Nclex Comprehensive Study Guide Flashcards ionicons-v5-c

The nurse provides care for a client diagnosed with pneumonia. The client has a history of type 2 diabetes. The client is an older adult and is malnourished. For which type of shock does the nurse monitor the client?1. Anaphylactic2. Cardiogenic3. Septic4. Neurogenic

Septic - Older adults with chronic diseases who are malnourished or debilitated are at great risk for septic shock.Think like a nurse: The nurse will apply knowledge of anatomy and physiology regarding the normal function of the respiratory system. Next, using knowledge of pathophysiology, the nurse will consider the impact pneumonia has on respiratory function. The nurse knows that pneumonia can lead to sepsis and septic shock in vulnerable clients, such as the client in this scenario. Once sepsis is identified, the nurse anticipates giving antibiotics (after all appropriate cultures are collected), monitoring the client's hemodynamic status, and implementing the sepsis bundle (e.g., lactic acid monitoring, fluid replacement, and vasopressor).

The nurse administers insulin glulisine by subcutaneous injection to a client diagnosed with diabetes mellitus (DM). Which time after the injection will the nurse expect the greatest risk for hypoglycemia to occur? 1. 60 minutes2. 30 minutes3. 15 minutes4. 12 minutes

60 Minutes - As insulin glulisine peaks, hypoglycemia risk is greatest. Insulin glulisine reaches its peak concentration 60 minutes after subcutaneous administration.Think like a nurse: The nurse needs to recall the purpose and mechanism of action of the prescribed medication. The nurse needs to be acutely aware that insulins have different onsets, peaks, and lengths of effectiveness, in order to be prepared for client reactions. For this client, the prescribed insulin will peak 1 hour after administration. The nurse needs to observe the client at this time to evaluate for signs of a hypoglycemic reaction, which includes lethargy, slurred speech, and cold, clammy skin. Specific knowledge regarding insulins is a safety consideration for the client.

The nurse teaches a client who is newly diagnosed with type 1 diabetes mellitus. Which information does the nurse include in the client's discharge teaching? (Select all that apply.)1. Insulin administration.2. Symptoms and treatment of hypoglycemia.3. Reduction of physical activity.4. The use of a portable blood glucose monitor.5. Elimination of carbohydrates from diet.

1. Insulin administration - The body does not produce insulin in type 1 diabetes mellitus, so the client needs to learn insulin administration2. Symptoms and treatment of hypoglycemia - It is critical for the client to learn to recognize the symptoms of hypoglycemia and to understand the ways to manage hypoglycemia.4. The use of a portable blood glucose monitor - A glucose monitor is needed to check blood glucose frequently.Think like a nurse: Important topics to be included in teaching a client newly diagnosed with type 1 diabetes mellitus (DM) include the disease process, physical activity, diet and menu planning, medication adherence, blood glucose monitoring, risk reduction, and psychosocial trajectories. The client should be familiar in differentiating the signs and symptoms of hypoglycemia and hyperglycemia. Before teaching, the nurse should first assess the client's baseline knowledge. The teach-back method is used to verify the client's understanding. The American Diabetes Association recommends that people with diabetes mellitus who are meeting treatment goals and have stable blood glucose levels have the hemoglobin A1C test twice a year. Health care providers may repeat the hemoglobin A1C test as often as four times a year until blood glucose levels reach recommended levels. The goal is to keep A1C levels below 7% for clients with DM.

The nurse provides care for a client who had an exploratory laparotomy a day ago due to a small-bowel obstruction. Upon assessment, the client reports the pain is 4 out of 10. Which actions will the nurse implement? (Select all that apply.)1. Administer oxycodone 5 mg /acetaminophen 325 mg tablets by mouth.2. Prepare a dose of ketorolac 30 mg by IV push.3. Push the patient-controlled analgesia (PCA) button.4. Assist the client to ambulate in the hall.5. Encourage the client to eat a high-fiber diet.6. Auscultate for bowel sounds in four quadrants.

2. Prepare a dose of ketorolac 30 mg by IV push - IV pain medication such as ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is an appropriate intervention for this client 's pain. In addition, this client will have an NG tube after surgery to repair a small-bowel obstruction. Administering pain medication by mouth is not appropriate at this time. 4. Assist the client to ambulate in the hall - After abdominal surgery, trapped air can cause gas pains. Ambulation is the best way to help this gas to move out of the body via the rectum. 6. Auscultate for bowel sounds in four quadrants - Part of the post-operative abdominal assessment is auscultation of bowel sounds. Hypoactive or absent bowel sounds may indicate formation of an ileus.

The nurse supervises care on the medical-surgical unit. Which situation does the nurse attend to first?1. The unlicensed assistive personnel (UAP) enters the room of the client diagnosed with Pneumocystis jiroveci pneumonia while wearing gown, N95 mask, and gloves.2. A client who returned to the unit after a right pneumonectomy is placed in a room with a client diagnosed with emphysema who is receiving IV antibiotics.3. The family of a client reports that the toilet in the client's bathroom is overflowing.4. A client diagnosed with tuberculosis is ready for discharge and waiting for discharge instructions.

2. A client who returned to the unit after a right pneumonectomy is placed in a room with a client diagnosed with emphysema who is receiving IV antibiotics - Post-operative clients are considered "clean" or uncontaminated and should not be placed with the client who is considered contaminated. The client who is diagnosed with emphysema and receiving IV antibiotics is considered contaminated. Therefore, this situation requires immediate intervention by the nurse.Think like a nurse: In determining which client to see first, the nurse thinks about who is most unstable or at highest risk for injury. Infection control should be the priority for the client recovering from surgery. The client with a pneumonectomy is at risk for contracting an infection very easily and should not be roomed with a client who has the potential for an infection. While several of the other clients have needs, none of them are at current risk for injury.

The nurse plans care for a client diagnosed with left-sided paralysis and slurred speech. Which direction is most important for the nurse to provide to an unlicensed assistive personnel (UAP)?1. Report any incontinence.2. Turn the client every 2 hours.3. Keep the head of the bed elevated to 30 degrees.4. Change the linens immediately following a bath.

3. Keep the head of the bed elevated to 30 degrees - Elevating the head of the bed facilitates venous drainage from the brain and reduces intracranial pressure. It is best to also maintain the head in a midline neutral position.Think like a nurse: The nurse considers the outcome of each action and utilizes the ABCs to prioritize. The client has left-sided paralysis and slurred speech, which are symptoms of a stroke. It is important to keep the head of the bed elevated for a client with a stroke to reduce intracranial pressure and prevent aspiration, and to ensure unrestricted venous outflow from the cranium and meet circulatory and airway needs. The nurse needs to recognize which direction to the unlicensed assistive personnel (UAP) is related to client safety and reduces risk for harm. Directing the UAP to keep the head of the bed elevated for this client is within the scope of practice of the UAP.

The nurse teaches a client about measures to prevent deep vein thrombosis formation. Which client statement indicates to the nurse the need for further teaching?1. "I'm glad I can travel by plane without any special precautions."2. "I just bought some tight-fitting clothing. Now I can't wear it."3. "It's going to be hard to remember to avoid crossing my legs when sitting."4. "I sit at a desk all day. I'll have to remember to take a walk every hour or two."

1. "I'm glad I can travel by plane without any special precautions." - The client should exercise the feet and legs while seated and walk around when possible during long plane trips.Think like a nurse: The nurse knows a deep vein thrombosis (DVT) is a blood clot in a blood vessel of the leg. When preparing teaching material on actions to prevent the development of this disorder, the nurse should mentally explore the possible causes for the blood to pool in the lower extremities. A DVT is closely associated with immobility, including sitting or lying in one position for an extended period of time. The client should be instructed to avoid sitting for longer than 1 to 2 hours regardless of the situation. The nurse should recognize that because of erroneous thoughts, the client in this scenario needs additional teaching.

A client seeks medical attention for cramping pelvic pain and saturating five sanitary napkins over a 2 hour period. Which questions are most important for the nurse to ask the client when conducting the health history of the current issue? (Select all that apply.) 1. "Are you feeling dizzy?"2. "When was the first day of your last period?" 3. "Are you taking ibuprofen for your pain?"4. "When did the bleeding start?"5. "When did you last have intercourse?"6. "What did you eat at your last meal?"

1. "Are you feeling dizzy?" - Dizziness is an adverse effect from blood loss. Asking about dizziness helps determine the effects bleeding has on the client. 2. "When was the first day of your last period?" - Asking when the client experienced menstruation last is important to determine pregnancy potential and the possible loss of a pregnancy. 4. "When did the bleeding start?" - Asking when the bleeding started is important to gather history of this event, as it will help determine the amount of bleeding the client is experiencing. Think like a nurse: The nurse needs to assess the client to determine the potential cause for the bleeding. Questions should include when the bleeding started to determine the potential amount of blood loss and when the client's last menstrual period occurred in the event the client is experiencing a spontaneous abortion. Assessing the client for dizziness helps to determine if the blood loss is affecting total body fluid volume status.

The nurse provides care to a client reporting a cluster headache. Which nursing action is appropriate when providing care for this client? 1. Prepare for a head CT scan.2. Administer 100% oxygen via facemask.3. Measure erythrocyte sedimentation rate.4. Withhold prescribed sublingual sumatriptan.

2. Administer 100% oxygen via facemask. - Acute treatment of a cluster headache includes the provision of 100% oxygen delivered at a rate of 6 to 8 liters per minute for 10 minutes. This may be repeated after a 5-minute rest. Oxygen relieves the headache by causing vasoconstriction and increasing the synthesis of serotonin in the central nervous system.Think like a nurse: There are a variety of types and reasons for the development of a headache. Prior to determining the best intervention for this client, the nurse should review the pathophysiology related to a cluster headache. A cluster headache can occur anywhere within the head and cause sudden and acute pain. The application of 100% oxygen is the identified treatment to reduce the symptoms. Oxygen causes the blood vessels to constrict and helps reduce the throbbing pain. Other interventions include specific medication, which should be provided after oxygen prescribed oxygen therapy.

