart test 4. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM

2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning --Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine. These tests require the collection of all urine produced in a specified time period to ensure accurate test results. The proper container for any specific test is obtained from the lab. The collection container must be kept cool to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning void.

Define systemic lupus erythematosus

autoimmune disorder in which an abnormal immune response leads to chronic inflammation of different parts of the body

Clients with SLE should be advised to..

avoid harsh sunlight and ultraviolet light exposure, as well as harsh soaps and chemicals. --receive annual influenza vaccinations due to susceptibility to infections

Define electrical alternans

variation in QRS amplitude --could be present in cardiac tamponade.

Describe phentolamine (Regitine)

vasodilator injected subcutaneously to counteract the effects of some adrenergic agonists (norepinephrine or dopamine)

Raynaud phenomenon is characterized by...

vasospasm-induced color changes in the fingers, toes, ears, and nose. --can develop secondary to scleroderma

What should you do if you have obtained pulsating blood when drawing labs?

withdraw the needle and apply pressure for 5 minutes ---pulsating bright red blood indicates that an artery was accessed

The nurse is preparing a client for magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? SATA -"I ate lunch about 4 or 5 hours ago" -"I got a rash the last time I had IV contrast" -"I had my last period 6 weeks ago" -"I have a hearing aid implanted in my ear" -"I smoked a cigarette about an hour ago"

-"I got a rash the last time I had IV contrast" -"I had my last period 6 weeks ago" -"I have a hearing aid implanted in my ear" ---MRCP is a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium and is a safer, less-invasive alternative to endoscopic retrograde cholangiopancreatography. to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants or any previous allergy or reaction to gadolinium. A client with a history of rash following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy. Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP.

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statement made by the parents demonstrate correct understanding? SATA -"I can mix the medication in a bowl of my child's favorite cereal" -"I should give another dose if my child vomits after taking the medication" -"I should measure liquid medications using an oral syringe" -"I will encourage my child to help me as I prepare the medication" -"I will place my child in time-out if the medication is refused"

-"I should measure liquid medications using an oral syringe" -"I will encourage my child to help me as I prepare the medication" --For pediatric clients, liquid medications should be measured with oral syringes, which have small, well-defined increments and provide accuracy for small doses. Household measuring devices are inaccurate due to variability of size and differences in measuring methods. Pediatric clients may refuse medication due to a fear of unpleasant taste. Preschool children typically start to take initiative and affirm power over the environment. Encouraging participation promotes initiative and cooperation by giving the child a sense of control. The child may not finish eating food mixed with medication and would receive only a partial dose. Parents should notify the HCP if the child vomits after oral medication administration; additional medication may cause an overdose, as some medication may have been absorbed. Preschool children respond best to positive reinforcement and rewards as incentives for desired behavior

A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching? -"A 5/8 inch, 25 gauge needle is appropriate for intramuscular injection in newborns" -"I will clean the injection site with an antiseptic swab before administration" -"I will draw the medication into a 1-mL syringe" -"The medication should be administered into the deltoid muscle"

-"The medication should be administered into the deltoid muscle" --IM injections are commonly administered to newborns shortly after birth or before discharge. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred site for IM injections in newborns and infants. The deltoid muscle is an inappropriate injection site for newborns due to inadequate muscle mass. For IM injections, the needle length should be 5/8 inch for newborns and 5/8 to 1 inch for infants; these lengths are adequate for reaching the muscle mass while avoiding underlying tissues. A 22- to 25-gauge needle is appropriate for clients age <12 months. The medication should be administered using aseptic technique; cleaning the site with an antiseptic solution is appropriate. A 1-mL syringe should be used to measure very small doses in 0.01-mL increments for newborns, infants, and small children. Pediatric medication dosages can be very small and should be measured to two decimal places.

The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the healthcare provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse? -"Do you have any questions about the diagnosis?" -"There are medications available to treat Alzheimer disease" -"This new diagnosis must be frightening for you" -"we can help you make decisions about your care"

-"This new diagnosis must be frightening for you" --When clients and families are faced with significant life changes, the nurse should support the process of coping by encouraging emotional expression. The nurse provides support by expressing empathy, actively listening, and encouraging therapeutic communication

A nurse is caring for 4 clients. Which prescription by the healthcare provider would the nurse question and seek further clarification before administering? -0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours -IV bolus of 1000mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy -IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL -IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure

-0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours --the nurse should question the administration of a hypotonic IV solution to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associatedwith vomiting and diarrhea, burns, and traumatic injury. Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to this client (client 2). Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic diuresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9% sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature.

The nurse is preparing to administer an IM immunization to a 6-month old infant. Which needle length and injection site would be the most appropriate to minimize a local reaction to the vaccine components? -3/8 inch needle in the anterolateral thigh -5/8 inch needle in the ventrogluteal muscle -1 inch needle in the anterolateral thigh -1.5 inch needle in the ventrogluteal muscle

-1 inch needle in the anterolateral thigh --The needle length and injection site for IM injections are dependent on a client's age and muscle mass. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred IM injection site for newborns and infants. Selection of the most appropriate needle length is an important factor in ensuring immunization success and minimizing local reactions to vaccine components. If the needle is too short, the IM vaccine is injected into subcutaneous fat, resulting in vaccine failure due to poor mobilization of the antigen within adipose tissue. Infants typically require a 1 inch needle for IM injections. The ventrogluteal area in an infant does not have enough muscle mas for use and is not recommended until at least age 3.

The nurse is teaching a parent of an infant about administration of an oral medication. What should be included in the teaching? SATA -add the medication to the bottle of formula before feeding -direct liquid medication toward the inside of the infant's cheek -hold the infant in a semi-reclining position during administration -measure and administer the medication using an oral syringe -open the infant's mouth by gently pinching the nose shut

-direct liquid medication toward the inside of the infant's cheek -hold the infant in a semi-reclining position during administration -measure and administer the medication using an oral syringe --Giving oral medications to infants requires specialized techniques for safe administration. A plastic, disposable oral syringe can be used for accurate dosing and ease of delivery. Oral medication should be administered with the infant in a semi-reclining position, which is similar to the feeding position. This position promotes comfort, prevents aspiration, and may be better controlled by the nurse if the infant resists the medication. Liquid medications administered by oral syringe should be directed toward the back and inside of the infant's cheek. The medication should be dispensed slowly in small amounts, allowing the infant to swallow between squirts to prevent aspiration. Medications are never mixed in a bottle of infant formula as this can affect the taste and the infant may then refuse the formula in the future. Pinching the nose shut during medication administration may cause aspiration. The infant's mouth should be opened by applying gentle pressure to the chin or cheeks.

