Uworld Questions

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? 1. He is critically ill and we are caring for his needs 2. His heart has stopped and we are attempting to revive him 3. I dont know how he is doing but you need to come 4. I will have the health care provider talk to you once you arrive

1 Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) 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 (telling the truth) 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. (Option 2) This is a true statement but it is being given abruptly to the family without support or gradual adjustment. It might be so distressing that they cannot travel to the hospital safely. (Option 3) This is not a true statement and violates the principle of veracity. It will do nothing to help the family and might even cause them alarm that a nurse there is not informed about what is going on with their child. (Option 4) Although this is an option, it does nothing to deal with the situation and the family's needs adequately. It also "passes the buck" to another provider, and even though this provider can speak to them, the nurse should deal with the family's immediate needs at this point. Once they arrive, the health care provider is usually the one to tell family members about the client's prognosis. Educational objective:The ethical principle of beneficence means doing good. It can involve not saying all known information immediately but delaying notification until appropriate support is in place.

The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs further investigation? 1. I am taking an antibiotic for urinary tract infection 2. I had a negative tuberculosis skin test 2 weeks ago 3. I just received my yearly flu shot a week ago 4. I will continue taking naproxen at night to help with pain

1 Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that suppress the inflammatory response in autoimmune diseases such as rheumatoid arthritis, Crohn disease, and psoriasis. Due to the immunosuppressive action of TNF inhibitors, clients taking these drugs are at increased risk for infection. A client with current, recent, or chronic infection should not take a TNF inhibitor (Option 1). (Option 2) The immunosuppressive action of TNF inhibitors can activate latent tuberculosis (TB). Therefore, a tuberculin skin test (TST) should be administered prior to beginning TNF inhibitor therapy, and clients who test positively for latent TB must also undergo treatment for TB before starting therapy. Clients should have a TST every year while receiving the drug. (Option 3) Clients taking immunosuppressive TNF inhibitors (eg, adalimumab) should receive an annual inactivated(injectable) influenza vaccine to reduce the risk of contracting the flu virus. Clients taking TNF inhibitors or other immunosuppressants are at risk for infection and therefore should not receive live attenuated vaccines. (Option 4) Many clients with rheumatoid arthritis use nonsteroidal anti-inflammatory medications (eg, celecoxib, naproxen) in conjunction with antirheumatic and/or targeted therapies (eg, methotrexate, adalimumab, etanercept) to effectively treat pain and minimize inflammation. Educational objective:Clients with infection should not take tumor necrosis factor (TNF) inhibitors (eg, infliximab, adalimumab, etanercept) as these suppress the immune response. Before starting drug therapy, clients should be tested for tuberculosis and receive the inactivated (injectable) influenza vaccine. Clients taking TNF inhibitors should avoid live vaccines.

The nurse is providing discharge teaching for a client who suffered full-thickness burns. Which statement by the client demonstrates a need for further instruction on the rehabilitation phase of a burn injury? 1. I should avoid using lotion to prevent infection 2. I should perform RM exercises daily 3. I will avoid direct sunlight for at least 3 months 4. I will war a pressure garment to minimize scars

1 The rehabilitation phase begins after the client's wounds have fully healed and lasts about 12 months. The initiation of this phase depends on the extent of the burns and the client's ability to care for themselves. Interventions in the rehabilitation phase are aimed at improving mobility and independence and minimizing the potential for long-term complications. These interventions include: Counseling or other psychosocial support Gentle massage with water-based lotion to alleviate itching and minimize scarring Planning for reconstructive surgery Pressure garments to prevent hypertrophic scars and promote circulation (Option 4) Range-of-motion exercises to prevent contractures (Option 2) Sunscreen and protective clothing to prevent sunburns and hyperpigmentation (Option 3) (Option 1) Daily application of water-based lotion is necessary to minimize scar formation and alleviate itching. Infection is not likely as the rehabilitation phase begins after the wounds are fully healed. Educational objective:The rehabilitation phase begins after the client's wounds are healed. The goals of this phase are to increase the client's ability to perform activities of daily living and prevent long-term complications.

Which are appropriate examples of cost-effective Care? SATA 1. considering the inside of the sterile glove wrapper as a small sterile field 2. donning clean, rather than sterile gloves to remove a clients dressing 3. returning unopened, unused sterile supples from a clients room to the central supply room 4. reusing a tourniquet for multiple clients unless it is visibly soiled 5. using remaining sterile saline in a bottle opened 48 hours ago before discharging

1,2

The emergency nurse plans care for a female victim of sexual assault. Which of the following interventions should the nurse include in the care plan? Select all that apply. 1.Determine if the victim has douched or had a bath or shower since the incident 2.Educate the victim regarding the need for a pelvic examination 3.Obtain the date of the last menstrual period and current method of birth control 4.Perform head-to-toe assessment of injuries and document injury locations 5.Provide prescribed prophylactic antibiotic medications for sexually transmitted infection

1,2,3,4,5 Determining whether the client has bathed, showered, or douched, as these actions may compromise evidence (Option 1) Educating the victim that a pelvic examination is recommended to identify injuries and collect evidence (Option 2) Obtaining the date of the client's last menstrual period and current method of birth control to identify risk for pregnancy (Option 3) Performing a head-to-toe assessment to identify physical injuries requiring treatment and thoroughly documenting all injuries on a body map (Option 4) Providing prophylactic therapies for sexually transmitted infections and pregnancy (Option 5) Educational objective:Emergency nursing care of sexual assault victims includes determining whether evidence has been compromised (eg, shower, bath, douche), date of the last menstrual period, and current method of birth control. The nurse should inform the client about the pelvic examination, assess and thoroughly document all physical injuries on a body map, and provide prophylactic therapies for sexually transmitted infections and pregnancy.