The home care nurse visits a client undergoing external radiation therapy after a lumpectomy of the right breast. Which statement, made by the client, indicates that the nurse's teaching is effective? 1. "I should wear a loose-fitting bra made of 100% cotton."2. "I can apply scented lotion to the right side of my chest."3. "I should expose my right breast to the air and sun."4. "I can apply cold compresses to the right side of my chest."

1. "I should wear a loose-fitting bra made of 100% cotton." - The client should wear cotton clothing to prevent irritation and avoid restrictive or tight-fitting clothing to prevent skin chafing or irritation. Cotton is a breathable fabric that will reduce the perspiration buildup on the skin.Think like a nurse: The nurse is visiting a client receiving radiation treatment for breast cancer. The nurse is aware this type of treatment is performed by focusing a beam of radiation onto the area of pathology. Since the radiation enters the body through the skin, the nurse recognizes the high risk for injury and understands that protection and care of the skin is a priority. Skin care teaching for this client will included actions to prevent skin irritation, cleansing methods, and strategies to protect skin integrity. Evidence that teaching provided was effective is if the client's statement about the type of undergarment being worn is correct.

A university sponsors a trip abroad for students majoring in international law. At 0300, a student awakens the nurse to report frequency, urgency, and dysuria. Because of safety concerns, night travel is prohibited. Which action should the nurse take first? 1. Ask if the student has experienced this problem previously.2. Obtain the student 's temperature.3. Encourage the student to drink large volumes of fluid.4. Insist that the police override the curfew and allow travel.

3. Encourage the student to drink large volumes of fluid. - The client's symptoms are consistent with a urinary tract infection (UTI), and fluids will help flush the system and may relieve some discomfort. A warm sitz bath may also help relieve discomfort. Antibiotics, the treatment of choice for a UTI, can be obtained after curfew.Think like a nurse

The home care nurse receives a phone call from the caregiver for a client diagnosed with AIDS. The caregiver reports having the flu and is afraid of giving the client an infection. Which action does the nurse take first? 1. Instruct the caregiver to wear a well fitting surgical mask that covers the mouth and nose.2. Assess whether the caregiver is washing hands frequently before providing care.3. Determine if there is someone else available to provide care for the client.4. Inform the caregiver to clean the client's bathroom daily.

3. Determine if there is someone else available to provide care for the client.- The priority is to prevent the client's exposure to infection. The nurse should first determine whether another healthy caregiver can provide care in place of the caregiver with the flu. This will protect the client from exposure to the flu. Think like a nurse: The situation posed in the question represents a serious safety risk to the client with acquired immune deficiency syndrome (AIDS). The nurse must assess the situation and determine the best course of action. Ideally, the caregiver should not provide care to the client and should be sequestered from the client. If possible, another caregiver should be identified as a temporary substitute. If this is not possible, then the nurse should instruct the caregiver on infection control measures and also contact the health care provider to discuss the possibility of prescribing anti-influenza medication (e.g. oseltamivir phosphate) prophylactically for the client.

The nurse provides care to several hospitalized clients. Which clients does the nurse monitor closely for the development of pneumonia? (Select all that apply.)1. A client who has experimented with cigarettes.2. A client diagnosed with cystic fibrosis.3. A client diagnosed with Addison disease.4. An adult client diagnosed with hypertension.5. A client with a fractured rib due to an auto accident.6. A client in Buck traction due to a fractured hip.

2. A client diagnosed with cystic fibrosis.- Underlying lung disease is a risk factor for pneumonia. Cystic fibrosis causes chronic obstructive pulmonary disease and excess mucous production, as well as pancreatic exocrine deficiency. 5. A client with a fractured rib due to an auto accident.- The pain of a fractured rib causes shallow breathing and easily leads to pneumonia due to lack of lung expansion. 6. A client in Buck traction due to a fractured hip. - This client in Buck traction will be on bed rest, which decreases lung expansion. Therefore, the nurse should monitor this client closely for the development of pneumonia. Think like a nurse: Certain health problems increase the risk of developing pneumonia. The client with cystic fibrosis is at risk because the disease causes a chronic lung disorder. Pain of a fractured rib would be exacerbated by deep breathing and coughing. Shallow breathing with this disorder increases the risk for the development of pneumonia. Being in musculoskeletal traction reduces lung expansion and promotes stasis of pulmonary secretions, increasing the risk for pneumonia.

The nurse obtains a history from a client who is prescribed rosuvastatin. Which client report is most important for the nurse to report to the health care provider? 1. Rash.2. Headache.3. Abdominal pain.4. Muscle tenderness.

4. Muscle tenderness- Even though it is rare, one of the greatest risks to a client who is taking rosuvastatin (Crestor) is myositis, or muscle inflammation, that can progress to rhabdomyolysis. Therefore, a client report of muscle tenderness is the priority for the nurse to report to the health care provider.Think like a nurse: The nurse should recall the purpose, mechanism of action, and side or adverse effects of the prescribed medication. Rosuvastatin is a medication used to lower cholesterol. The nurse is aware medications in this classification (lipid lowering) has rhabdomyolysis as an adverse effect, which begins with muscle aching and soreness. Since the client is experiencing muscle tenderness, the medication will most likely need to be discontinued. The nurse should report the client's symptom to the health care provider for evaluation and adjustments in medication prescriptions.

The nurse provides care to a client receiving sulfamethoxazole-trimethoprim (SMZ-TMP). Which observation indicates that the client is experiencing a common side effect of this medication? 1. Hypotonia.2. Loss of hearing.3. Hypotension.4. Urticaria.

4. Urticaria. - A mild to moderate rash is the most common side effect of SMZ-TMP, which is a urinary tract anti-infective.Think like a nurse: The nurse is responsible for monitoring clients who are prescribed medications for both side effects and adverse reactions. While side effects are bothersome and may affect adherence, adverse reactions can be life-threatening. Adherence is particularly important for the client who is prescribed antibiotics such a sulfamethoxazole and trimethoprim (SMZ-TMP) as not completing the complete prescribed course can lead to drug resistance. The most common side effect for SMZ-TMP is a mild to moderate rash. The client should be educated regarding this information and provided with instruction on how to treat the rash if it occurs and when to notify the health care provider.

The client tells the nurse that the health care provider stated that the client has a thyroid problem. Which diagnostic study does the nurse expect to be prescribed to determine the size and composition of the thyroid gland?1. Ultrasonography.2. Electrocardiography.3. Thyroid scan with radioactive iodine - 123.4. Parathyroid function test.

1. Ultrasonography.- Ultrasonography can be used early in the evaluation process to rule out Graves' disease, nodular goiter, or other thyroid dysfunction.Think like a nurse: The nurse is aware that the choice of a diagnostic test is determined by the location of the target organ and body system. When assessing for a thyroid problem, the nurse is aware that the health care provider is likely to initially prescribe an ultrasound of the gland. The ultrasound is a non-invasive scan that provides information about the size and other characteristics, which could indicate the presence of disease. If abnormalities are found with the ultrasound, the health care provider is likely to prescribe an MRI, a radiographic uptake study, or biopsy.

The nurse provides care to a toddler-age client who has a laceration to the left hand. Which actions by the child require investigation by the nurse? (Select all that apply.)1. Persistently disobeys the parent after instructions to sit down.2. Explores items found within the exam room.3. Continues to scream after having the hand wrapped with gauze.4. Hides behind the parent during interactions with the nurse.5. Smiles when receiving a sticker after the treatment.

1. Persistently disobeys the parent after instructions to sit down.- Disobeying the parent indicates defiance and is a negative outcome of development.3. Continues to scream after having the hand wrapped with gauze.- Screaming after receiving treatment indicates fearful behavior and is a negative outcome of development. 4. Hides behind the parent during interactions with the nurse.- Hiding behind a parent indicates withdrawal and is a negative outcome of development. Think like a nurse: A toddler should demonstrate specific behaviors that indicate normal development. The child ignoring direction by the parent indicates an issue with expected development and should be investigated further. The child should not scream after treatment has concluded. This demonstrates fearfulness and suggests an adverse developmental finding. A child of this age should not be fearful and hiding when interacting with the nurse. This also requires further developmental assessment.

The nurse provides care for clients on the psychiatric unit. Which behavior indicates the client is beginning to develop a trusting relationship with the nurse?1. The client describes delusions to the nurse.2. The client discusses personal feelings with the nurse.3. The nurse feels more comfortable with the client.4. The nurse observes that the client appears less anxious.

2. The client discusses personal feelings with the nurse.- To encourage a trusting relationship, the nurse demonstrates genuineness and empathy, and shows positive regard and consistency. A client 's being able to discuss feelings demonstrates that the client trusts the nurse.Think like a nurse: To determine whether the client is developing a trusting relationship, the nurse will evaluate client behaviors. The nurse will not rely on the nurse's personal feelings or beliefs about the client, but will focus on the client's behaviors towards the nurse. Evidence of a trusting relationship includes the client being more open with the nurse and discussing personal thoughts, concerns, and feelings. The principles of therapeutic communication are key to development of a therapeutic nurse-client relationship.

The nurse develops a plan of care for a client diagnosed with dementia. Which intervention is important for the nurse to include in the plan of care?1. Reinforce the client 's distorted thought patterns.2. Use simple, short phrases when speaking with the client.3. Administer anti-anxiety medication.4. Plan a regular exercise program.

2. Use simple, short phrases when speaking with the client.- Using simple, short phrases can enhance a client 's ability to process information given.Think like a nurse: When planning communication with a client diagnosed with dementia, the nurse needs to understand the client's limitations. The client with dementia may not be able to process large amounts of information. The best approach is to use short statements with simple words to enhance this client's comprehension, and to understand that information may need to be presented more than one time. Regular conversation may cause the client to become more confused and exacerbate the symptoms.