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? SATA -disposable gown -face shield -gloves -N95 respirator -surgical mask

-disposable gown -face shield -gloves -surgical mask --Bacterial meningitis and many respiratory illnessesare transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet away from the client. Droplet precautions for routine care require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets. Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care. Dedicated medical equipment should remain in the room to limit spread of infection. For client care involving airborne precautions, a class N95 or higher respirator must be used instead of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated only for barrier protection from droplet splashing and for filtration of large respiratory particles

The nurse is precepting a new graduate nurse who is administering a prefilled enoxaparin injection to an obese client. Which action by the graduate nurse indicates the need for further education from the nurse preceptor? -discourages the client from rubbing the injection site after the injection -ejects the air bubble from the prefilled syringe before administration -inserts the needle and injects the medication at a 90-degree angle -selects an injection site on the left lateral side of the abdomen

-ejects the air bubble from the prefilled syringe before administration --Low-molecular-weight heparins are anticoagulants commonly used for prevention and treatment of deep venous thrombosis and pulmonary embolism. LMWH is administered subcutaneously and is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose. During injection, the air bubble follows the medication out of the syringe, ensuring that no medication is left behind. The nurse should not expel the air bubble prior to administration as this could result in an incomplete dose and medication error. After subcutaneous injection, the client should not rub the injection site as this increases bruising and the risk for hematoma. A 90-degree angle is appropriate for a subcutaneous injection in an obese client. In general, subcutaneous injections are administered at a 90-degree angle if 2 inches of tissue can be grasped or a 45-degree angle if only 1 inch of tissue can be grasped. Subcutaneous anticoagulants are best absorbed when administered in the lower part of the right or left lateral abdominal wall away from the umbilicus.

The nurse will anticipate administration of isotonic IV fluids in which clients? SATA -14-day-old client has urine output of 2 mL/kg/hr with flat fontanel -3-month-old client with diarrhea has a capillary refill of 4 seconds and mottling in lower extremities -8-year-old client has serum sodium of 131 and blood urea nitrogen of 15 mg/dL -client is having contractions every 10 minutes and will be receiving an epidural analgesic -client received a bolus of IV fluid for hyperemesis gravidarum, and urine output is 80 mL/4 hour and pulse is 120/min

-3-month-old client with diarrhea has a capillary refill of 4 seconds and mottling in lower extremities -client is having contractions every 10 minutes and will be receiving an epidural analgesic -client received a bolus of IV fluid for hyperemesis gravidarum, and urine output is 80 mL/4 hour and pulse is 120/min ---Isotonic IV fluids expand only the extracellular fluid and are used as fluid replacement for fluid volume deficit. Commonly examples are NS and LR. Capillary refill indicates adequate circulation and perfusion. Normal capillary refill time is less than 3 seconds, and a delay can be an indication of dehydration. Mottling is characterized by patches of pink, pale, and cyanotic. Clients in labor usually receive 500-1,000 mL of isotonic fluids prior to an epidural anesthesia as vasodilation below the epidural site can occur and result in hypotension. Up to 40% of these clients may experience hypotension after an epidural anesthesia. The preadministration of IV fluids can lessen hypotension. Hyperemesis gravidarum is severe vomiting that can result in dehydration. Despite being given some fluids, this client still needs additional fluids. Minimal obligatory urine output is 30mL/hr or 120 mL/4 hr. Urine output is the best indicator of adequate rehydration. Tachycardia with pulse of 120/min indicates dehydration unless there is another clear etiology. Uirnary output of 2 ml/kg/hr and a flat fontanel are normal findings in an infant. Normal serum sodium in children is 138-145. Hyponatremia often results from excess fluids. There would be no need to give this client (option 3) additional fluids. Normal BUN in children is 5-18 mg/dL and BUN is elevated with dehydration or a need for fluid. The range provided for client (option 3) is normal and does not indicate that additional fluids are required.

The nurse is caring for 4 clients requiring IV fluid therapy. For which client should the nurse anticipate the need for isotonic crystalloid administration? -25-year-old with a closed-head injury and signs of increasing intracranial pressure -45-year-old with acute gastroenteritis and dehydration -60-year-old with seizures and serum sodium of 112 mEq/l -68-year-old with chronic renal failure and hypertensive crisis

-45-year-old with acute gastroenteritis and dehydration --Isotonic fluid therapy is used to treat clients with extracellular fluid deficits. Clients at risk for cerebral swelling (increased intracranial pressure, hyponatremia) require hypertonic fluid administration to decrease cellular swelling. Isotonic fluid administration may cause fluid overload in clients with renal failure.

The nurse plans to administer 9:00am medications via the NG route to a client with an NG tube. The nurse contacts the PHCP to clarify which prescriptions that are contraindicated using this route? SATA -enteric-coated ibuprofen 200-mg tablet -extra-strength acetaminophen 500-mg tablet -metoprolol extended-release 50-mg tablet -sulfamethoxazole double-strength 800-mg tablet -tamsulosin 0.4-mg slow-release capsule

-enteric-coated ibuprofen 200-mg tablet -metoprolol extended-release 50-mg tablet -tamsulosin 0.4-mg slow-release capsule --enteric-coated drugs have a barrier coating that dissolves at a slower rate to protect the stomach from irritant effects. Crushing enteric-coated medications disrupts the barrier coating and may cause stomach irritation. In addition, the particles from the coating may clog the NG tube, particularly small-bore NG tubes. Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly within a specific time frame. Crushing these medications alters this property and introduces the risk of adverse effects from toxic blood levels due to more rapid drug absorption. Therefore, the nurse should first contact the PHCP for clarification

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? -a private room with contact and droplet precautions -a private room with negative airflow and contact and airborne precautions -a private room with positive airflow and airborne precautions -a semi-private 2-bed room with standard precautions

-a private room with negative airflow and contact and airborne precautions --Shingles is a reactivation of the varicella-zoster virus. It is more likely to occur when a client's immune system is compromised by disease or treatments. Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes directly to the outside rather than recirculating to the rest of the hospital. Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions.