The nurse is providing discharge teaching to a client newly diagnosed with ulcerative colitis. Which of the following statements by the client indicate that teaching has been effective? Select all that apply. 1. I need to eat a diet high in calories and protein so that I avoid losing weight 2. I need to take multivitamins containing calcium daily 3. I should avoid consuming alcoholic beverages 4. I should drink at least 2 liters of water daily and more when I have diarrhea 5. I will keep a symptom journal to note what I eat and drink during the day

1,2,3,4,5, Ulcerative colitis (UC) is a form of inflammatory bowel disease characterized by remitting periods of mucosal irritation in the large intestine, resulting in profuse, bloody diarrhea. Management of clients with UC often includes dietary interventions to reduce symptoms and prevent reoccurrence, malnutrition, and dehydration. Nutrition and hydration management: Diets consisting of high-calorie, high-protein foods are recommended to prevent weight loss and muscle wasting (Option 1). Multivitamins containing calcium are often prescribed to supplement nutrition and should be taken regardless of symptoms (Option 2). Oral hydration is critical in UC as >10 liquid stools may occur daily during flares, placing clients at risk for dehydration. Instruct clients to drink at least 2 liters of water daily (Option 4). Dietary triggers for UC vary greatly between individuals and may include dairy, nuts/legumes, cereal, alcohol, caffeine, and fatty and processed foods. Diet journaling is recommended to assist with identifying triggers (Option 5). Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided (Option 3). Educational objective:Ulcerative colitis (UC) is an inflammatory bowel disease that is managed with dietary interventions in addition to medication. Clients with UC should maintain a high-calorie, high-protein diet; drink at least 2 liters of water per day; take multivitamins as prescribed; maintain a symptom journal in relation to daily dietary intake; and avoid triggers.

A 6 year old client was diagnosed with type 1 diabetes. the nurse would like to encourage the client to participate in disease management. Which of the following diabetes care tasks are appropriate for the child to perform? SATA 1. chose insulin injection site with parental oversight of rotation schdule 2. push plunger of insulin syringe after a parent interest and stabilizes the needle 3. select and clean the site for finger stick blood glucose testing 4. use a chart to determine insulin dose based on glucometer reading 5. verbalize two or 3 signs and symptoms of hypoglycemia

1,2,3,5 The nurse should offer school-aged children (age 6-12) as much opportunity as possible to participate in care to promote psychosocial development (industry versus inferiority) and provide a sense of control. Parents should transfer management of care to the child in small steps based on the child's skill level and cognitive ability. School-aged children are in the concrete operational stage of development and are most successful performing simple, concrete taskswith a limited number of steps. Appropriate diabetes management tasks for school-aged children include: Choosing and cleaning a finger for blood glucose testing before a parent or caregiver performs the puncture (Option 3) Selecting the site for insulin injection, with a parent or caregiver verifying appropriate site rotation (Option 1) Pushing the syringe plunger to administer insulin after a parent or caregiver inserts the needle (Option 2) Identifying signs and symptoms of hypoglycemia and hyperglycemia (Option 5) (Option 4) Adjusting insulin doses based on glucose readings is too complicated for school-aged children, and mistakes can be life-threatening. Children develop the cognitive ability to analyze test results and adjust insulin doses at approximately age 14. Educational objective:Children should participate in their diabetes management. The school-aged child can choose and clean a finger for a blood glucose reading, select the insulin injection site, push the plunger to administer insulin after parents or caregivers insert the needle, and identify signs of hypoglycemia and hyperglycemia.

A client at 38 weeks gestation is brought to the emergency department after a motor vehicle crash. She reports severe, continuous abdominal pain. The nurse notes frequent uterine contractions and mild, dark vaginal bleeding. What actions should the nurse take? Select all that apply 1. anticipate emergent cesarean birth 2. apply continuous external fetal monitoring 3. asses routine vitals every 4 hours 4. draw blood for type and crossmatch 5. initiate IV access with a 22 gauge catheter

1,2,4 Placental abruption occurs when the placenta separates prematurely from the uterine wall, causing hemorrhage beneath the placenta. Abruptions are classified as partial, complete, or marginal and may be overt (visible vaginal bleeding) or concealed (bleeding behind placenta). Risk factors include abdominal trauma, hypertension, cocaine use, history of previous abruption, and preterm premature rupture of membranes. Symptoms and their severity depend on extent of abruption and include abdominal and/or back pain, uterine contractions, uterine rigidity, and dark red vaginal bleeding. Tachysystole (ie, excessive uterine contractions), with or without fetal distress, is often present, and continuous fetal monitoring is necessary (Option 2). A type and crossmatch should be drawn as treatment may include blood transfusion (Option 4). In severe cases, emergent cesarean birth is indicated (Option 1). Although blood loss is maternal, the loss of functional placental surface area can result in decreased placental perfusion, impaired fetal oxygenation, and fetal death. (Option 3) Maternal vital signs should be assessed frequently for signs of shock (eg, tachycardia, hypotension) as client condition can decline rapidly. In this acute scenario, assessment of vital signs every 4 hours is not sufficient. (Option 5) Abruption may require rapid volume replacement with IV fluid and blood products, requiring large-bore IV access. Peripheral IV access with a 16- or 18-gauge catheter should be initiated. Educational objective:Placental abruption usually presents with abdominal pain and dark red vaginal bleeding. The main concerns are maternal blood loss resulting in hypotension and shock and fetal compromise. Maternal stabilization and expedited birth are indicated.

The most recent laboratory results for a 12-month-old who is HIV-positive show a CD4 lymphocyte count of 500/mm3and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? Select all that apply. 1. Hib 2. Hep A 3. MMR 4. PCV 5. Varicella

1,2,4 Children who are HIV-positive and not severely immunocompromised can receive routine childhood immunizations. Children with severe immunosuppression as indicated by CD4 lymphocyte counts and/or percentages should not receive any live vaccines, including MMR and varicella.