Which information will the nurse include when teaching the client about the self-management of an implantable cardioverter/defibrillator (ICD)? (Select all that apply.)1. Continue taking antidysrhythmic medications until the health care provider directs otherwise.2. Do not wear tight clothing or belts over the ICD generator.3. Notify the local fire department about having an ICD.4. Avoid activities that involve rough contact with the ICD.5. Report symptoms such as nausea, fainting, and weakness.

1. Continue taking antidysrhythmic medications until the health care provider directs otherwise.- Even after ICD placement, the client will need to continue taking antidysrhythmics until otherwise directed by the health care provider. 2. Do not wear tight clothing or belts over the ICD generator.- Tight clothing and a belt could cause irritation to the ICD generator. 4. Avoid activities that involve rough contact with the ICD.- Rough activities, such as contact sports, may cause ICD electrodes to become dislodged. 5. Report symptoms such as nausea, fainting, and weakness. - Nausea, fainting, and weakness indicate low cardiac output and must be reported to the health care provider. Think like a nurse: After implantable cardioverter/defibrillator (ICD) implantation, the client typically is provided with a product brochure that includes key information on living with an ICD. The nurse can reinforce teaching, reminding the client to keep the incision dry for at least 4 to 5 days after insertion. The client should be informed of what signs and symptoms (e.g., redness, swelling, fever) to report to the health care provider. It is important that the client continue to take prescribed cardiac medications (e.g., antidysrhythmics) and follow up with the cardiologist for routine interrogation of the ICD. Before teaching, the nurse should first assess the client 's baseline knowledge. The teach-back method is used to verify client 's understanding.

A client with heart failure and type 1 diabetes mellitus is found unresponsive. Which action will the nurse take first?1. Open four packets of sugar and empty them on the client's tongue.2. Call for help.3. Begin chest compressions.4. Administer glucagon subcutaneously, as prescribed.

2. Call for help.- After establishing unresponsiveness, the nurse should call for help, check for breathing, and assess for a pulse.- The nurse should begin chest compressions immediately, if the client is not breathing (or only gasping) and does not have a pulse.- The nurse needs to further assess the client instead of assuming that hypoglycemia is the cause of unresponsiveness. After determining that hypoglycemia is the cause, the nurse should administer glucagon by subcutaneous or intramuscular injection, as prescribed.Think Like A Nurse: The nurse can implement different interventions when finding a client unresponsive. The first action would be to implement the airway, breathing, and circulation (ABCs) of emergency care and assess for an airway. Since an airway is not an identified issue in this scenario, the nurse should proceed to call for help. Even though the client has a history of heart failure and type 1 diabetes mellitus, there is not enough information to determine if the client is demonstrating a hypoglycemic reaction or an acute cardiovascular event. Without further assessment information, the best action is to first call for help.

The home health nurse visits an older adult client with diabetes and osteoporosis. The client lives with an adult child in a two-story home. Which statement by the child most concerns the nurse?1. "My parent loves taking a hot bath with scented bath oil."2. "My parent is taking more interest in daily activities."3. "I feel guilty leaving my parent alone, even for half an hour."4. "I am not sure what we are going to do when winter comes."

1. "My parent loves taking a hot bath with scented bath oil."- The hot bath with oils presents a safety risk. Oils in the bath water can result in a slippery shower or bathtub surface. This is particularly concerning for the client with osteoporosis. Hot bath water can dry or damage the skin. The client with diabetes may have neuropathy, which can decrease the client's ability to perceive pain and recognize an injury. Think like a nurse: This client has co-morbidities and multiple risk factors to consider. The client is older, will likely have altered gait stability, and lives in a home with stairs. Diabetes decreases sensation in the feet and increases risk of injury. Osteoporosis increases the risk of fractures. The client may experience vasodilation and hypotension after a hot bath and is creating slippery skin by using oil. The risk of injury is a more immediate threat compared to the other concerns and is a physiological need according to the Maslow hierarchy, making this the nurse 's priority.

The nurse teaches a class to pregnant clients. The nurse discusses fetal movements and positions during labor that facilitate the birth of the fetus. Which information does the nurse include? (Select all that apply.)1. The sutures and fontanelles of the fetal head allow it to mold as it passes through the pelvis.2. The most common orientation is the transverse lie.3. The fetal attitude is normally one of flexion.4. The fetal head is fully flexed in the brow presentation.5. The fetal occiput is in the left front quadrant of the mother 's pelvis.

1. The sutures and fontanelles of the fetal head allow it to mold as it passes through the pelvis.- The sutures and fontanelles of the fetal head allow it to mold as it passes through the pelvis. 3. The fetal attitude is normally one of flexion.- Fetal attitude is normally one of flexion with the head flexed forward and the arms and legs flexed. 5. The fetal occiput is in the left front quadrant of the mother 's pelvis.- The fetal occiput is in the left front quadrant of the mother 's pelvis, in the left occiput anterior (LOA) position. This position facilitates delivery. Think like a nurse: Prenatal classes are essential especially for first-time mothers. In addition to the nurse teaching the mother and spouse or significant other about the birthing process, the mother can be given folic acid, checked for immunity to rubella and blood type, as well as advised about smoking, drinking alcohol, and eating a healthy diet, even before the baby is conceived. Once a woman is pregnant, prenatal visits to a health care provider will include examinations to determine the health of the mother and developing fetus. Before teaching, the nurse should first assess the client 's baseline knowledge. The teach-back method is used to verify the client 's understanding.

The nurse counsels a client who is trying to conceive on how to best prevent neural tube defects. Which water-soluble vitamin is important for preventing neural tube defects?1. Riboflavin (vitamin B2).2. Folic acid (vitamin B9).3. Ascorbic acid (vitamin C).4. Thiamine (vitamin B1).

2. Folic acid (vitamin B9)- Maternal folic acid deficiency is a risk factor for the development of neural tube defects (spina bifida). A daily consumption of 0.4 mg of folic acid is recommended for women of childbearing age.Think like a nurse: The nurse is aware that adequate fetal development in utero is contingent upon the health of the mother. The developing fetus needs specific nutrients to ensure for optimal organ development and function. Any maternal nutritional deficiency may be reflected and observed upon birth of the baby. One such nutritional deficiency is folic acid. A deficiency in this vitamin has been linked to the development of neural tube defects in the developing fetus. Because this birth defect can be avoided, clients are counseled to take folic acid supplements prior to and throughout a pregnancy.

The nurse provides care for clients in the gastroenterology clinic. In which order does the nurse rank these clients regarding the risk for developing colorectal cancer? (Arrange in order from greatest to least risk of developing colorectal cancer. All options must be used.)- 29-year-old Caucasian female, following a vegetarian diet, history of inflammatory bowel disease.- 37-year-old Caucasian male, high intake of red meats, great uncle diagnosed with colorectal cancer- 42-year-old African-American male, drinks two servings of alcohol daily, high intake of processed meats.- 45-year-old African-American female, smokes cigarettes, physically inactive

- 42-year-old African-American male, drinks two servings of alcohol daily, high intake of processed meats.- 45-year-old African-American female, smokes cigarettes, physically inactive- 37-year-old Caucasian male, high intake of red meats, great uncle diagnosed with colorectal cancer- 29-year-old Caucasian female, following a vegetarian diet, history of inflammatory bowel disease.- The nurse needs to be aware of the risk factors associated with specific diseases and conditions. When evaluating which client is at greatest risk, the nurse needs to add up the known risk factors for each client based on their personal and medical history. Keep in mind that risk factors can include issues that cannot be altered, such as gender or age. Likewise, some risk factors can be altered when associated with lifestyle choices, such as diet, smoking, and exercise.Think like a nurse: Risk factors for the development of colorectal cancer include African-American race, male gender, alcohol intake, diet high in red and processed meats, cigarette smoking, sedentary lifestyle, family history of the disorder, and a disease process that affects the intestines. After counting up the risk factors, the 42-year-old African- American client has the greatest risk, followed by the 45-year-old African-American female, 37-year-old Caucasian male, and, lastly, the 29-year-old Caucasian female.

An adolescent experiences severe left lower quadrant abdominal pain 2 days after the start of a menstrual period. Which response is the best for the nurse to make when the parent asks for pain medication so the client can participate in cheerleading tryouts? 1. "You will need to discuss that with the health care provider. "2. "Your child probably should not be trying out for the cheerleading squad today. "3. "The signs and symptoms sound as if they involve more than the menstrual period. "4. "You appear very concerned about your child 's condition. "

3. "The signs and symptoms sound as if they involve more than the menstrual period. "- A sudden onset of severe pain could indicate tissue injury or rupture of an organ.Think like a nurse: The nurse is facing a situation where the amount of discomfort is greater than is expected for the situation. An adolescent client can experience abdominal cramping with menstruation. However, this client's level of pain is severe and should be further assessed. Unfortunately, the client's parent is distracted with another event and is not taking the client's pain issue into consideration. The nurse needs to support the client by stating that the symptoms need further evaluation and intervention prior to assuming the cause is menstruation.

The nurse receives report from the previous shift on four clients. In which order will the nurse assess the clients? (Please arrange in order. All options must be used.)- A client requesting pain medication for post-surgical pain rated 7 on a 0-10 scale.- A client with Alzheimer disease who is disoriented to place, time and event.- A client who has a new prescription to insert a nasogastric (NG) tube with low, intermittent suction.- A client with a subdural hematoma who has a sudden onset of acute confusion.