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home. What intervention does the nurse prioritize to promote proper self care? -assess the client's feelings about placement at a skilled nursing facility for care -educate the client on the risks of tissue death if not properly cared for at home -explore the client's ability and motivation to perform care at home -provide the client with the supplies needed to change dressings as recommended

-explore the client's ability and motivation to perform care at home --Self care is a critical component of health. However, barriers to self care are multifactorial. The nurse must assess for adequate knowledge and ability to perform self-care activities and the desire to complete such activities. Once the barriers have been identified, the nurse can work with the client to create an individualized plan to meet healthcare needs

When preparing medication from a glass ampule, the nurse ensures safety and prevents contamination during medication administration by:

-flicking upper stem of the ampule with a fingernail several times to ensure removal of medication from the ampule neck -using sterile gauze to break the ampule neck away from the nurse's body to prevent injury from glass shards -setting the ampule on a flat surface or inverting it to withdraw the medication -disposing of the ampule in a sharps container

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections? SATA -after insertion, secure the catheter with a sterile, semi-permeable dressing -clean ports with an alcohol swab prior to accessing the catheter system -prior to insertion, apply chlorhexidine, using friction, to the venipuncture site -prior to insertion, shave excess hair over the selected venipuncture site -replace or remove the venous catheter every 48 hours

-after insertion, secure the catheter with a sterile, semi-permeable dressing -clean ports with an alcohol swab prior to accessing the catheter system -prior to insertion, apply chlorhexidine, using friction, to the venipuncture site ---The nurse should select an IV catheter site on an upper extremity, preferably the hand or forearm. To reduce the incidence of catheter-related infections, the selected site should be cleaned with antiseptic solution using friction and then allowing to air-dry completely. Chlorhexidine is preferred as it achieves an antimicrobial effect within 30 seconds,whereas povidine-iodine takes >2 minutes. After insertion, the catheter hub should be secured with a narrow strip of sterile tape to prevent accidental removal or excessive back-and-forth motion, which can introduce microorganisms into the vein. In addition, a sterile, transparent, semipermeable dressing should be used to secure the catheter hub to reduce infection risk and allow visualization of the site. When the catheter is accessed, the needleless port should be cleansed with an alcohol swab to kill externally colonized microorganisms

Basic steps for suppository administration include:

-apply clean gloves and position the client appropriately based on age and size -lubricate the tip of the suppository with water-soluble jelly -insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years -angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa to ensure systemic absorption. -hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion -if a BM occurs within 10-30 minutes, observe for the presence of the suppository

The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? SATA -apply moisture barrier cream to dry skin -clean perineal area after incontinent episodes -massage bony prominences frequently -place foam-padded seat cushions on chairs -reposition clients in bed every 6 hours

-apply moisture barrier cream to dry skin -clean perineal area after incontinent episodes -place foam-padded seat cushions on chairs --Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction and shearing forces. The nurse should assess every client's risk for pressure injuries upon admission at least once daily during hospitalization.

The nurse should teach a client receiving a clonidine patch to...

-apply patch to a dry hairless area on the upper arm or chest -wash hands before and after application -rotate sites with each new patch application -discard patch away from children or pets with sticky folded together -never wear more than 1 patch at a time -never stop using the patch abruptly

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include? SATA -apply patch to the upper arm or chest -fold used patches in half with sticky sides together before discarding -remove patch if dizziness occurs when getting up -rotate sites each time a new patch is applied -shave hair before applying patch

-apply patch to the upper arm or chest -fold used patches in half with sticky sides together before discarding -rotate sites each time a new patch is applied --Clonidine is a potent antihypertensive agent and is available as a transdermal patch. The patches should be replaced every 7 days and can be left in place during bathing

A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time? -ask about the client's recent bowel and bladder habits -assess the home for sources of excessive noise -provide information about respite and adult day care -review behavior-management techniques with caregiver

-ask about the client's recent bowel and bladder habits --Alzheimer disease is a form of dementia that causes a progressive decline of cognitive and physical abilities. Behavioral changes (agitation, aggression) often result from the client's inability to identify a stressor. Stressors may include pain or problems with elimination or eating. The nurse's priority must be identifying and solving problems related to the client's basic physiological needs according to the Maslow hierarchy of needs

The nurse is preparing to infuse 2 units of packed red blood cells to a client with a gastrointestinal bleed. Which actions should the nurse take? SATA -assess client's vital signs -infuse both units simultaneously -obtain a Y tubing set and prime with normal saline -plan to remain with client during the 1st 14 minutes of transfusion -set infusion pump to delivery unit over 30-45 minutes -spike filtrated intravenous tubing with dextrose 5% water

-assess client's vital signs -obtain a Y tubing set and prime with normal saline -plan to remain with client during the 1st 14 minutes of transfusion --always verify blood products, type and crossmatch results, and client identifiers with another nurse prior to transfusion. Obtain vital signs before, during, and after blood administration. Use Y tubing primed with NS and an IV pump for administration. Watch for transfusion reaction and stop the transfusion immediately if a reaction occurs.

What skin care should be provided to prevent pressure ulcers?

-barriers to incontinence -hydration -moisturizer

What are the risks associated with long-term use of ketorolac?

-bleeding -gastrointestinal ulcers -kidney injury

The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? SATA -attaches an 18-gauge injection needle to a syringe for withdrawal of medication -breaks the ampule neck away from the nurse's body to prevent injury from the glass -disposes of the empty glass ampule in a sharps container -injects air into the glass ampule prior to withdrawing the medication -rests and steadies the needle on the ampule's outer rim to withdraw medication

-breaks the ampule neck away from the nurse's body to prevent injury from the glass -disposes of the empty glass ampule in a sharps container --When preparing medication from a glass ampule, the nurse breaks the ampule away from the body and discards it in the sharps container. The nurse withdraws medication using a filter needle to prevent the injection of glass shards, avoids touching the needle to contaminated ampule edges, and avoids injecting air to prevent spillage

What nutrition techniques should be used to prevent pressure ulcers?