The nurse prepares to admit a client with worsening cirrhosis who is on the waiting list for a liver transplant. Based on the client's electronic health record, the nurse anticipates which assessment findings? Select all that apply. Click on the exhibit button for additional information. 1. ascites 2. brusing 3. constipation 4. itching 5. lethargy

1,2,4,5, Cirrhosis of the liver occurs when chronic liver disease (eg, hepatitis C infection) causes scar tissue and nodules, which can decrease liver function and lead to liver failure. Clients with end-stage liver disease may experience exacerbations requiring hospitalization and acute intervention. Numerous laboratory abnormalities occur in the setting of liver failure and correlate with assessment findings (eg, high serum ammonia resulting in hepatic encephalopathy) (Options 1, 2, 4, and 5). (Option 3) Lactulose, an osmotic laxative, decreases serum ammonia levels by causing ammonia to be excreted through stool. The desired therapeutic effect is the production of 2 or 3 soft bowel movements each day; therefore, clients receiving lactulose should not exhibit constipation. Educational objective:Laboratory abnormalities common in liver failure include low serum albumin (causes ascites), elevated INR (increases risk for bruising and bleeding), elevated serum ammonia (causes lethargy and confusion), and increased bilirubin (causes jaundice and itching).

A client at 41 weeks gestation is admitted to the labor and delivery unit for labor induction. The nurse is assisting with an amniotomy. What actions should the nurse anticipate? 1. assessing the fetal heart rate before and after the procedure 2. checking the clients temperature every 2 hours 3. informing the client she will feel a sharp pain during the procedure 4. keeping the client in a supine position after the procedure 5. noting the characteristics of the amniotic fluid

1,2,5 Amniotomy refers to the artificial rupture of membranes (AROM) and may be performed by the health care provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is not applied firmly to the cervix. A prolapsed cord can cause fetal bradycardia due to cord compression. The nurse should assess the fetal heart rate before and after the procedure (Option 1). The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and without a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong, foul odor may indicate infection (Option 5). Once the membranes are ruptured, there is an increased risk for infection. The nurse should monitor the client's temperature at least every 2 hours after AROM (Option 2). (Option 3) As with any vaginal examination, the client may feel some pressure and discomfort during an amniotomy. However, the actual AROM procedure, or "breaking the bag of water," is painless. (Option 4) Supine positioning decreases uteroplacental blood flow and fetal oxygenation. The client should be assisted to upright positions after AROM to allow for drainage of amniotic fluid and to encourage the fetal head to remain firmly applied to the cervix. Educational objective:When assisting with an amniotomy, the nurse should assess the fetal heart rate, note the characteristics of the amniotic fluid, and assist the client to an upright position after the procedure

A nurse is caring for an intubated client receiving a continuous sedative infusion. Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia? Select all that apply. 1. elevate HOB 30-45 degrees 2. performing hourly in-line endotracheal suctioning 3. practicing strict hand hygeine 4. providing frequent oral care with chlorehexidine 5. scheduling daily sedation vacations

1,3,4,5 Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia (VAP) due to sedation and impairment of natural defenses (eg, coughing) by artificial airways. Interventions to reduce the risk of VAP include: Elevating the head of the bed 30-45 degrees (ie, semi-Fowler position) (Option 1) Providing oral care with antiseptic solutions (eg, chlorhexidine mouthwash) and suctioning subglottic secretions (Option 4) Performing scheduled daily sedation vacations and maintaining appropriate client sedation levels (Option 5) Practicing strict hand hygiene (Option 3) (Option 2) Endotracheal suctioning should be performed only when clinically indicated (eg, adventitious breath sounds, coughing, elevated peak airway pressure). Frequent suctioning increases the risk for tracheal and bronchial trauma, bleeding, and hypoxia. Educational objective:Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia (VAP) due to sedation and use of an artificial airway. VAP prevention includes elevating the head of the bed 30-45 degrees, providing regular oral hygiene with chlorhexidine solution, practicing strict hand hygiene, and performing daily sedation vacations.

The home health nurse assesses a child and suspects that the child is being abused. Which of the following questions are appropriate for the nurse to ask the caregiver? Select all that apply" 1. How would you describe your childs usual behavior at home 2. These bruises seem excessive and suspicious. How did they happen? 3. What forms of discipline do you use with your child? 4. When you are stressed, what coping mechanisms do you use? 5. Who watches your child when you are at work?

1,3,4,5,

A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? Select all that apply. 1. Desensitization to a specific stimulus or situation 2. discussing the interpersonal difficulties that have led to the clients psychological problems 3. helping the client develop insight into the psychological causes of the disorder 4. relaxation techniques 5. self-observation and monitoring 6. teaching new coping skills and techniques to reframe thinking

1,4,5,6 Cognitive behavioral therapy (CBT) can be effective in treating anxiety disorders, eating disorders, depressive disorders, and medical conditions such as insomnia and smoking. These types of disorders are characterized by maladaptive reactions to stress, anxiety, and conflict. CBT requires that the client learn the skill of self-observation and to apply more adaptive coping interventions. CBT involves 5 basic components: Education about the client's specific disorder Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity Physical control strategies - deep breathing and muscle relaxation exercises Cognitive restructuring - learning new ways to reframe thinking patterns, challenging negative thoughts Behavioral strategies - focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events (Option 2) This describes interpersonal psychotherapy. (Option 3) This describes psychodynamic or psychoanalytic therapy. Educational objective:CBT teaches clients to reframe their thought processes and develop new adaptive approaches for coping with anxiety, stress, and conflict. CBT requires that the client learn about the disorder and engage in self-observation and monitoring, relaxation techniques, desensitization activities, and changing negative thoughts.

The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury. Which statement by the student nurse indicates a need for further education 1. "I will auscultate the neck to asses for endotracheal cuff leaks" 2. " I will perform endotracheal suctioning routinely after oral care" 3. "I will provide oral care and oral suctioning every 2 hours" 4." I will reposition the client from side-to side at least every 2 hours"

2

The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? 1. client day 1 post op laparoscopic cholecystectomy who is awaiting discharge 2. client with dementia and urinary incontinence wearing an external tint device 3. client with history of splenectomy 15 years ago, now admitted with a PE 4. client with lupus nephritis who is prescribed treatment with azathioprine