- A client with a subdural hematoma who has a sudden onset of acute confusion.- A client requesting pain medication for post- surgical pain rated 7 on a 0-10 scale.- A client who has a new prescription to insert a nasogastric (NG) tube with low, intermittent suction.- A client with Alzheimer disease who is disoriented to place, time and event.- The client with a subdural hematoma experiencing a change in level of consciousness indicates potential increased intracranial pressure. The client has a new and acute symptom related to circulation, which places the client at risk for immediate harm. This client should be seen first. The client requesting pain medication for acute pain is experiencing an immediate need. This client should be seen second. There are no indications of any immediate problems, but there is a new prescription that should be carried out (NG tube insertion). The nurse can see this client third. The client is experiencing the expected symptoms of Alzheimer disease. This client has no immediate needs and can be seen last.Think like a nurse: The nurse should consider each client health problem and determine which condition is most acute. Of the clients listed, the client with a subdural hematoma experiencing changes in level of consciousness is the most acute. The change in consciousness could be caused by increasing intracranial pressure and become life-threatening. The client requesting medication for post-operative pain should be cared for next.

The nurse provides care to a client who is prescribed diphenhydramine. Which client conditions cause the nurse to question the prescription? (Select all that apply.)1. Closed-angle glaucoma.2. Diarrhea.3. Urinary retention.4. Peptic ulcer.5. Nausea.6. Small bowel obstruction.

1. Closed-angle glaucoma.— Diphenhydramine is an antihistamine with anti-cholinergic effects. It is contraindicated in closed-angle glaucoma, as the anti-cholinergic effects will increase intra-ocular pressure. 3. Urinary retention.— Diphenhydramine should not be used in clients with urinary retention, as the anti-cholinergic effects will worsen the retention. 4. Peptic ulcer.— Diphenhydramine should be avoided in clients with peptic ulcer disease as it increases the risk for bleeding. 6. Small bowel obstruction.— Diphenhydramine should be avoided in clients with a small bowel obstruction, as the anti-cholinergic effects may contribute to the obstruction. Think like a nurse: The nurse must distinguish among a medication's therapeutic effects, side effects, and adverse effects. The nurse determines the medication's therapeutic effects based on the indications for administering the medication. Some drugs have unintended, beneficial side effects. However, adverse effects are always undesirable and may be life-threatening. Diphenhydramine blocks (antagonizes) histamine-1 receptors, which makes this medication useful for treating clients who are experiencing an allergic reaction. Diphenhydramine's anticholinergic action causes a side effect of drowsiness, which may be beneficial to clients who experience insomnia. The anticholinergic effects also may help with treatment of clients who experience diarrhea. Conversely, diphenhydramine may exacerbate constipation. The combination of antihistamine and anticholinergic effects may help reduce motion sickness for certain clients.

The nurse observes staff providing care to assigned clients. Which observation indicates to the nurse that care is appropriate?1. The LPN/LVN wears gloves for a client with a stage 1 pressure injury.2. The unlicensed assistive personnel (UAP) wears gloves while ambulating a client with an indwelling urinary catheter.3. The nurse wears clean, non-sterile gloves when removing an indwelling urinary catheter.4. The unlicensed assistive personnel (UAP) removes the mask before removing the gloves when caring for a client on droplet precautions.

3. The nurse wears clean, non-sterile gloves when removing an indwelling urinary catheter.- Sterile gloves are required when inserting the urinary catheter. However, clean, non-sterile gloves can be worn when removing the catheter. Think like a nurse: Clean gloves should be worn when removing an indwelling urinary catheter due to the risk of coming into contact with the client's bodily fluids. The use of sterile gloves when unnecessary is considered a misappropriation of supplies.

The nurse plans care for a client diagnosed with antisocial personality disorder. The client participates in group therapy. Which action is most important for the nurse to take during the group therapy session? 1. Provide time to explore the client's past.2. Demonstrate acceptance of the client and the client's behavior.3. Set limits on the client in a nonpunitive manner.4. Encourage sublimation of the client's leadership potential.

3. Set limits on the client in a nonpunitive manner.— Clients diagnosed with antisocial personality disorders are manipulative and act out. In order to establish trust and avoid power struggles, limits must be set in a nonpunitive manner.Think like a nurse: The nurse needs to mentally ask, "What are the expected behaviors from a client with antisocial personality disorder?", "How can the client's behavior be managed?", and "How can the therapeutic atmosphere of the group therapy be maintained?" A client with an antisocial personality disorder is prone to drama and acting out without concern for others. Anger can be a reaction to setting behavioral limits. The best approach is for the nurse to set non-punitive behavioral limits with the client, such as limiting the client's verbal participation or specifically asking other members to talk. Other members of the group are encouraged to participate, regardless of the client's behavior.

The nurse provides care for a client with a hemoglobin level of 6.8 g/dL (68 g/L). Which intervention does the nurse implement first when providing care for this client?1. Draw a type and crossmatch for 2 units of packed red blood cells.2. Place the client on 2 liters of oxygen per nasal cannula.3. Insert a 19-gauge intravenous catheter.4. Place the client on a cardiac monitor.

2. Place the client on 2 liters of oxygen per nasal cannula.— This hemoglobin level is critically low, which indicates less circulating oxygen. It is important to be certain that the available hemoglobin is well-oxygenated. The nurse first will apply oxygen to the client to address the oxygenation needs. The normal hemoglobin for men is 13 to 18 g/dL (130 to 180 g/L), and for women it is 12 to 16 g/dL (120 to 160 g/L).Think like a nurse: Hemoglobin is the oxygen-carrying capacity of the blood. When the hemoglobin level is low, the amount of available oxygen to nourish the body organs and tissues is affected. The priority action is to provide supplemental oxygen to maximize tissue oxygenation.

The nurse follows up a community education session by asking clients to describe ways to reduce their cancer risk. Which client statement requires clarification by the nurse? (Select all that apply.)1. "I will limit my exposure to second-hand smoke."2. "I will walk for 30 minutes, at least 5 days a week."3. "I should stop eating meat."4. "I will lose 20 pounds."5. "I should not go outside on very sunny days."6. "I will avoid being around persons consuming alcohol."

3. "I should stop eating meat."- The nurse should clarify that it is not necessary to give up all meat. If the client desires to omit meat, the nurse may inform the client of ways to meet dietary requirements without meat. 4. "I will lose 20 pounds."- The nurse should clarify that persons should strive for a normal weight. Each client will have different weight loss or maintenance goals, depending on age, gender, height, and weight. 5. "I should not go outside on very sunny days."- the nurse should clarify that clients may spend a moderate amount of time in the sun, as long as they use sunscreen and wear a protective hat and clothing. 6. "I will avoid being around persons consuming alcohol." - The nurse should clarify that clients should limit alcohol intake, but being around persons who drink is not a risk factor for cancer. Think like a nurse: Risk factors for the development of cancer include smoking, obesity, inactivity, sun exposure, high intake of red meat, and chronic intake of alcohol. The client should limit, but does not need to abstain from, eating all red meat. The client should be encouraged to attain and maintain a normal body weight. The client should wear sunscreen or protective clothing in the sun, but not completely avoid the sun. Personal alcohol intake should be limited. Avoiding second-hand smoke is an established method to reduce cancer risk.

The nurse makes rounds on the medical unit to assess the care given by the unlicensed assistive personnel (UAP). Which observation requires an intervention by the nurse?1. The UAP places the fingers of one hand on the wrist of a client in order to evaluate the respirations.2. The UAP prepares to take a blood pressure in the left arm of a client recovering from a right mastectomy.3. The UAP weighs a client on a standing scale while the client is balanced on crutches.4. The UAP prepares to take an oral temperature on a client recovering from a rhinoplasty.

4. The UAP prepares to take an oral temperature on a client recovering from a rhinoplasty.- Rhinoplasty compromises the ability of the client to breathe through the nose due to the packing in both nostrils. If the client has to keep the mouth closed for an oral temperature measurement, the client cannot breathe. Think like a nurse: The nurse should evaluate and monitor the UAP's competency periodically. This will ensure the provision of high-quality and safe client care. Given that the client is unable to breathe through the nose due to the packing in both nostrils, the nurse should inform the UAP during the handoff report how the temperature can be taken (e.g., via the axilla). If the UAP is unfamiliar with caring for clients with rhinoplasty, the nurse should encourage the UAP to ask questions.

The nurse reviews a list of clients waiting to be seen in the emergency department (ED). Which clients will the nurse select to be seen immediately? (Select all that apply.)1. Experiencing a tingling sensation in the face and arm.2. Reporting chest heaviness.3. Experiencing redness on the lower legs for the past week.4. Reporting a needle stick while being medicated.5. Demonstrating drowsiness after taking cyclobenzaprine.6. Experiencing headache, fever, and neck stiffness.

1. Experiencing a tingling sensation in the face and arm.— Face and arm tingling could indicate a stroke. The client requires immediate evaluation. 2. Reporting chest heaviness.— Chest heaviness requires an immediate electrocardiogram and laboratory tests to rule in or rule out a myocardial infarction. 4. Reporting a needle stick while being medicated.— Receiving a needle stick may require post-exposure prophylaxis if the client is high risk or known to have an infectious disease. 6. Experiencing headache, fever, and neck stiffness.— Headache, fever, and neck stiffness are manifestations of meningitis. The client needs to be assessed immediately. Think like a nurse: When deciding which clients are a priority, the nurse can utilize the ABCs (airway, breathing, circulation) or Maslow's hierarchy of needs. Since the clients all have a range of symptoms, each one should be analyzed individually for acuity and long-term outcome. Symptoms of a stroke include face and arm tingling. This client is at risk for cerebral edema and possible brain herniation. Chest heaviness is a manifestation of an acute myocardial infarction. This client is at risk for sudden cardiac death. The client with a needlestick needs immediate prophylaxis to prevent the development of a blood-borne infection. The client with a headache, stiff neck, and fever is demonstrating signs of meningitis and should be isolated until a definitive diagnosis is obtained.