-calorie counting (30-35 kcal/kg/day) -enteral nutrition -high-protein nutritional supplements -deficiency assessment

The nurse on the telemetry unit is preparing client medications in the medication room at the nurse's station. The nurse should perform which actions to be consistent with client safety practices related to medication administration? SATA -check laboratory values before administering anticoagulants -compare medication, dosage, and route to prescription orders prior to administration -discard any unlabeled medications -open unit dose packages and place medications in a dispensing cup to take to the bedside -wear gloves to handle unopened individual unit dose medication packages

-check laboratory values before administering anticoagulants -compare medication, dosage, and route to prescription orders prior to administration -discard any unlabeled medications --The nurse must follow the 6 rights of medication administration. Additionally, one of the National Patient Safety Goals is to "improve the safety of using medications". This includes labeling all medications as soon as prepared, discarding any medications that are found unlabeled, and taking extra care for clients who take anticoagulant drugs. Individual dose packages should be opened at the client's bedside and should be placed in a medication cup only immediately prior to administration. Gloves are generally not required during medication preparation or handling of unopened packages or vials, although hand hygiene should be performed both prior to preparation or handling and again prior to administration.

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time? -administer an inhaled bronchodilator -check marked insertion depth of the tube -request a prescription for a diuretic -start the client on incentive spirometry

-check marked insertion depth of the tube --a nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. If a client with a feeding tube develops signs of aspiration pneumonia, the feeding should be stopped immediately and tube placement checked. Some facilities use capnography to determine placement; if a senor detects exhaled carbon dioxide from the tube, it is in the client's airway and must be removed immediately. An inhaled bronchodilator may be prescribed to treat aspiration pneumonia, but the priority is to stop the feeding and check tube placement to prevent additional aspiration. Crackles may be heard with fluid overload, aspiration, or pneumonia. A diuretic would be appropriate if a client is experiencing pulmonary edema from fluid overload. Incentive spirometry promotes expansion of the lungs and resolves atelectasis, but is not the priority.

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? -check the healthcare provider's prescription in the medical record -explain that the healthcare provider has prescribed the medication -look up the medication in the pharmacology reference -teach the client about the purpose of the medication

-check the healthcare provider's prescription in the medical record -When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration. If an error is ruled out, the nurse should follow up with appropriate teaching. Explaining that the nurse is just following orders is rarely the correct answer. A pharmacology reference can verify information about the medication, but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date.

A nurse is preparing to insert a peripheral IV catheter dons clean gloves, applies a tourniquet to the client's arm, and immediately identifies a site for venipuncture. What are the remaining steps that the nurse should take? (5 steps)

-cleanse selected site while using an antiseptic swab -anchor vein by holding skin taut -insert needle bevel-side up until blood return is observed -advance catheter hub while retracting stylet -remove stylet and attach extension or infusion

The nurse is evaluating a return demonstration by the client of a dry dressing change. Which action by the client would cause the nurse to intervene? -client applies sterile adhesive dressing over gauze without touching the wound bed -client applies sterile gauze moistened with sterile saline to wound surface -client cleanses site with a sterile saline swab in a spiral pattern from the center out -client removes old dressing with clean gloves and checks site for signs of infection

-client applies sterile gauze moistened with sterile saline to wound surface --Prior to discharge, the nurse evaluate the client's ability to perform home wound care. When performing a simple dry dressing change, the client should: don clean gloves and perform hand hygiene before and after removing the old dressing; cleanse the wound bed using sterile saline by moving from "clean" to "dirty" or from the center of the wound outward; thoroughly dry the wound and surrounding skin using sterile gauze to prevent maceration of underlying tissues; monitor the site for signs of infection; apply dry, sterile gauze over the wound bed

What is required for contact precautions?

-client should be placed in a private room or semi-private with another client with the same infection -dedicate equipment for client -wear gloves when entering the room -perform excellent hand hygiene before exiting the room -wear gown with client contact and remove it before leaving the room -place door notice for visitors -ensure client leaves the room only for essential clinical reasons

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action? -assess the condition of the IV site -check 2 client identifiers before administering medications -consult a medication guide for compatibility -wash hands prior to administering medications

-consult a medication guide for compatibility --The priority when administering 2 IV medications concurrently is to determine drug compatibility. Incompatible drugs given through the same IV line will deteriorate or form a precipitate. This change is visualized through either a color change, a clouding of the solution, or the presence of particles. If 2 or more drugs are not compatible, the nurse may consider inserting a second IV or consulting the pharmacists and the healthcare provider to determine the safest and most beneficial plan for the client.

The registered nurse is providing nursing care with a licensed practical nurse and unlicensed assistive personnel. The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain. Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication What is the most appropriate action for the RN to take? -administer the hydromorphone -ask the licensed practical nurse to administer the medication -ask the unlicensed assistive personnel to take repeat vital signs -contact the healthcare provider

-contact the healthcare provider --A STAT order indicates that the medication should be given immediately and only one time. A new prescription for the medication must be acquired before the dose can be repeated. The most appropriate action is to contact the healthcare provider to request an as-needed prescription for pain medication

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia. The health care provider's prescription states: IV potassium chloride 10 mEq/100 mL 5% dextrose in water now, infuse over 30 minutes. What is the nurse's priority action? -assess the patency of the peripheral IV site -check the most current serum potassium level -contact the healthcare provider to verify the prescription -set the electronic IV pump to 100 mL/hr

-contact the healthcare provider to verify the prescription\ --The recommended rates for an intermittent IV infusion of potassium chloride are no greater than 10 mEq over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr when infused through a central line. If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr over 30 minutes = 20 mEq/hr. A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the healthcare provider to verify this prescription is the priority action.

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first? -collect a urine specimen and send to the lab -deflate the balloon on the urinary catheter -remove the catheter by gently pulling from the urethra -use a sterile 4X4 pad to absorb the blood around the meatus

-deflate the balloon on the urinary catheter --Because signs of traumatic injury are present, the nurse should follow steps to remove the catheter before further complications such as obstruction occur. A urine specimen can be collected after the balloon is deflated or after the catheter is removed if needed. The meatus should be cleaned after balloon deflation.