2 Cellulitis is a common skin bacterial infection that is usually treated with IV antibiotics in clients with diabetes mellitus. Room 2 is the best assignment option for this client with cellulitis. The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to those in rooms 1, 3, and 4. (Option 1) The client who is 1 day postoperative laparoscopic cholecystectomy (surgical procedure with small incisions) is at increased risk for infection. The client with cellulitis should not be placed in room 1. (Option 3) Although this client has pulmonary embolism, the history of prior splenectomy leads to a very high lifelong risk of rapid sepsis. Splenectomy clients need vaccination against encapsulated organisms (eg, pneumococcus, meningococcus, and Haemophilus influenzae type B). Even a low-grade fever should be taken seriously in these clients. The client with cellulitis should not be placed in room 3. (Option 4) Lupus nephritis is a serious renal complication of systemic lupus erythematosus (SLE), an inflammatory autoimmune disease that can lead to end-stage kidney disease. The systemic disease and the immunosuppressant(azathioprine [Imuran]) prescribed to slow its progression increase infection risk. The client with cellulitis should not be placed in room 4. Educational objective:A client with an infection should not be assigned to a semi-private room with a client who had surgery or is immunocompromised and receiving immunosuppressants as these clients are highly susceptible to infection. Post-splenectomy clients are also at lifelong risk for rapid sepsis.

The nurse is assessing a 3-month-old during a well-child visit. Which developmental finding should the nurse expect to observe in the client? 1. Infant cries and clings to parent when members of the health care team come near 2. infant kicks, smiles, and coos when a familiar face comes into view 3. infant transfers a ball from one hand to the other 4. infant turns from the back to the abdomen

2 Developmental milestones (eg, motor, sensory, verbal, cognitive) are known patterns of growth and development noted in most children by a specific age. These milestones are used as a general assessment guide, although each child has a unique pattern of development. By age 3 months, the infant recognizes familiar items and faces (Option 2). Any 3-month-old who does not respond to familiar faces may have visual impairment or an underlying neurological disorder (eg, autism). (Option 1) Stranger anxiety is part of the infant's normal social and cognitive development and usually begins around age 6 months. (Option 3) Transferring objects from one hand to the other hand is a fine motor skill that usually develops between age 6 and 9 months. Failure to develop this skill may indicate neuromuscular or developmental delays. (Option 4) A 3-month-old is usually not strong enough to roll from the back to the front. Infants should be able to turn from the abdomen to the back at around age 4 months and then from the back to the abdomen by age 6 months. Failure to roll over by age 6 months may indicate slower-than-normal neck, leg, back, and arm muscle development and should be investigated. Educational objective:Developmental milestones (known patterns of growth and development) are used as a general assessment guide. By age 3 months, the infant should recognize familiar items and faces. Any 3-month-old who does not respond to familiar faces (eg, by cooing) may have visual impairment or an underlying neurological disorder (eg, autism).

The nurse is performing a postpartum assessment 12 hours after the prolonged vaginal delivery of a term infant. Which assessment findings should be reported to the health care provider? 1. complaints of discomfort during fundal palpation 2. foul smelling lochia 3. oral temp of 100.1 (37.8 C) 4. WBC count 24,000

2 A foul odor of lochia suggests endometrial infection. This client has an increased risk of infection due to her prolonged labor, which involved multiple cervical examinations. The odor of lochia is usually described as "fleshy" or "musty." A foul smell warrants further evaluation. Other signs of endometrial infection are maternal fever, tachycardia, and uterine pain/tenderness. (Option 1) Palpation of the postpartum uterine fundus is commonly uncomfortable for the client. If the client complains of increasing pain, further evaluation is needed. (Option 3) Major signs and symptoms of endometrial infection include temperature above 100.4 F (38.0 C); chills; malaise; excessive uterine tenderness; and purulent, foul-smelling lochia. During the first 24 hours postpartum, the temperature is normally elevated; temperature above 100.4 F (38 C) requires further evaluation. (Option 4) The WBC count is normally elevated during the first 24 hours postpartum (up to 30,000/mm3 [30.0 x 109/L]). Leukocyte levels that are not decreasing require further evaluation. Educational objective:Signs of endometrial infection include elevated temperature, chills, malaise, excessive pain, and foul-smelling lochia. During the first 24 hours postpartum, temperature and WBC count are normally elevated. Fever and leukocyte counts that do not decrease require further evaluation

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? SATA 1. decrease fluid intake to 1 glass with each meal and at bedtime 2. encourage the client to bear down while attempting to void 3. inspect the perineal area for evidence of skin breakdown 4. ,measure post void residual volumes as prescribed 5. tell the client to wait 30 seconds after voiding and then attempt to void again

2,3,4,5 Overflow urinary incontinence occurs due to compression of the urethra (eg, uterine prolapse, prostate enlargement) or impairment of the bladder muscle (eg, spinal cord injury, diabetic neuropathy, anticholinergic medications). Both types involve incomplete bladder emptying and urinary retention, which lead to overdistension and overfilling of the bladder and frequent involuntary dribbling of urine. When caring for clients with overflow incontinence, the nurse should: Implement a fixed voiding schedule (eg, every 2 hours) to prevent bladder overfilling. Instruct the client to use the Valsalva maneuver (ie, "bearing down") and Credé maneuver (ie, gently applying pressure to the lower abdomen) to help facilitate bladder emptying (Option 2). Assess the perineal area for skin breakdown related to incontinence (Option 3). Measure postvoid residual volumes as prescribed to ensure that the client is not retaining large amounts of urine (Option 4). Instruct the client to wait 20-30 seconds after voiding and then attempt to void a second time (ie, double voiding) to help empty residual urine (Option 5). (Option 1) Fluid restriction can lead to dehydration with concentrated urine, which irritates the bladder and increases the risk for urinary tract infection. Dehydration also contributes to constipation, which worsens incontinence by compressing the bladder.