The nurse notes that an adolescent client without any previous health problems is prescribed intravenous and oral fluids to treat meningitis. For which serious complication does the nurse monitor this client?1. Heart failure.2. Hypovolemic shock.3. Cerebral edema.4. Pulmonary edema.

3. Cerebral edema.- Since the client has inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure.Think like a nurse: The nurse should recall the pathophysiologic and infectious disease processes of meningitis. In this illness, the meninges are irritated with either a bacteria or virus. This irritation causes nuchal rigidity and photophobia as two major symptoms of the disorder. It is essential to keep in mind the location of the infection and the impact interventions will have on the client's status. The nurse should be aware of actions that contribute to increased intracranial pressure (IICP). One major cause of IICP is fluid overload. Since the client is prescribed both oral and intravenous fluids, the risk for IICP is high. The client needs close monitoring.

The health care provider prescribes acetaminophen 650 mg PO for a client with an allergy to codeine. The nurse administers acetaminophen with codeine PO. The nurse then notifies the health care provider and administers diphenhydramine 50 mg IM as prescribed. After informing the client of the error, which action is most important for the nurse to take?1. Apologize to the client for administering the wrong medication.2. Ask the client to remain in bed for 3-4 hours.3. Explain to the client the symptoms of a reaction to codeine.4. Clarify why the nurse administered the diphenhydramine.

2. Ask the client to remain in bed for 3-4 hours.— The combination of acetaminophen with codeine and diphenhydramine can cause drowsiness and increase the client's risk for falls. The nurse should request that the client stay in bed for several hours to reduce this risk. Think like a nurse: The nurse needs an understanding of the effects of medications. In addition, the nurse's primary concern is always client safety. Recognition of the expected effects of the medications given to the client indicates an increased risk for falls. The incorrectly provided medication includes an opioid, which can cause sedation. The diphenhydramine can cause drowsiness. The client's risk for falling is increased because of the adverse effects of both of these medications.

The nurse watches as a parent and infant interact. The infant throws a toy to the floor numerous times. The parent picks up the toy and gives it back to the infant. If the parent does not immediately return the toy, the infant cries loudly. Which statement by the nurse is best?1. "Be sure to wipe the toy off each time before you give it back. These floors are filthy."2. "Your baby is either stubborn or wants attention, I cannot figure out which."3. "I remember when my own baby used to do that."4. "I bet your baby is about 11 months old. This is normal behavior."

4. "I bet your baby is about 11 months old. This is normal behavior."— At 11 months, an infant drops an object deliberately in order that it can be picked up. Even if the infant is not 11 months, equating a problematic behavior with a developmental norm can help decrease the parent's probable sense of aloneness, inadequacy, embarrassment, and frustration. Think like a nurse: The nurse should recognize that developmental milestones can provide important information when providing care to the pediatric client. One such milestone is object permanence, which develops late in infancy. A client at 11 months of age throws an object in order for it to be retrieved by someone else. When the object is not retrieved, it is not uncommon for the infant to protest. This is considered normal behavior for the client, which should be shared with the parents.

A client receives a prescription for clopidogrel. Which laboratory results are important for the nurse to monitor based on this new prescription? (Select all that apply.)1. Hemoglobin.2. Hematocrit.3. Platelet count.4. International normalized ratio (INR).5. Activated partial thromboplastin time (aPTT).

1. Hemoglobin.— Clopidogrel is an oral antiplatelet medication that interferes with platelet aggregation. Adverse effects include hemorrhage, bleeding, hematuria, and hemoptysis. A decreased hemoglobin may indicate bleeding. 2. Hematocrit.— A decreased hematocrit may indicate bleeding. Think like a nurse: Hemostasis refers to the cessation of bleeding from a damaged blood vessel. Coagulation, which is one step in the complex process of hemostasis, refers to blood clot formation. The coagulation cascade, which involves a complex series of chemical reactions between clotting factors, results in formation of the fibrin protein. Treatment of the client who experiences hypercoagulation may include administration of medications that (a) affect platelet function or (b) selectively target one or more mechanisms involved in the clotting cascade. Antiplatelet medications, such as clopidogrel, decrease the platelets' tendency to stick to one another and require monitoring of the client's bleeding time. Anticoagulant medications, such as warfarin, heparin, and fondaparinux sodium, alter the function of clotting factors and require monitoring of international normalized ratio (INR), prothrombin time (PT), or activated partial thromboplastin time (aPTT).

A client in a semiprivate room with a roommate is visited by an employee from the hospital business office. The employee discusses the client's inability to pay for services. The client then reports to the nurse that a right to privacy was violated. Which action does the nurse take first?1. Escort the client to a private setting.2. Tell the client that his roommate was probably not listening.3. Inform the client that the business office had to straighten out the client's account.4. Contact the business office so the client can talk with the employee.

1. Escort the client to a private setting.— This prevents further violation of client privacy while the nurse addresses the concern. Think like a nurse: The nurse has a responsibility to ensure that client privacy is maintained at all times. Certain aspects of the client's care is confidential (such as personal financial information) and should not be discussed where other clients can overhear. Having more than one client in a hospital room presents a challenge with maintaining client privacy. Although the employee from the business office violated client privacy, the nurse should not repeat the offense and must talk with the client in a private setting.

The nurse provides care for a newborn who passed meconium stool in utero. The newborn's respiratory rate is 32 breaths/min, heart rate is 114 beats/min, and good muscle tone is present immediately after delivery. Which action is most important for the nurse to take?1. Suction newborn's mouth and nose with a bulb syringe.2. Assist the newborn's respiratory effort with a resuscitation bag.3. Dry and wrap the newborn in warm blankets.4. Request the health care provider suction the newborn's trachea.

1. Suction newborn's mouth and nose with a bulb syringe.— Maintaining a patent airway is a priority for the newborn with potential for aspiration.Think like a nurse: Upon delivery, one of the greatest challenges of the newborn is adjusting to extrauterine life. At times though, the fetus may be stressed and begin to make these adjustments before delivery. One indication of in utero stress is the fetus passing the first stool before delivery. Should this occur, the fecal material can easily be aspirated by the fetus. Upon delivery, the primary action is to assure the patency of the newborn's airway by suctioning all material from the nose and mouth. The newborn's respirations should be closely assessed and preparations made for emergency resuscitation if necessary.

After creating a genogram, the nurse identifies that a client is at risk for hypertension. Which secondary preventive health interventions will the nurse include in the client's plan of care? (Select all that apply.)1. Consume a diet low in sodium.2. Join an aerobic exercise class.3. Monitor blood pressure frequently.4. Avoid the consumption of alcohol.5. Monitor cholesterol level.

3. Monitor blood pressure frequently.- Secondary prevention may be directed at individuals who are at risk for the development of a health problem. The goal for health intervention during this phase is early detection and diagnosis of health problems before clients exhibit symptoms of disease. Having blood pressure monitored frequently is an example of secondary prevention. 5. Monitor cholesterol level.- Secondary prevention may be directed at individuals who are at risk for health problems. The goal for health intervention during this phase is early detection and diagnosis of health problems before clients exhibit symptoms of disease. Having cholesterol level monitored is an example of secondary prevention. Think like a nurse: Secondary prevention is aimed at slowing or stopping the progression of an existing health alteration. The client may or may not be symptomatic. Screening is an example of secondary prevention. For the client with hypertension, secondary prevention includes aggressive lifestyle changes to incorporate a healthy diet, increased physical activity, and blood pressure monitoring. Desired outcomes include stopping or slowing the progress of hypertension, implementing interventions to return to optimal health, and preventing ongoing illness and complications.

The home care nurse visits a client diagnosed with cardiomyopathy. The client asks the nurse, "How will I know if I am overdoing it? " Which response by the nurse is best?1. "If you feel fatigued, you have done too much. "2. "Follow the list that the health care provider gave you. "3. "Coughing up more sputum is a good indication. "4. "To prevent doing too much, allow your family to help you. "

1. "If you feel fatigued, you have done too much. "- Fatigue is a useful guide in gauging activity tolerance in clients with decreased cardiac output. Think like a nurse: One of the first symptoms that indicates activity intolerance is fatigue. Another is acute dyspnea or shortness of breath. Increased sputum production could mean the development of pulmonary edema and should be reported to the health care provider. The client should be encouraged to maintain as much independence as is physically possible. The nurse's advice to follow the health care provider's directions does not address the client's question.

The nurse provides care for clients in a long-term care facility. A client is diagnosed with Legionnaire disease. Which action by the nurse is appropriate?1. Place the client on droplet precautions.2. Ask for maintenance on the institution's hot water tank.3. Sterilize the utensils used by the client.4. Place filters on the air ducts of the client's room.

2. Ask for maintenance on the institution's hot water tank.— Legionnaire disease is caused by Legionella pneumophila, which is found in warm, stagnant water such as hot water tanks and is spread by the aerosolized route from the environmental source to the client. Maintenance on the hot water heater is required to eliminate the source.Think like a nurse: The nurse assesses the environment of clients and evaluates for any safety risks present. Legionnaire disease is caused by a microorganism that proliferates in warm, standing water. Since this disease was diagnosed in a client who resides in a long-term care facility, all the hot water tanks need to be cleaned and flushed to clear the microorganism out of the facility's water system. This prevents other clients from becoming infected. Clients should be monitored for symptoms of Legionnaire disease, such as fever, body aches, and cough. Clients who are 50 years of age and older, clients who smoke, clients with chronic lung disease, clients with immunodeficiency, and clients with underlying diseases (e.g., diabetes, renal disease, hepatic disease) are at highest risk for infection with Legionnaire disease.

The nurse provides care to a client in labor who is undergoing augmentation. The nurse notes three consecutive late decelerations on the client's electronic fetal monitor tracing. Which action does the nurse implement first?1. Position the client on the left side.2. Turn off the intravenous oxytocin infusion.3. Administer oxygen by face mask at 10 L per min.4. Increase the rate of intravenous fluid administration.