The clinic nurse is assessing the client's understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease. Which statement indicates that the client has a correct understanding of this medication? -"A capsule holds the powdered medication that I have to put in a special inhaler" -"I do not need to rinse my mouth with water after taking tiotropium" -"Tiotropium helps control my COPD by reducing inflammation in my airway"

-"A capsule holds the powdered medication that I have to put in a special inhaler" --tiotropium is a long-acting, 24-hour, anticholinergic, inhaled medication used to control COPD. It is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client proper administration prior to the first dose, emphasizing that the capsule should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion, During future appointments, the nurse should assess the client's ability to use this medication correctly. Client's should rinse the mouth after using tiotropium and inhaled steroids to remove any medication remaining in the mouth, which decreases the risk of developing thrush. Tiotropium is a controller medication for COPD with a peak effect of approximately 1 week; therefore, it should not be used as a rescue medication. Anticholinergic inhaled medications do not reduce inflammation in the airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help dry up airway secretions.

A client who has been prescribed several medications asks, "Can I take over-the-counter (OTC) medications with my prescriptions?" Which of the following statements by the nurse is appropriate? SATA -"Always ask the healthcare provider or pharmacist before taking OTC medications" -"Ingredients in some OTC medications may interact with prescription medications" -"It is best to avoid OTC medications, but herbal and supplement products are usually safe" -"Remember to discuss all medications, herbs, and supplements you take with you healthcare providers" -"Taking OTC medications can sometimes hide symptoms of a serious disease or illness"

-"Always ask the healthcare provider or pharmacist before taking OTC medications" -"Ingredients in some OTC medications may interact with prescription medications" -"Remember to discuss all medications, herbs, and supplements you take with you healthcare providers" -"Taking OTC medications can sometimes hide symptoms of a serious disease or illness" ---OTC medications are available without a prescription and are used to treat common illnesses. It is estimated that nearly four times as many health conditions are independently managed with OTC medications as are managed under supervision of a healthcare provider. Prior to taking OTC medications, the client should talk with a HCP or pharmacist, particularly if already taking prescribed medications. Even when taken as directed by the OTC medication label, interactions and adverse effects may occur when used in combination with prescription medications. All medications, herbal products, and supplements must be discussed with HCPs so that they can be reconciled and considered before changing or adding new treatments. When OTC medications are used to manage symptoms, the diagnosis and treatment of serious underlying medical conditions may be delayed.

A client with a nasogastic tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? SATA -discard aspirated gastric residual in a biohazard container -flush the nasogastric tube before and after administering the feeding -place the client is the semi-Fowler position -Start the feeding after obtaining a gastric residual volume of 75 mL -start the feeding when the gastric residual has pH of 6

-flush the nasogastric tube before and after administering the feeding -place the client is the semi-Fowler position -Start the feeding after obtaining a gastric residual volume of 75 mL --When administering bolus enteral feedings, the nurse should elevate the head of the bed to 30-45 degrees and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk. Many institutions require the nurse to hold feeding if the client must remain supine. Feeding tubes should be flushed before and after feedings to keep the tube patent. Gastric residual volumes are traditionally checked every 4 hours with continuous feeding or before each bolus feeding. Per facility policy, enteral feedings may be held for high GRV to reduce aspiration risk. Low GRV indicates that the client is tolerating feedings well. Some facilities no longer routinely check GRVs because recent evidence shows that the procedure may not truly indicate aspiration risk and actually impairs calorie delivery. Regardless of GRV checks, the nurse should closely monitor clients for symptoms of intolerance, which may indicate that feedings should be held or reduced in volume.

A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm3. What information contained in the admission history of this client will need to be addressed during discharge education? -eats steamed vegetables daily -enjoys eating grilled shrimp weekly -gardens as hobby -takes a bath daily and applies moisturizer

-gardens as hobby --This client has a very low absolute neutrophil count; having <500 cells/mm3 indicates severe neutropenia and increases the risk of infection. All risks for infection should be minimized in a client with neutropenia. Soil contains many pathogens, including Aspergillus fungus, which could expose this client to infection. Gardening and contact with fresh flowers and plants should be avoided when a client is at increased risk for infection. In addition, the client's room should not have standing water. Strict hand-washing is recommended. The client should be placed in a private room while in the hospital and all visitors should wear a mask

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? SATA -gloves when contact with body fluids is anticipated -gloves when starting an intravenous line -gown, gloves, face shield, and googles for every client encounter -hand hygiene before and after providing client care -N95 respiratory mask and face shield

-gloves when contact with body fluids is anticipated -gloves when starting an intravenous line -hand hygiene before and after providing client care --Hand hygiene is performed before and after providing client care. HIV is a blood-borne virus, and standard precautions are sufficient protection against viral transmission. The nurse wears gloves when anticipating exposure to blood or body fluids. Isolation gowns are applied if the nurse if the nurse anticipates splashing of body fluids on clothing. A face shielfd and goggles are applied if splashing in the eyes is a possibility. The nurse should always don gloves when starting an intravenous line.

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? SATA -advance past the external sphincter only -guide suppository along the rectal wall -hold buttocks together firmly after insertion -position client supine with knees and feet raised -use gloved fifth finger for insertion

-guide suppository along the rectal wall -hold buttocks together firmly after insertion -position client supine with knees and feet raised -use gloved fifth finger for insertion ---Pediatric administration of rectal suppositories is similar to the adult technique, with a few key modifications due to the small size of a child's colon and varying developmental needs. Age-appropriate explanations and/or distractions should be implemented to reduce distress. Toddlers and infants may benefit from distraction with a toy; preschoolers and older children can be instructed to take deep breaths or count during the procedure.

The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen. The nurse intervenes when the student performs which action? -instills ear drops at room temperature -instills ear drops with dropper by occluding the ear canal -places a cotton ball loosely in outermost auditory canal after the instillation -pulls pinna up and back and instills drops

-instills ear drops with dropper by occluding the ear canal --Otic medications are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect trapped in the ear canal. They are contraindicated in a client with a perforated eardrum.