A client is in a suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? SATA 1. Apical pulse 2. cap refill 3. lung sounds 4. pupillary response 5. skin color and temperature

2,5, Shock is a life-threatening syndrome characterized by decreased perfusion and impaired cellular metabolism. A lack of perfusion at both the tissue and cellular level (anaerobic metabolism) occurs due to decreased cardiac output, ineffective blood flow, and inability to meet the body's demand for increased oxygen. Sustained hypoperfusion activates compensatory mechanisms (eg, neural, hormonal, biochemical) to maintain homeostasis and reverse the consequences of anaerobic metabolism. Shock will progress through 4 stages (initial, compensatory, progressive, irreversible). Early identification and intervention help to prevent stage progression. Adequacy of tissue perfusion in a client with shock syndrome and possible organ dysfunction is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity temperature, and peripheral pulses. Capillary refill indicates adequacy of blood flow to the peripheral tissues. It is measured by the time taken for color (pink) to return to an external capillary bed (nail bed) after pressure is applied to cause blanching. In an adult, color should return in less than 3 seconds. Normal skin color and temperature are indicators of the adequacy of peripheral blood flow; these are usually within normal limits during the initial and compensatory stages of shock. (Option 1) Apical pulse is a central pulse and does not indicate adequacy of peripheral tissue perfusion. (Option 3) Lung sounds indicate the adequacy of ventilation and gas exchange, not peripheral tissue perfusion. (Option 4) Pupillary response is an indicator of cerebral function, not peripheral tissue perfusion. Educational objective:The adequacy of blood flow to peripheral tissues is determined by measuring capillary refill and assessing skin color and temperature; these are usually within normal limits during the initial and compensatory stages of shock.

In the emergency department, a pediatric client is placed on mechanical ventilation by means of an endotracheal tube. Several hours later, the nurse enters the room and finds the client in respiratory distress. It is most important for the nurse to take which of these actions? 1. asses the client for intercostal retractions 2. asses the clients blood pressure in both arms 3. auscultate the clients lung sounds 4. observe the color of the clients fingernail beds

3 A client experiencing respiratory distress while receiving mechanical ventilation should be assessed for proper ventilation first. The nurse needs to determine if the mechanical ventilation equipment is still properly placed in the trachea. An endotracheal tube (ET) can become displaced with movement. By assessing the client's lung sounds, the nurse can quickly determine if ET placement has been compromised (Option 3). Airway is the priority for this client. By auscultating the client's lung sounds, the nurse can determine if the client has an open airway. (Option 1) This is an assessment of the client's breathing, which is not the priority at this time. (Option 2) This is an assessment of the client's circulation, which is not the priority at this time. (Option 4) This is an assessment of the client's circulation, which is not the priority at this time. Educational objective:Clients with respiratory distress should be assessed for a patent airway first. The nurse should assess the client's airway to determine if it is present or needs to be established.

A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphoretic and reports dizziness. Which action should the nurse perform first? 1. check the vital signs 2. draw blood for hemoglobin and hematocrit 3. lower the head of the bed 4. maintain an IV line with normal saline

3 Acute blood loss is a medical emergency, and the nurse needs to carry out interventions rapidly. Lowering the head of the bed or placing the client in the supine position maintains blood perfusion to the brain and other vital organs. This can be done quickly to help stabilize the client before performing other interventions. (Option 1) Assessing and recording vital signs is appropriate and should be reported to the health care provider, but this is not the priority. (Option 2) Monitoring hemoglobin and hematocrit levels is appropriate to assess the severity of blood loss and need for possible blood transfusion. Blood loss typically takes a few hours to reflect on the client's laboratory report; therefore, this is not the priority. (Option 4) Ensuring IV access and continuing fluid administration is appropriate. This maintains fluid volume due to blood loss and corrects or reduces potential for hypovolemic shock. This can be done after lowering the head of the bed. Educational objective:A client with significant blood loss has a medical emergency, and interventions that will hemodynamically stabilize the client should take priority.

A nurse caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider? 1. 2+ pitting edema with the AVF 2. Loud swooshing sound auscultated over the AVF 3. Pale skin of the hand of the arm with the AVF 4. surgical site pain reported by the client as a 3 during hand exercises.

3 Arteriovenous fistula (AVF) is a permanent hemodialysis access surgically created by connecting an artery to a vein, typically in the forearm or upper arm. This anastomosis diverts arterial blood into the vein, which increases intravenous blood flow and causes the vein to thicken and expand (ie, "mature"). The matured AVF can then sustain frequent access by large-bore needles during hemodialysis. Arterial steal syndrome is an AVF complication that occurs when the anastomosed vein "steals" too much arterial blood, causing distal extremity ischemia. Symptoms occur distal to the AVF, including skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill. Without prompt intervention, ischemia may lead to limb necrosis (Option 3). (Option 1) After AVF creation, edema may occur due to venous congestion but typically improves spontaneously. Extremity elevation helps reduce edema. Severe or prolonged edema (eg, >2 weeks) could indicate venous hypertension that may require surgery to prevent AVF failure. (Option 2) A loud swooshing sound (ie, bruit) auscultated over the AVF is expected due to turbulent blood flow at the arteriovenous anastomosis. (Option 4) Hand-grip exercises (eg, ball squeezing, hand flexing) are encouraged after AVF creation to promote fistula maturation. Postoperative surgical site pain is expected; however, pain distal to the AVF may indicate tissue ischemia. Educational objective:Arterial steal syndrome is a complication of arteriovenous fistula (AVF) creation that impairs distal extremity perfusion and may result in tissue ischemia and necrosis. Symptoms include skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill distal to the AVF.

A school nurse is caring for 4 clients with type 1 diabetes. Which of these clients should be assessed first? 1. 5 year old whose capillary bel is 71 mg/dl 2. a 7 year old who is busy drawing pictures and refusing to eat lunch 3. a 9 year old who is sweating after recess and irritably states "I am so hungry": 4. an 11 year old whose prescribed dose of insulin glargine is 3o minutes overdue

3 Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) presents an immediate danger to the client as life-threatening neurologic impairment (eg, lethargy, seizures, coma) can occur when the brain becomes glucose depleted. If a client with diabetes has symptoms of hypoglycemia (eg, sweating, irritability, tremor, tachycardia, hunger), the nurse should immediately assess the client, check capillary blood glucose, and provide a simple carbohydrate snack that can be digested rapidly (eg, juice, soft drink, candy) (Option 3). (Option 1) A client with blood glucose of 71 mg/dL (3.9 mmol/L) should be monitored for hypoglycemia; blood glucose should be reassessed within 30 minutes. However, a client displaying symptoms of hypoglycemia should be assessed first. (Option 2) Skipping a meal could cause a client with diabetes to become hypoglycemic. The nurse should assess the client and redirect the client to eat; however, this client is not the highest priority. (Option 4) Insulin glargine (Lantus) is a long-acting (basal) insulin with a duration of 24 hours. It has no peak and is not used to correct acute hyperglycemic events. This medication should be given as close to the scheduled time as possible, but this client does not take priority over a client with symptomatic hypoglycemia. Educational objective:A client with symptoms of hypoglycemia (eg, sweating, irritability, tremor, tachycardia, hunger) should be assessed immediately. Without treatment, hypoglycemia may progress to life-threatening neurologic impairment (eg, lethargy, seizures, coma) as the brain becomes glucose depleted.