1. Position the client on the left side.— Positioning the client on the left side is the priority action to increase placental perfusion for the client who is experiencing late decelerations during augmentation of labor. Think like a nurse: When persistent late decelerations are noted, further assessment is not needed prior to taking action. Interventions include re-positioning the client to the left side or to the knee-chest position to increase uterine blood flow, administering oxygen and fluid to increase oxygenation and cardiac output, and correcting the stimulus of the late decelerations. Late decelerations may stem from excessive contractions or maternal hypotension. Late decelerations are caused by decreases in fetal oxygenation and subsequent fetal hypertension. If allowed to continue, fetal hypoxia results in sustained fetal bradycardia.

The school nurse notes that an 8-year-old child experiences stomach aches that are relieved after the nurse contacts the parents at work. Which action is the most important for the nurse to take? 1. Ask the child what is eaten for breakfast and dinner.2. Ask the child to describe life at home.3. Report this event to social services.4. Ask the parents how the child behaves prior to school.

4. Ask the parents how the child behaves prior to school. - The nurse needs to validate anxiety, especially separation anxiety. The child may be worrying about the parents and is relieved when the nurse talks to the parents.Think like a nurse: The child is experiencing some form of separation anxiety. Finding out how the child behaves before leaving to go to school will help the nurse validate the source for the child's anxiety. It is premature to assume that the child is in danger and needs social service intervention.

While performing abdominal thrusts to remove a foreign body, the client becomes unconscious. Which action is appropriate for the nurse to implement at this time? (Select all that apply.)1. Begin chest compressions.2. Look in the client's mouth for a foreign body.3. Insert an oropharyngeal airway.4. Open the client's airway using a head-tilt, chin-lift maneuver.5. Activate the emergency response system.

1. Begin chest compressions.— If the client with a foreign body airway obstruction becomes unresponsive and is not breathing, the nurse should begin chest compressions.2. Look in the client's mouth for a foreign body.— Before delivering ventilations, the nurse should look into the client's mouth. If the nurse sees a foreign body that can be easily removed, the nurse should remove it.4. Open the client's airway using a head-tilt, chin- lift maneuver.— The nurse should open the client's airway using the head-tilt, chin-lift maneuver.5. Activate the emergency response system.— The nurse should call for nearby help to activate the emergency response system, so help is available to aid resuscitation efforts.Think like a nurse: Foreign bodies may cause either mild or severe airway obstruction. Poor air exchange (e.g., cyanosis, inability to speak, silent cough) and difficulty breathing are signs of choking. The nurse may observe the client clutch the neck, which is the universal sign of choking. The nurse should first ask, "Are you choking?" If the client nods the head to indicate "yes" and is unable to vocalize, this verifies the presence of a severe airway obstruction. The nurse should then perform abdominal thrusts on the adult client until the obstruction is relieved or until the client loses consciousness. Chest thrusts should be performed if the nurse is unable to encircle the client's abdomen due to obesity. If the client becomes unresponsive, the nurse should assist the client to the ground, shout for additional help, and immediately begin cardiopulmonary resuscitation (CPR).Content Refresher

The client is placed on cephalexin prophylactically after surgery. Which foods will the nurse encourage the client to eat?1. Bran cereals and fruits.2. Egg whites and lean meats.3. Yogurt and acidophilus milk.4. Fish and poultry meats.

3. Yogurt and acidophilus milk.— Yogurt and acidophilus milk will help maintain normal intestinal flora, which may be altered by cephalexin. The nurse should encourage the client to eat these foods. Think like a nurse: When reviewing the client's prescribed medications, the nurse would ask, "Are there medications here with side effects that should be addressed?" An antibiotic such as cephalexin can adversely effect the number and functioning of normal gastrointestinal flora. The client needs to ingest foods that restore the flora, such as yogurt and acidophilus milk. Foods high in fiber or protein will not help return the balance of normal intestinal flora.

The home health nurse visits a home occupied by two parents, their preschool-age child, and an older adult grandparent who has been living with them for 2 months. The nurse visits to assess the grandparent after treatment for a fall and broken arm. Which statement by the child most concerns the nurse?1. "My grandparent's cat got a cut on his stomach and will not come out of the corner. Can you fix it?"2. "Sometimes when I drink milk, I throw up."3. "We never go anywhere anymore since my grandparent moved in with us."4. "I want to be a doctor when I grow up and take care of hurt children and animals all over the world."

1. "My grandparent's cat got a cut on his stomach and will not come out of the corner. Can you fix it?"— The cat's injuries and behaviors may indicate pet abuse, which can be a sign of other abuse going on in the home. This home has three categories of people at risk for abuse: child, spouse, and older adult. The grandparent was treated for injuries that might have been related to abuse. The nurse should further assess the situation for indicators of abuse.Think like a nurse: Older adults are vulnerable and may be at risk for abuse. The nurse should be aware of various forms of abuse, including financial, physical, emotional, and sexual. For clients who are suspected of being abuse victims, a detailed medical evaluation is necessary as signs and symptoms of medical and psychiatric conditions may mimic manifestations of abuse. Signs of abuse may include specific patterns of injury. The nurse should interview clients separately from caregivers. Cognitive function should be assessed in all clients who are possibly being abused.

The nurse reviews the care needs for a group of postpartum clients. Which client does the nurse identify as being the most at risk for developing a hemorrhage? 1. Client with a distended bladder. 2. Client with an episiotomy.3. Client with engorged breasts.4. Client requesting assistance with fundal massage.

1. Client with a distended bladder. - A distended bladder is likely to displace the uterus to the left or the right. This will interfere with uterine contraction, which could cause a postpartum hemorrhage. Think like a nurse: A distended bladder prevents the contraction of the uterus after delivery. If bladder distention persists, the blood vessels in the uterus will continue to bleed, increasing the risk for a hemorrhage. Fundal massage helps constrict the uterus to expel clots and encourages the constriction of uterine vessels.

The nurse assesses a 2-hour old newborn. The nurse notes the newborn's hands and feet are bluish in color. To which reason does the nurse attribute this finding?1. A lack of adjustment to environmental temperature.2. Poor perfusion of blood to the periphery of the body.3. A lowered oxygen tension.4. A low hemoglobin level.

2. Poor perfusion of blood to the periphery of the body.- Acrocyanosis is a bluish color of hands and feet of the newborn. This is an expected finding and is caused by sluggish peripheral circulation.Think like a nurse: After delivery the nurse needs to focus on two clients: the mother and the newborn. Assessment of the newborn is focused on how well the baby is adjusting to extrauterine life. This assessment is completed through the use of the Apgar scoring system. One criteria is the color of the infant's body and extremities. Ideally, the body and extremities should be pink, which indicates adequate perfusion. If the extremities are blue-tinged, perfusion of the newborn is not at the maximum level and the newborn needs more time to adjust to being outside of the uterus.

The nurse prepares to obtain vital signs on a client. The client's previous blood pressure reading was 138/76 mm Hg and the client's pulse rate was 68 beats/minute. How long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?1. 45 to 60 seconds.2. 30 to 45 seconds.3. 10 to 20 seconds.4. 15 to 20 seconds.

2. 30 to 45 seconds.- To ensure that the diastolic has been determined, the cuff shouldbe released slowly until the mid-60s mmHg for someone with the client'sprevious reading. Since the cuff should be deflated at a rate of 2 to 3 mm persecond, a range of 90 mmHg will require 30 to 45 seconds.MATH:138-76 = 6262 + 30 mmHg (standard measurement to go above systolic)92/3 = 30.7 and 92/2 = 4630-45 secondsThink like a nurse: The American Heart Association states that the cuff should be deflated at a rate of about 2 to 3 mm Hg per second to obtain an accurate blood pressure measurement. The systolic pressure is the blood's force against the artery walls in order to pump blood to peripheral organs. The first sound the nurse hears means the systolic pressure is now greater than the pressure exerted on the artery by the inflated blood pressure cuff. The diastolic pressure is reflective of the pressure on the artery walls as the heart relaxes between forceful beats. Blood pressure readings are altered by cardiac output and arterial stiffness.

A client experiences a pulmonary embolism after abdominal surgery. Which information in the client's history will contraindicate the use of thrombolytic therapy?1. Has type 2 diabetes mellitus.2. Takes medications as needed for angina pectoris.3. Is recovering from a concussion that occurred 3 weeks ago.4. Uses an inhaler for treatment of asthma.

3. Is recovering from a concussion that occurred 3 weeks ago.— Thrombolytic therapy is contraindicated in a client who experienced a trauma within the past 2 months. Other contraindications include active internal bleeding, history of hemorrhagic stroke, intracranial or intraspinal surgery, intracranial neoplasm, arteriovenous malformation, aneurysm, and severe uncontrolled hypertension.Think like a nurse: Typically, a health care facility has a standardized checklist (on paper or electronic) to evaluate the client for contraindications for thrombolytic (fibrinolytic) therapy. Major trauma, surgery (including laser eye surgery), and GI/GU bleed within the past 2 to 4 weeks are contraindications for thrombolytics. Other contraindications include: systolic BP > 180 to 200 mm Hg or diastolic BP > 100 to 110 mm Hg; right vs. left arm systolic BP difference > 15 mm Hg (this is why it important to check BP in both arms); history of structural central nervous system disease; significant closed head/facial trauma within the previous 3 months; stroke > 3 hours or < 3 months ago; pregnancy; any history of intracranial hemorrhage; bleeding, clotting problem, or blood thinners; and serious systemic disease (e.g., advanced cancer, severe liver or kidney disease).

The nurse presents information to staff regarding anatomic changes that occur shortly after birth to facilitate a newborn's adaptation to extrauterine life. Which anatomic changes are included by the nurse in the teaching session? (Select all that apply.)1. Decrease in pulmonary vascular resistance.2. Closure of the foramen ovale.3. Closure of the ductus arteriosus.4. Decrease pressure in the left atrium. 5. Closure of the ductus venosus.