The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total parenteral nutrition through a right peripherally inserted central venous catheter. The nurse should implement what actions to prevent complications during this procedure? SATA -instruct the client to hold the breath when changing the injection caps and tubing -instruct the client to keep the head to the right side during the dressing change -perform hand hygiene before and after the procedure -place the client in the Trendelenburg position before the procedure -wear sterile gloves and a surgical mask when changing the dressing

-instruct the client to hold the breath when changing the injection caps and tubing -perform hand hygiene before and after the procedure -wear sterile gloves and a surgical mask when changing the dressing --Peripherally inserted central venous catheters are commonly used for long-term antibiotic administration, chemotherapy treatments, and nutritional support with total parenteral nutrition. Complications related to the PICC are occulsion of the catheter, phlebitis, air embolism, and infection due to bacterial contamination. Prior to a central line dressing change, the nurse performs hand hygiene. The central line dressing changes is performed using sterile technique with the nurse wearing a mask to prevent contamination of the site with microorganisms or respiratory secretions. During injection cap and tubing changes, the client is instructed to hold their breath to prevent air from entering the line, traveling to the heart, and forming an air embolism. If an air embolism is suspected, the client should be placed in the Trendelenburg position (head down) on the left side, causing any existing air to rise and become trapped in the right atrium

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? SATA -keep dedicated equipment for client -perform hand hygiene before exiting the room -place a "no visitors" sign on the client's door -wear a face mask when in the room -wear an isolation gown when providing direct care

-keep dedicated equipment for client -perform hand hygiene before exiting the room -wear an isolation gown when providing direct care --In addition to standard precautions, the client infected with multidrug-resistant organisms will require contact precautions. The client with MRSA or VRE are allowed to have visitors. However, these individuals will need instructions from the nursing staff about hand hygiene and the use of gloves and gowns and their disposal prior to leaving the client's room. A sign should be placed on the client's door to inform visitors about these precautions. A face mask is required for droplet precautions, not contact precautions.

The nurse is caring for a 2-year-old who is refusing oral antibiotics. What is the nurse's next action? -ask the healthcare provider to switch to IV antibiotics -hide the antibiotic in the child's favorite food or beverage -offer the child a choice of orange or apple juice with the antibiotic -tell the child that the medication tastes just like candy

-offer the child a choice of orange or apple juice with the antibiotic --The need for control is common during the toddler stage of psychosocial development, and administering oral medications can be challenging. The nurse should offer the toddler limited choices and avoid questions that require a yes or no response. Medication should not be referred to as candy as this increases the risk for a toxic ingestion.

What repositioning techniques should be used to prevent pressure ulcers?

-pad bony prominences -pad medical devices -lift, do not pull -limit chair time -minimize shearing and frictional forces -turn every 2-4 hours

Steps for removing an indwelling catheter include the following

-perform hand hygiene -ensure privacy and explain the procedure to the client -apply clean gloves -place a waterproof pad underneath the client -remove any adhesive tape or device anchoring the catheter -follow specific manufacturer instructions for balloon deflation -loosen the syringe plunger and connect the empty syringe hub into the inflation port -deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL -remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client -if any resistance is met, stop the removal procedure and consult with the urologist for removal -empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy -remove gloves and perform hand hygiene

Steps to administering otic medications

-perform hand hygiene -position the client side-lying with the affected ear up -pull pinna up and back -administer prescribed number of ear drops -instruct the client to remain side-lying for 2-3 minutes -place cotton ball loosely in the outer ear canal for 15 minutes

Steps for reconstituting powdered medication for parenteral administration

-perform hand hygiene and don clean gloves -withdraw an amount of air from the vial equal to the prescribed amount of diluent to create negative pressure that will be equalized when the diluent is injected into the vial. -inject the appropriate diluent into the vial. -roll the vial between the palms of the hands to gently mix the solution. Avoid shaking the vial as bubbles may develop. -withdraw the reconstituted medication from the vial into a sterile syringe for administration. -verify the dosage by checking the prepared medication against the medication administration record and medication label -label the syringe with the medication name and dosage to prevent medication errors at the bedside

When exiting the room of a client on both contact and airborne precautions, the nurse should perform the following actions in order:

-place the call light within the client's reach and ensure that the client's bed is locked and in the lowest position -remove the gown and gloves in order of most to least contaminated. The nurse can remove gloves, then gown or alternately. -discard the gown and gloves and then perform hand hygiene -exit the negative pressure room and immediately close the door to prevent infectious airborne microorganisms from escaping into the hallway or isolation anteroom -remove and discard the N95 respirator mask and then perform final hand hygiene

The nurse performs nasogastric tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first? -ask the client to take several small sips of water -continue to slowly advance the tube until placement is reached -gently remove the tube and reinsert in the other naris if possible -pull back on the tube slightly and then pause to give the client time to breath

-pull back on the tube slightly and then pause to give the client time to breath --During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement, asking the client to take small sips of water to facilitate advancement to the stomach. The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible.

What are the steps for administering an IM injection using the Z-track technique?

-pull skin 1-1.5 inches laterally away from the injection site. -hold skin taut with nondominant hand -insert needle at 90-degree angle. The taunt skin facilitates entry of needle and angle ensures reaching the muscle -inject medication slowly into the muscle while maintaining traction -wait 10 seconds after injecting the medication and withdraw the needle while maintaining traction on the skin (allows medication to diffuse before needle removal and help prevent tracking) -release the hold on to the skin (allows tissue layers to slide back to their original position, sealing off the needle tract) -apply gentle pressure at injection site without massaging.

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old. Which is an appropriate action by the nurse? -have the child sit upright with the child tilted down -pull the pinna upward and back -remove the medication from the refrigerator just before use -touch the dropper to the entrance of the ear canal

-pull the pinna upward and back --When administering otic medication to children age 3 and older, the pinna is pulled upward and back to straighten the ear canal. The child is placed in a prone or supine position with the head turned to the appropriate side, and the medication is allowed to drop against the wall of the canal.