The nurse is admitting a client who had a masectomy 6 months ago and is scheduled for elective surgery. During the physical assessment, the nurse notices a 0.5cm mobile, firm, contender lymph node in the upper arm. What action should the nurse take? 1. anticipate the scheduling if a biopsy 2. apply ice to the node 3. reassure the client that this is an expected finding 4. request an antibiotic

3 Ordinarily, lymph nodes are not palpable in adults. However, a lymph node that is palpable, superficial, small (0.5-1 cm), mobile, firm, and nontender is considered a normal finding. It could easily be explained by the relatively recent mastectomy (trauma) with resulting inflammation and lymph flow interference. A tender, hard, fixed, or enlarged node is an abnormal finding. Tender nodes are usually due to inflammation but hard or fixed nodes could indicate malignancy. (Option 1) A biopsy is performed for an abnormal lymph node finding that could suggest malignancy. (Option 2) The swelling is caused by inadequate lymph drainage or inflammation, not localized edema. Ice is not recommended for this normal finding. (Option 4) There is no indication of lymphangiitis requiring antibiotics. This may produce a red streak with induration following the course of the lymphatic collecting duct. Infected skin lesions may also be present. Educational objective:A lymph node that is superficial, palpable, small (≤1 cm ), mobile, firm, and nontender is a normal finding. Hard and fixed nodes are most concerning as they are likely due to malignancy. Tender nodes usually indicate inflammation/infection.

A nurse is discussing parallel play with the parent of a 2 year old. Which statement by the parent indicates understanding of the discussion? 1. I encourage working in a group to build towers with large blocks 2. I have a chalk board available to teach the alphabet and numbers 3. I set out a basket of various balls in the backyard when other children come to play 4. I try to organize games that involve a team approach

3 Parallel play is typical behavior of a toddler and involves activities focused on improving motor skills, imitative efforts, and the use of multiple senses. Toddlers play alongside, rather than with, other children. Having a variety of different balls for a group of children allows each child to be present with others and participate as they desire. Other examples of parallel play activities include pushing and pulling large toys; smearing paint; playing with dolls or toy cars; and digging in a sandbox. (Option 1) Working in groups is an appropriate play activity for children in the preschooler period. (Option 2) The classroom approach does not promote parallel play. Using large chalk to draw allows the child creative expression in an unstructured manner. (Option 4) A toddler is challenged by the concept of team games, which requires attention to the group's effort. Educational objective: Toddlers engage in parallel play, which involves playing alongside, not with, other children. Activities such as playing with dolls or toy cars, pushing and pulling large toys, smearing paint, and digging in a sandbox encourage parallel play.

The nurse receives a new prescription for tamoxifen for a client with breast cancer. Which information found in the client's medical record would require follow-up with the health care provider? 1. documentation of an allergy to shellfish and peanuts 2. history of quitting cigarette smoking 5 years ago 3. hospitalization with deep venous thrombosis 1 year ago 4. previous treatment for depression following the death of a parent

3 Tamoxifen is a selective estrogen receptor modulator that is prescribed to treat certain types of breast cancer and to prevent breast cancer recurrence. Tamoxifen works by blocking estrogen receptors in certain estrogen-sensitive tissues (eg, breast, vagina), but it also increases affinity for estrogen in some tissues, such as the uterus. In the treatment of breast cancer, tamoxifen inhibits growth of estrogen receptor-positive tumors. Clients typically take tamoxifen for several (eg, 5-10) years after treatment to prevent breast cancer recurrence. Common side effects of tamoxifen therapy, like the effects typically seen in menopause (eg, hot flashes, vaginal dryness, menstrual irregularities), are related to decreased estrogen. Follow-up would be required for clients with symptoms or a history of tamoxifen's most serious side effects, including: Thromboembolic events (eg, deep venous thrombosis, pulmonary embolism, stroke) (Option 3) Endometrial cancer (eg, abnormal vaginal bleeding) (Options 1, 2, and 4) Shellfish and peanut allergies, previous smoking history, and history of depression are not contraindications for treatment with tamoxifen. Educational objective:Tamoxifen is a selective estrogen receptor modulator prescribed for the treatment and prevention of estrogen receptor-positive breast cancers. Serious side effects include thromboembolic events (eg, deep venous thrombosis) and endometrial cancer.

To obtain accurate continuous blood pressure readings via radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is this located? 1. Angle of louis at 2nd ICS to left of sternal border 2. Aortic area at 2nd ICS to right of sternal border 3. level of atria at the 4th ICS, 1/2 anterior-posterior diameter 4. 5th ICS at mid clavicular line

3 To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter (½ AP)of the chest wall. If the transducer is placed too low, the reading will be falsely high; if placed too high, the reading will be falsely low. This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-monitoring device. The upper arm should be at the level of the phlebostatic axis. (Option 1) The angle of Louis is the palpable raised notch where the manubrium and sternum are joined. This anatomical location is useful in counting the ICSs and in finding auscultatory areas. (Option 2) The aortic area is an auscultatory area located at the 2nd ICS to the right of the sternal border. (Option 4) The mitral area (apex), an auscultatory area, and the point of maximal impulse are located at the 5th ICS at the MCL. Educational objective:The anatomical location of the phlebostatic axis is the 4th ICS, at the midway point of the AP diameter (½ AP) of the chest wall. The stopcock nearest the transducer is placed here to assure accurate pressure measurements.