1. Decrease in pulmonary vascular resistance.- As blood flows through the lungs and fetal shunts close, increased blood flow dilates pulmonary vessels. This change occurs to maintain blood pressure. 2. Closure of the foramen ovale.- This circulatory system change occurs at or soon after birth, as the result of pressure changes in the lungs, heart, and major vessels.3. Closure of the ductus arteriosus. - This circulatory system change occurs by the fourth day as the result of pressure changes in the lungs, heart, and major vessels. 5. Closure of the ductus venosus.- This circulatory system change occurs as the result of pressure changes in the lungs, heart, and major vessels. Think like a nurse: At birth, the newborn shifts from a parasitic-type role (i.e., obtaining all needed nutrients, temperature regulation, gas exchange, and waste removal from the umbilical cord, placenta, and mother) to a much more physiologically self-sufficient role. With the newborn's first breath, a series of physiologic changes occur, including drainage or reabsorption of amniotic fluid from the lungs. Fetal circulation ends for the newborn as the ductus arteriosus and foramen ovale close.

A client is scheduled for knee replacement surgery and expresses a desire to make an autologous blood donation. Which client statement about autologous blood donation is most important for the nurse to follow up on?1. "I will make the first donation this week since my surgery is scheduled in 8 weeks."2. "I may have to start taking oral iron supplements."3. "I am glad that I can give up to 6 units of blood."4. "I have to make the last donation at least 1 week before surgery."

1. "I will make the first donation this week since my surgery is scheduled in 8 weeks."- Blood for the autologous donation is collected 6 weeks before the scheduled surgery. This statement would require additional follow up by the nurse. Think like a nurse: he nurse must provide education to the client who wishes to make an autologous blood donation prior to a surgical procedure. Once the information is presented, the nurse must evaluate whether the client has an appropriate understanding of the process and requirements. The earliest time the client can donate blood for this purpose is 6 weeks prior to the scheduled procedure. Therefore, the client statement indicating the first donation at 8 weeks prior to the surgery indicates the need for further teaching on this subject matter.

The nurse provides care to a client with a pulse oximeter probe. Which situation requires intervention by the nurse?1. Probe is on the ring finger and there is clear polish on the nail.2. Emitting and receiving sensors of the probe are directly opposite each other.3. Hand with the probe attached is directly beneath a procedure light to prevent chilling.4. Oxygen saturation alarm is set at 95%.

3. Hand with the probe attached is directly beneath a procedure light to prevent chilling.— Exposure of the probe to direct sunlight or strong light causes an inaccurate measurement. The probe should be covered with a dry washcloth and rotated every 4 hours to prevent skin irritation.Think like a nurse: The performance of the pulse oximeter is dependent on the client's pulse. If the client has a weak or absent peripheral pulse, readings will not be accurate. Clients who are cold may have vasoconstriction in their fingers and toes that also may compromise arterial flow and result in falsely low readings. Bright natural or artificial lights (e.g., procedure light) that shine directly on the pulse oximetry sensor may lead to inaccurate results because the pulse oximeter measures the amount of light transmitted through arterial blood. Dirty sensors, dark-colored nail polishes, and dried blood may affect the accuracy of the readings by hindering or altering the light absorption of the contact probes.

An older adult client with pneumonia has a temperature of 101.2 F (38.4 C), pulse of 112 beats/min, respirations of 22 breaths/min, and BP of 90/50 mm Hg. For which findings will the nurse notify the health care provider? (Select all that apply.) 1. Lactic acid level 5.0 mEq/L (0.555 mmol/L).2. White blood cell count of 15,000 (15 x 103/microL).3. Blood pressure of 90/50 mm Hg.4. Apical heart rate of 112 beats per minute.5. Oral temperature of 101.9 degrees F (38.8 degrees C).

1. Lactic acid level 5.0 mEq/L (0.555 mmol/L).- A normal lactic acid level is 0.5 to 2.2 mEq/L (0.0555 to 0.2442 mmol/L). Elevated levels indicate inadequate oxygenation in the body or the presence of shock. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 2. White blood cell count of 15,000 (15 x 103/microL).- An elevated white blood count indicates an infection, which is an expected finding for pneumonia. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 3. Blood pressure of 90/50 mm Hg.- A drop in blood pressure indicates potential shock, which could be life-threatening in the client with pneumonia. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 4. Apical heart rate of 112 beats per minute.- A rapid apical heart rate occurs with an infection. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 5. Oral temperature of 101.9 degrees F (38.8 degrees C).- An elevated oral temperature indicates an infection, which is an expected finding with pneumonia. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. Think like a nurse: Pneumonia is a bacterial or viral infection in the lungs. Symptoms include elevated temperature and a change in respiration, in addition to upper and lower respiratory congestion. Based on the 2016 Surviving Sepsis Campaign, an elevated lactic acid level in addition to the low blood pressure indicate severe sepsis. Current guidelines indicate that these symptoms, in addition to the elevated WBCs, tachycardia, and elevated temperature are all manifestations the nurse reports to the health care provider.

The nurse assesses a school-age child with suspected Hodgkin lymphoma. Which finding is most characteristic of this disease?1. Fever and malaise.2. Enlarged, painful inguinal lymph nodes.3. Firm, painless, and movable adenopathy in the cervical area.4. Anorexia and weight loss.

3. Firm, painless, and movable adenopathy in the cervical area.- Firm, painless, and movable adenopathy of the cervical area is associated with this disease. Think like a nurse: Prior to assessing this client, the nurse should mentally review the pathophysiology of the disease process to serve as a guide for identifying symptoms of the illness. In Hodgkin lymphoma, cancer cells develop in the lymph nodes and glands, primarily those of the neck region. When assessing this client, the nurse should expect to find enlarged lymph nodes along the neck. These nodes will be firm, painless, and freely movable upon palpation. The findings are classic characteristics of a metastatic disease of the lymph system. The nurse will then assess the client for additional, but more generalized, manifestations of Hodgkin lymphoma.

A client returns to the unit following a pyelolithotomy through a flank incision. Which assessment finding does the nurse expect?1. Breath sounds that are clear on the nonoperative side, diminished on the operative side.2. Breath sounds that are diminished on the nonoperative side, clear on the operative side.3. Breath sounds that are diminished on both sides.4. Breath sounds that are clear on both sides.

4. Breath sounds that are clear on both sides.- This is an expected outcome. While the client post-pyelolithotomy is at risk for pleural effusion and lung puncture due to the site of the surgery, the expected outcome is clear breath sounds. Think like a nurse: The client had surgery to remove a kidney stone. The nurse needs to be aware of certain findings, postoperatively, that are expected, and others that may indicate the development of complications. Clear breath sounds indicate adequate oxygenation and ventilation. Because of the location of the incision, the client may hesitate to take deep breaths. The nurse must encourage the client to turn, cough, and take deep breaths to decrease the likelihood of developing complications post surgery, such as pneumonia, atelectasis, or pleural effusion.

The nurse provides care for a client with a fear of flying. The client is taking a job that will require frequent long-distance travel. Which intervention is best for the nurse to recommend to the client?1. Asking the health care provider for a prescription for lorazepam.2. Suggesting insight-oriented therapy.3. Calling the crisis hotline prior to a flight.4. Using systematic desensitization.

4. Using systematic desensitization.— Systematic desensitization enables the client to encounter a phobic object gradually while using relaxation techniques. This will enable the client to be successful in the new role. Think like a nurse: The nurse needs to carefully analyze the client's situation and help determine a method of treatment that specifically meets the client's needs. The client's ability to fly will affect the client's success with a new job. The client needs a method of dealing with the phobia in a timely manner. One appropriate technique used to overcome a phobia is called systematic desensitization. This is where the phobia is broken down into separate parts and the individual is exposed to the parts in progression. For this client, this may mean going to an airport, going through security, sitting in the waiting area, entering an airplane, sitting in a seat, and then staying for an entire flight.

The nurse in the prenatal clinic assesses a client at 7 weeks ' gestation. The client is 5'7" (170.2 cm) tall and weighs 125 lb (56.8 kg). The client reports to the nurse concerns about gaining too much weight during the pregnancy. Which response by the nurse is appropriate?1. "You seem to be concerned about gaining weight. It 's too early to think about that now. "2. "You are already thin. You will not have any problems with gaining too much weight. "3. "You don 't need to worry about your weight gain. I'm sure you 're used to eating balanced meals. "4. "You should gain 3 to 5 pounds (1.4 to 2.3 kg) during your first trimester and eat foods rich in calcium, protein, and iron. "

4. "You should gain 3 to 5 pounds (1.4 to 2.3 kg) during your first trimester and eat foods rich in calcium, protein, and iron. "- This statement is the best response because it addresses the client's concerns while providing information. The client should gain 3 to 5 pounds (1.4 to 2.3 kg) in the first trimester, along with focusing on enhancing intake of foods rich in calcium, protein, and iron. Think like a nurse: Client education is an expected competency for every nurse. An essential first step is to assess the client 's teaching and learning needs, including literacy issues. Health literacy skills have been shown to be a stronger predictor of health status than age and educational level. The prenatal care visit is a great opportunity to educate the client on health promotion and disease prevention. For optimal comprehension and compliance, education materials should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations. The nurse can have the client keep a weight diary throughout pregnancy.

The nurse provides care for a client admitted for an adrenalectomy for treatment of Cushing syndrome. Which intervention is most important for the nurse to implement?1. Evaluate the client 's mood.2. Monitor the client 's blood glucose.3. Take the client 's temperature.4. Obtain the client 's weight.