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Which actions are appropriate to protect the client from injury? SATA -attach wrist restraint straps to the upper side rails -position the client supine to keep restraint straps taut -release restraints at regular intervals and assess behavior -use a square knot to tie restraint straps to the bed -use gauze to pad bony prominences under restraints

-release restraints at regular intervals and assess behavior -use gauze to pad bony prominences under restraints --when caring for a client in restraints, the nurse should implement these interventions at regular intervals, according to agency policy (typically Q2 H): provide skin care and ROM exercises; ensure basic needs are being met; assess skin integrity and neurovascular status of restrained extremities; pad bony prominences under restraints, if necessary, to protect skin; determine the need for continued restraint by releasing restraints briefly and assessing clients reactions. Restraint straps should be attached to areas that move with the bed frame. Areas that do not move with the base or move independently of the frame should never be used. Supine positioning increases aspiration risk as the client may be unable to self-reposition if vomiting occurs. Side-lying or semi-Fowler position promotes drainage of emesis or oral secretions. Restraint straps should be tied in a quick-release knot, in case of emergency, and never a square knot.

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed? -instructs client to close eyelid and move eye around; applies pressure to the lacrimal duct for 30-60 seconds -pulls lower eyelid down gently with thumb and forefinger against bony orbit to expose the conjunctival sac -removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus -rests hand on client's forehead and holds dropper 1-2 cm above the conjunctival sac

-removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus --To administer opthalmic medications, follow these steps: remove secretions from the eyelid by wiping from the inner to outer canthus; pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac; apply pressure to the lacrimal duct if medication has systemic effects (beta blockers, timolo maleate)

A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain. Which situation would require intervention by the precepting nurse? -chooses to administer 60 mcg of the prescribed 50-100 mcg of IV fentanyl for the first dose -dilutes hydromorphone with 5 mL of normal saline and injects IV push over 2 minutes -injects 1 mg of morphone sulfate undiluted via IV push over 5 minutes -selects a 25-gauge 1/2 inch needle to inject ketorolac intramuscularly

-selects a 25-gauge 1/2 inch needle to inject ketorolac intramuscularly --Ketorolac is an NSAID analgesic administered for short-term relief of mild to moderate pain. Usage should not exceed 5 days due to adverse effects. Ketorolac IM should be administered into a large muscle using the Z-track method to mitigate burning and discomfort. A 1 to 1.5 inch needle is recommended to inject medication into the proper muscular space in average-weight individuals. Selecting a smaller first dose is appropriate if the nurse is unsure of how the client will respond to the medication. If needed, the larger amount can be given the next time a dose is requested or an additional one-time dose can berequested from the healthcare provider if breakthrough pain occurs. Hydromorphone IV push, given undiluted or diluted with 5 mL of sterile water or NS should be administered slowly over 2-3 minutes. Undiluted morphine IV push should be administered slowly over 4-5 minutes

The nurse is administering cleansing enemas to a client the night before bowel surgery. During instillation of the enema, the client reports cramping and pain. What action should the nurse take? -have the client take slow, deep breaths -stop infusing the solution for 30 seconds, then resume at a slower rate -tell the client the process will not take much longer -withdraw the tube approximately 2 cm and continue the infusion

-stop infusing the solution for 30 seconds, then resume at a slower rate --The rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation. Having the client take slow, deep breaths may be helpful, but the infusion should be stopped first.

The graduate nurse is inserting an oropharyngeal airway into a client emerging from general anesthesia. Which action by the graduate nurse causes the nurse preceptor to intervene? -measures the oropharyngeal airway against the cheek and jaw angle before insertion -rotates the device tip downward once it reaches the soft palate -suctions secretions from the mouth and pharynx prior to device insertion -tapes the external portion of the inserted oropharyngeal airway to the client's cheek

-tapes the external portion of the inserted oropharyngeal airway to the client's cheek ---Oropharyngeal airways are temporary artificial airway devices used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. As consciousness and the ability to protect the airway return, the client often coughs or gags, indicating a need to remove the OPA. Clients may also independently remove or expel it. Nurses caring for a client with an OPA must ensure that the device is easily removable from the client's mouth because an obstructed OPA may cause choking and aspiration. Appropriate OPA size should be measured prior to insertion because an inappropriate size could push the tongue back and cause airway obstruction. The OPA should be measured with the fiange next the to client's cheek. With correct size, the OPA curve reaches the jaw angle. When inserting an OPA, the nurse should initially suction the upper airway to remove secretions. The OPA is then inserted with the distal end pointing upward toward the roof of the mouth to prevent tongue displacement and tracheal obstruction. Once the OPA reaches the soft palate, the nurse rotates the OPA tip downward toward the esophagus, which pushes the tongue forward and maintains airway patency.

The nurse observes a client self-administering nasal fluticasone. Which observation would require the nurse to intervene and provide further teaching? -a sitting position is assumed as the head is bowed slightly forward -the client points the spray tip toward the nasal septum during instillation -the nasal spray tip is inserted into the nostril as the other nostril is occluded -while administering the medication, the client inhales deeply through the nose

-the nasal spray tip is inserted into the nostril as the other nostril is occluded --the proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When educating a client on how to self-administer nasal sprays, the nurse includes pointing the nasal spray tip toward the side and away from the center of the nose

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate? -get the client out of bed and away from the radiation source -manually reinsert the implant and notify the healthcare provider -use long-handled forceps to secure the implant in a lead container -wrap the implant in the linens and place it in a biohazard bag

-use long-handled forceps to secure the implant in a lead container --An internal radiation implant emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, the nurse should monitor closely for evidence of implant dislodgment. The dislodged implant emits radiation that can be dangerous to healthcare workers at the bedside. Long-handled forceps and a lead-lined container should be kept in the room of the client who has a radioactive implant in case of dislodgment. If dislodgment occurs, the nurse should first use long-handled forceps to place the implant in a lead-lined container to contain radiation exposure. The nurse should also notify the healthcare provider.

The nurse in the ICU is giving UAP directions for bathing a client who has a surgical incision infected with methicillin-resistant Staph aureus (MRSA). Which instructions would be most effective for reducing infection? -assist the client to the shower and provide directions to use antibacterial soap -delay the bath until the client has receives antibiotic therapy for 24 hours -use a bath basin with warm water and a new washcloth for each body area -use packaged pre-moistened cloths containing chlorhexidine to bathe the client

-use packaged pre-moistened cloths containing chlorhexidine to bathe the client --Current evidence supports the recommendation for clients with MRSA or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. bathing clients in this way can significantly reduce MRSA infection.