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure? Select all that apply. 1. Educate the client about the procedure and obtain informed consent 2. initiate NPO status 6 hours prior to the procedure 3. obtain baseline vital signs, abdominal circumference, and weight 4. place client in high fowlers position or as upright as possible 5. request that the client empty the bladder

3,4,5 Paracentesis is performed to remove excess fluid from the abdominal cavity or to collect a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for treating ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Prior to a paracentesis, nursing actions include: Verify that the client received necessary information to give consent and witness informed consent Instruct the client to void to prevent puncturing the bladder (Option 5) Assess the client's abdominal girth, weight, and vital signs (Option 3) Place the client in the high Fowler position or as upright as possible (Option 4) (Option 1) Paracentesis is an invasive procedure requiring delivery of informed consent by the health care provider (HCP). The HCP explains the benefits and risks of the procedure. The nurse's role is to witness informed consent and verify that it has occurred. (Option 2) NPO status is not required for paracentesis, which is often performed at the bedside or in an HCP's office using only a local anesthetic. Educational objective:Paracentesis is an invasive procedure for removing fluid from the abdominal cavity to improve symptoms or collect a specimen for testing. After informed consent has been obtained, the client should be encouraged to void to prevent bladder trauma, be positioned upright, and have a set of baseline vitals, weight, and abdominal circumference measurements collected before the procedure begins.

The nurse performs nasogastric (NG) 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? 1. ask the client to take several sips of water 2. continue to slowly advance the tube until placement is reached 3. gently remove the tube and reinsert the other Paris if possible 4. pull back on the tube slightly and then pause to give the client time to take a few breaths

4 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 (Option 2), asking the client to take small sips of water to facilitate advancement to the stomach (Option 1). 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 (Option 3). Educational objective:Coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx. When this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube.

The nurse assesses a pediatric client who was diagnosed with diarrhea caused by Escherichia coli. The nurse is most concerned with which finding? 1. blood streaked stoles 2. client drank fruit juice 3. dry mucous membranes 4. petechiae noted on the trunk

4 Hemolytic uremic syndrome (HUS) is a life-threatening complication of Escherichia coli diarrhea and results in red cell hemolysis, low platelets, and acute kidney injury. Hemolysis results in anemia, and low platelets manifest as petechiae or purpura. Therefore, the presence of petechiae in this client could indicate underlying HUS and needs further assessment. (Option 1) E coli bacteria infect people through contaminated food or water and attack the digestive system. Blood-streaked stool due to intestinal irritation is a common symptom associated with this illness. Treatment is aimed at preventing dehydration, and clients usually improve in about a week. (Option 2) Fruit juices are discouraged in acute diarrhea as they have high sugar (osmolality) and low electrolyte content. Continuing the client's normal diet (solid foods) is encouraged as it shortens the duration and severity of the diarrhea. (Option 3) Dry mucous membranes are a sign of dehydration, a common complication of any persistent diarrhea. Dehydration should be treated promptly, especially in children; however, as long as fluid is replenished, the condition is not life-threatening. Educational objective: Hemolytic uremic syndrome is a life-threatening complication of Escherichia coli diarrhea. Clinical features include anemia (pallor), low platelets (petechiae and purpura), and acute kidney injury (low urine output).

a client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client? 1. alprazolam 2. dextromehtorphan 3. lisinopril 4. valsartan

4 Major side effects of angiotensin-converting enzyme (ACE) inhibitors include: Symptomatic hypotension Intractable cough Hyperkalemia Angioedema (allergic reaction involving edema of the face and airways) Temporary increase in serum creatinine For clients unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) such as valsartan or losartan are recommended. ARBs prevent the vasoconstrictor and aldosterone-secreting effects of angiotensin II by binding to the angiotensin II receptor sites. (Option 1) Alprazolam is an anxiolytic. It is not used in the treatment of heart failure. (Option 2) Dextromethorphan is a cough suppressant. A cough caused by an ACE inhibitor will not be improved by a cough suppressant. (Option 3) Lisinopril is an ACE inhibitor. This client has been unable to tolerate this class of drug. Educational objective:ARBs are recommended for clients unable to tolerate ACE inhibitors.

The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription? 1. diarrhea 2. frequent burping 3. headache 4. sucking lip motions

4 Metoclopramide is a commonly used antiemetic medication that treats nausea, vomiting, and gastroparesis by increasing gastrointestinal motility and promoting stomach emptying. With extended use and/or high doses, metoclopramide may lead to the development of tardive dyskinesia (TD), a movement disorder that is characterized by uncontrollable motions (eg, sucking/smacking lip motions) and is often irreversible (Option 4). The movement alterations of TD may impact a client's essential activities of daily living (eg, eating, dressing) and overall quality of life. The nurse should question the administration of a medication associated with TD in clients experiencing movement alterations. (Option 1) Metoclopramide increases gastrointestinal motility, which may result in diarrhea in some clients. This symptom is reversible and usually easily managed. (Option 2) Burping is not a typical side effect associated with metoclopramide. (Option 3) Headache is a common adverse effect of metoclopramide that typically improves spontaneously. Educational objective:Clients receiving metoclopramide at high doses and/or for extended periods are at risk for developing tardive dyskinesia (TD), an often irreversible movement disorder. The nurse should question a prescription for metoclopramide if symptoms of TD (eg, uncontrollable lip smacking, hand wringing, rocking) are present.

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? 1. Dilute the formula with water 2. discontinue the tube feeding 3. send a stool sample to the lab for culture and sensitivity 4. slow the rate of administration of the feeding

4 Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their higher osmolality, hypertonic formulas sometimes cause nausea, vomiting, 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, nausea, and vomiting. 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. (Option 1) Diluting enteral formulas is not necessary. This practice may increase the risk of intolerance secondary to microbial contamination. A diluted formula supports microbial growth better than a full-strength formula. Diluting total enteral nutrition may also be detrimental because the client may receive inadequate nutrition; it will take a larger volume of fluid to provide the same number of calories and protein. (Option 2) It is not necessary to discontinue the feeding; the client needs nutrition support. (Option 3) Sending a stool sample for culture and sensitivity would be appropriate if bacterial contamination or a bacterial infection is suspected as the cause of the diarrhea. It is not the best nursing action in this situation. Educational objective:Complications of total enteral nutrition at the start of treatment are nausea, vomiting, and diarrhea. These signs and symptoms can usually be alleviated by slowing down the rate of administration and then gradually increasing the rate to the established goal.

Four clients in labor are requesting pain relief. The nurse understands that which client can safely receive a dose of IV butorphanol tartrate, an opioid agonist-antagonist, at this time? 1. multipara at 6cm dilation with recent heroin use 2. multipara at 9cm dilation with an urge to push 3. Nulipara at 3cm dilation desiring to ambulate 4. nullipara at 7cm dilation Manning with contractions

4 Opioid agonist-antagonist medications used in labor include butorphanol tartrate (Stadol) and nalbuphine hydrochloride (Nubain). Maternal adverse effects include sedation, dizziness, and nausea. Butorphanol tartrate crosses the placental barrier, peaking in 30-60 minutes; its duration of action is approximately 2-4 hours. If given near the time of birth, there is a risk for newborn respiratory depression, which may require naloxone (Narcan) to reverse the effects. IV opioids are safest for clients who will give birth 2-4 hours after administration so that the opioid effect has time to wear off before the birth. IV opioids are also best for clients in active labor or those with a well-established contraction pattern because opioid administration may slow labor progression in the latent phase (Option 4). (Option 1) Although this client is in active labor, recent heroin use is a contraindication to opioid agonist-antagonists because of the risk for maternal and/or fetal withdrawal symptoms. (Option 2) An urge to push may indicate imminent birth, especially in a multiparous client. To ensure newborn safety, imminent birth is a relative contraindication for the administration of narcotics. (Option 3) Opioid administration in latent labor may slow labor progression. In addition, medication adverse effects (eg, sedation, dizziness) are a safety concern for a client desiring to ambulate. Educational objective:Opioid agonist-antagonist medications (eg, butorphanol tartrate [Stadol]) are most appropriate for clients in active labor with no contraindications (eg, imminent birth, opioid dependence). Opioids have maternal adverse effects (eg, sedation, dizziness, slow labor progression) and may cause newborn respiratory depression.

What intervention is essential prior to starting a client on atorvastatin therapy? 1. assessing for muscle strength 2. assessing the clients dietary intake 3. determining if the client is on digoxin therapy 4. Monitoring liver function tests

4 Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy. (Option 1) Statins can also cause muscle aches and, rarely, severe muscle injury (rhabdomyolysis). Clients should be educated to report the development of muscle pains while on therapy. Assessment of muscle strength is not necessary prior to starting therapy. (Option 2) Assessment of dietary intake prior to therapy is not essential. Dietary teaching would have been performed prior to determining that medication therapy was necessary. (Option 3) Atorvastatin may slightly increase serum digoxin levels; however, it is not essential to determine if the client is on this medication prior to starting therapy. Educational objective:Statin medications (eg, rosuvastatin, atorvastatin) can cause hepatotoxicity and muscle aches. Liver function tests should be assessed prior to the start of therapy.

The charge nurse on the medical surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? 1. Client with diabetes mellitus and chronic kidney disease who is on hemodialysis and has a serum glucose level of 256 mg/dL 2. Client with chronic HIV infection and overwhelming fatigue with a CD4 count of 200/mm 3. Client with cellulitis of the leg due to a spider bite who has a white blood cell count of 13,000 4. Client with severe epistaxis due to a traumatic nasal fracture who had a platelet count of 85,000

4 The best option is room 4 with the client who has severe epistaxis and decreased platelet count (normal 150,000-400,000/mm3 [150-400 x 109/L]) as this does not place the immediate post-operative client at increased risk for infection. (Options 1, 2, and 3) The clients in these rooms place the postoperative client at increased risk for infection: Room 1: A client with diabetes mellitus and advanced chronic kidney disease may have infectious complications due to increased susceptibility to infection resulting from an altered immune response and decreased leukocyte function due to hyperglycemia. In addition, hemodialysis increases the risk for infection due to invasive lines and catheters. Room 2: A low CD4+ cell count (<500/mm3 [0.5 x 109/L], normal is 500-1,200/mm3 [0.5-1.2 x 109/L]) in a client with chronic HIV infection indicates disease progression. It can also indicate progression of asymptomatic early infections to more advanced symptomatic infections. Room 3: The client with cellulitis and an increased white blood cell count (>11,000/mm3 [11.0 x 109/L]) has an infection. Educational objective:An immediate post-operative client should not be assigned a bed in a room with a client who is contagious or potentially infected as this poses an increased risk for infection.

The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming off orientation? 1. client diagnosed with chronic anemia receiving iron via IV route 2. client newly admitted with uncontrolled diabetes and a blood glucose greater than 600 3. client undergoing ultrafiltration for congestive heart failure 4. client with a prescription for routine hemodialysis who has chronic renal failure

4 The nurse is looking for the most stable client to assign to the new nurse. The client who is scheduled for hemodialysis has a chronic disorder and receives this therapy on a regular basis. There is no indication that this client might be unstable. (Option 1) There is a high incidence of IV iron causing hypersensitivity reactions, including anaphylaxis. Therefore, a test dose needs to be given first. This client should be assigned to a more experienced nurse. (Option 2) The client with hyperglycemia is at high risk for diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic coma. Both are associated with acute and chronic complications and require careful assessment and prompt nursing intervention. This client should also be assigned to a more experienced nurse. (Option 3) Ultrafiltration (removal of excess fluid) is a complex task that requires extra training to perform. It is performed for clients who are not responding to IV diuretics. In addition, clients receiving ultrafiltration are more likely to be hemodynamically unstable due to their advanced heart failure; therefore, it is better for these clients to receive care from an experienced nurse. Educational objective:The client with a complex illness or one who is unstable (uncontrolled diabetes with hyperglycemia) should be assigned to a more experienced nurse. In addition, tasks requiring advanced skills (ultrafiltration, IV administration of high-risk medications) should be assigned to nurses who have had time to refine their basic skills and have acquired more advanced assessment expertise.