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client. The nurse knows that the parent understands the teaching when the parent does which of the following? -allows the client to sip the medication from a cup -expels the medication from a dropper onto the back of the tongue -mixes the medication in the infants bottle of formula -using a syringe, administers the medication in small amounts into the back of the cheek

-using a syringe, administers the medication in small amounts into the back of the cheek --using a syringe to measure the medication is the most accurate technique to ensure that the proper amount of medication is being administered. The correct procedure for administering oral medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk for choking and ensures that all the medication is consumed.

Steps performed by a nurse when assisting a lumbar puncture.

-verify informed consent -gather the lumbar puncture tray and needed supplies -explain the procedure to older child and adult -have client empty bladder -place client in the appropriate position (side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table) -assist the client in maintaining the proper position -provide a distraction and reassure the client throughout the procedure -label specimen containers as they are collected -apply a bandage to the insertion site -deliver specimens to the laboratory

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? -ask another nurse for help -delegate the task to unlicensed assistive personnel -premedicate the client for pain -verify the client's activity prescription

-verify the client's activity prescription --A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the healthcare provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall.

The nurse inserts a small-bore nasogastric tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first? -crush and administer medications -dilute enteral formula as prescribed -flush the tube with 30 mL of water -verify tube placement with an X-ray

-verify tube placement with an X-ray --enteral feedings are given to provide nutrition to clients who are unable to take in nutrients by mouth. Placement verification is imperative prior to initiating enteral feedings to prevent complications such as aspiration. Lung aspiration can lead to pneumonia, acute respiratory distress syndrome, and abscess formation. After placement is verified, the nurse may flush the tube with water, administer prescribed medications, flush the tube again, and then prepare and deliver the enteral feeding

Common applications of droplet precautions

-Neisseria meningitidis -Haemophilus influenzae type B -diphtheria -mumps -rubella -pertussis -Group A Strep -viral influenza

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? -arrange for the client's service dog to come to the healthcare facility as soon as possible -describe the environment in detail so the client can ambulate safely with a cane -instruct the unlicensed assistive personnel to walk beside the client and lead by the hand - walk slightly ahead of the client with the client's hand resting on the nurse's elbow

- walk slightly ahead of the client with the client's hand resting on the nurse's elbow --On the first postoperative day, the nurse assists the client with ambulation to evaluate alertness, pain level, signs of orthostatic hypotension, problems with gait or mobility, and ability to ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids. Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client. The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely. After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit. Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely.

The nurse teaching a client with newly diagnosed Sjogren's syndrome how to self-administer ophthalmic lubricating ointment medication. Which statement that the client makes indicates the need for further teaching? -"After applying the ointment, I'll tightly close my eyes and rub the lid for 2-3 minutes" -"I'll squeeze a thin strip of ointment on my lower eyelid, from the inner to the outer edge" -"I'll tilt my head back, pull my lower lid down, and look upward when administering the ointment" -"I'll use my ointment at bedtime and my eye drops during the day"

-"After applying the ointment, I'll tightly close my eyes and rub the lid for 2-3 minutes" --Ophthalmic lubricants replace tears and add moisture to the eyes. They are prescribed to treat dry eyes, a common symptom in clients with Sjogren's syndrome, an autoimmune disorder. Administering an ophthalmic ointment by tightly closing the eyes and rubbing the lid for 2-3 minutes can squeeze the ointment out of the eye and cause injury. The client is taught to gently close the eyes for 2-3 minutes to distribute the medication after applying the ointment.

What are examples of isotonic crystalloid solutions?

-0.9% NaCl -LR

The healthcare provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock. The nurse should anticipate the rapid infusion of which intravenous solution initially? -0.9% sodium chloride -5% albumin -Dextrose 5% and lactated Ringer's -Dextrose 5% and water

-0.9% sodium chloride --Isotonic solutions are used for immediate fluid resuscitation in clients with hypovolemic shock

What are examples of hypotonic crystalloid solutions?

-2.5% dextrose and water -0.45% NaCl

PASS

-Pull the pin on the handle to release the extinguisher's locking mechanism -Aim the spray at the base of the fire -Squeeze the handle to release the contents/extinguishing agent -Sweep the spray from side to side until the fire is extinguished

What is the typical site of injection for subcutaneous injections?

-abdomen -posterior upper arm -thigh

A nurse is making a home visit when a fire starts in the client's kitchen trash can. The client has a fire extinguisher. The nurse should take which actions to properly operate the fire extinguisher? SATA -aim the nozzle at the base of the fire -pull out the pin on the handle -shake the canister prior to use -squeeze the handle to spray -sweep the spray from side to side

-aim the nozzle at the base of the fire -pull out the pin on the handle -squeeze the handle to spray -sweep the spray from side to side ---A small fire can quickly become very dangerous. During an emergency situation, such as a fire, anxiety can narrow a person's focus, causing hesitation or difficulty in responding to the situation, especially when operation of unfamiliar equipment is involved. The mnemonic PASS is often used to help people remember the steps used in operating a fire extinguisher.

What is the typical injection site for intramuscular injections?

-deltoid -vastus lateralis -ventrogluteal

What are the 6 rights of medication administration?

-right client (using 2 identifiers) -right medication -right dose -right route -right time -right documentation

The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose? -1 mL -3 mL -10 mL -30 mL

10 mL --Flushing the lumen of a central venous access device with normal saline is recommended to assess patency before medication infusion, prevent medication incompatibilities after infusion, and prevent occlusion after blood sampling. A 10-mL syringe is generally preferred for flushing the lumen of a CVC. The smaller the syringe, the greater the amount of pressure per square inch exerted during injection, increasing the risk for damage to the CVC. The "push-pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any resistance. Injecting against resistance can damage the CVC, which may result in complications, including embolism and malfunction. The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC.

What happens when hypotonic solutions are infused into the extracellular vascular compartment?

body fluids shift out of intravascular compartments into interstitial tissue and cells

What is the usual site location for intradermal injections?

inner forearm