2. Monitor the client 's blood glucose.- Hypercortisolism causes hyperglycemia and the blood glucose is monitored closely. Other symptoms include fatigue, weakness, osteoporosis, cramps, edema, hypertension, decreased resistance to infection, truncal obesity, buffalo hump, and moon face. Think like a nurse: Cushing syndrome is caused by an increased amount of cortisol in the body. Cortisol adversely effects blood glucose, causing hyperglycemia. Because of this, the client's blood glucose level should be monitored frequently.

When arriving for a home visit, the nurse learns that a toddler has just swallowed another family members ' medication. Which action will the nurse take first?1. Call poison control.2. Notify the health care provider.3. Assess the child.4. Administer syrup of ipecac.

3. Assess the child.— The child should be immediately assessed before implementing any actions. The child might need cardiopulmonary resuscitation or treatment of other symptoms, such as seizure activity.Think like a nurse: Developmentally, a toddler is curious and is interested in learning about the environment. Because of this, small objects, medications, and chemicals should be removed or secured in the environment to prevent the child from accidentally ingesting a potentially harmful substance. In this scenario, the toddler ingested another person's medication. The first action to take is to assess the toddler for adverse effects. Depending upon the findings, the nurse can suggest additional actions, the first of which is to contact the Poison Control Center for direction for treatment.

The nurse assesses a group of clients for risk of skin breakdown. The nurse identifies which client as being lowest risk for developing skin breakdown?1. A client who is incontinent of feces.2. A client with nutritional deficiencies.3. A client who is confined to bed.4. A client with mental illness.

4. A client with mental illness.— This condition does not place the individual at increased risk for skin breakdownThink like a nurse: The skin is the largest organ in the body and is prone to developing changes in texture, color, and integrity. When identifying the client most at risk for skin breakdown, the nurse should consider factors that affect skin integrity. These factors include age, nutritional status, mobility, general health condition, and cleanliness. In this scenario, the client with a mental health disorder does not have a factor that directly affects skin integrity. The nurse recognizes this client as being least at risk for experiencing skin breakdown.

The industrial nurse supervises the health care needs at a local plant. It is announced on the news that a device has exploded in a heavily populated area away from the plant and that individuals near the site have become ill. Several hours later, workers at the plant come to the nurse and demand antibiotics to protect them against potential effects of the device. Which is the best response by the nurse?1. "I cannot administer medication without a prescription. "2. "Tell me about how you are feeling. "3. "The cause of the illness has not been identified. "4. "Do you have any allergies to medications? "

2. "Tell me about how you are feeling. "- This assessment helps the nurse to identify specific concerns. The nurse needs to find out more information before determining the appropriate course of action. Think like a nurse: Several hours after an explosion, people in a populated area near the explosion site become ill. As a result, workers come to the industrial health nurse demanding antibiotics, even though the explosion occurred a distance from the plant. The nurse should think, "How can I best address the worker's demands?" The nurse should first assess the workers to determine whether they have signs and symptoms of illness. If present, the nurse should report such signs and symptoms to the health care provider. The health care provider may prescribe antibiotics depending on the suspected cause of illness.

The nurse instructs a group of high school parents at a local health fair. Which statements by the parents during the discussion period require follow up by the nurse? (Select all that apply.)1. "My teenager is very independent and doesn't need constant supervision after school."2. "My teenager can be impulsive at times, but is improving on problem solving skills."3. "Although I've made some mistakes in my life, I feel that I am a good role model for my teenager."4. "My child is moody and requires some guidance when frustrated with homework."5. "It is important to consistently tell my teenager what to do every day."

2. "My teenager can be impulsive at times, but is improving on problem solving skills."- Impulsiveness in an adolescent should be explored in greater detail and requires follow up. 5. "It is important to consistently tell my teenager what to do every day."- Needing constant direction does not contribute to an ideal level of development with this age group. Think like a nurse: The nurse should focus teaching to the parents of adolescents on reducing high risk behavior and encouraging healthy behaviors. Impulsiveness can lead to high risk behavior and should be followed up by the nurse. Parents are the ideal role models for an adolescent, and positive behaviors should be encouraged. Evidence of an expected level of development includes independence, which reduces the need for constant supervision, so the need for constant direction should be further analyzed.

The nurse monitors the progress of a client recovering at home from a laryngectomy. Which client behavior requires the nurse to intervene?1. Uses a finger to apply water-soluble ointment around the stoma.2. Inserts a few drops of water into the stoma every evening.3. Leaves the stoma uncovered when taking a bubble bath.4. Covers the stoma with a cotton scarf when outside.

2. Inserts a few drops of water into the stoma every evening.- Humidification should be provided with a humidifier or nebulizer and not by inserting water into the stoma. Think like a nurse: In client teaching, it is important that the client can articulate, via the teach-back method, the rationale of every activity. Instilling water, even only a few drops, into the tracheostomy stoma is an indication of a serious learning gap. The client should be taught about risk and consequences of aspiration. The nurse may reinforce instructions using short videos (e.g., from the website of professional organizations), return-demonstration, and printed materials. Hand hygiene remains a key activity in preventing spread of infection.

An infant is prescribed amoxicillin trihydrate 20 mg oral suspension every 8 hours by mouth. Which instruction will the nurse provide to the client 's parent?1. Administer after feeding and burping.2. Protect the medication from sunlight and warmth.3. Add the medication to the child 's formula and allow it to stand for 5 minutes.4. Shake the medication before giving it.

4. Shake the medication before giving it. — The medication particles are not totally dissolved in a suspension. The medication needs to be shaken before preparing a dose.Think like a nurse: For a client with a newly prescribed medication, focus instructions on the medication 's administration procedures, therapeutic effects, and adverse effects. Include instructions to shake amoxicillin to ensure delivery of the prescribed dose needed to treat the client 's condition. For the infant client, it is essential to instruct the parents to never mix a medication with formula or food unless specifically instructed to do so. This can alter the medication 's action, the client might not consume the entire dose, or the client may begin refusing the food or formula.

The nurse assesses a client who is diagnosed with hypoparathyroidism. Which data, if found in the client's medical history, are associated with the diagnosis of hypoparathyroidism? (Select all that apply.)1. Carpal spasms.2. History of convulsions.3. Renal calculi.4. Pathologic fractures.5. Muscle irritability.

1. Carpal spasms.- Carpal spasms are associated with hypoparathyroidism. A positive Trousseau sign, a positive Chvostek sign, muscle irritability, and tetany occur as a result of hypocalcemia. 2. History of convulsions.- Convulsions may occur in the client diagnosed with hypoparathyroidism because of neuromuscular irritability secondary to hypocalcemia. 5. Muscle irritability.- Convulsions may occur in the client diagnosed with hypoparathyroidism because of neuromuscular irritability secondary to hypocalcemia. Think like a nurse: The parathormone (PTH) regulates serum calcium. Normally, in the bone, PTH stimulates bone resorption and inhibits bone formation, resulting in release of calcium and phosphate into the blood. When there is not enough PTH, hypocalcemia results. The client might report tingling of the lips and fingertips and increased muscle tension and stiffness. In extreme cases, laryngospasms may be observed. The nurse needs to monitor the client for airway obstruction. When giving IV calcium replacement, the nurse should infuse the medication slowly because rapid infusion may cause serious hypotension and cardiac arrest. Ideally, the client should be attached to a bedside cardiac monitor.

A nurse driving home from work observes a car go off the road into a shallow embankment. Which client does the nurse advise the arriving paramedics to transport to the hospital first?1. A crying infant restrained in a rear-facing child safety seat.2. The restrained front seat passenger who has a laceration to the right side of his head.3. The restrained rear seat adult passenger who has a deformity of the right forearm and who reports pain at the site.4. The restrained driver who has faint discoloration around the umbilicus and reports abdominal pain.

4. The restrained driver who has faint discoloration around the umbilicus and reports abdominal pain. — Ecchymosis around the umbilicus or in either flank indicates retroperitoneal bleeding and is an emergency. This client takes priority for transport to the hospital.Think Like A Nurse: The nurse realizes that clinical judgement and critical thinking is driven by the integrated processes of nursing. To determine which client is the priority, the nurse should first assess the status of airway-breathing-circulation (ABCs) due to the emergent threat to life related to abnormal findings. In this scenario, all clients appear to be conscious and are not experiencing any issues with breathing. The client bleeding from the head has a superficial laceration, which is not life threatening. However, the client with abdominal ecchymosis is most likely experiencing bleeding from internal injuries. This is the priority client for emergency care.

The nurse assesses a client in the outpatient clinic reporting repeated severe headaches. Which action does the nurse take first?1. Obtain a description of the headache.2. Determine how the client usually relieves headaches.3. Ask how long the client has been having headaches.4. Obtain a list of medication the client is currently taking.

1. Obtain a description of the headache.— The nurse should ask the client to describe the headache in the client's own words. Headache is usually a symptom and not a disease, and can be a result of neurological disease, vasodilation, or skeletal muscle tension. The description of the headache will assist the nurse to determine what course of action is best. Think like a nurse: The first nursing action is always to assess, unless the client is in distress. The nurse should ascertain as much information as possible about the characteristics of the headaches. The information will be subjective and should be as detailed as possible, including a description of the kind and level of pain, along with the duration, frequency, and any preemptive events. This assessment will help determine the potential cause and identification of interventions that will be most appropriate to relieve the pain.

The nurse provides care for the client diagnosed with septic shock. Which observation most concerns the nurse?1. The peripheral pulses are strong and bounding and the respiratory rate is 26 breaths per minute.2. The white blood cell differential results indicate that there are predominantly band neutrophils rather than segmented neutrophils.3. The skin changes from warm, dry, and flushed to cool, clammy, and pale.4. There is blood at a venipuncture site and around an intravenous catheter.

4. There is blood at a venipuncture site and around an intravenous catheter. - The bleeding is an indicator of disseminated intravascular coagulation (DIC), a life-threatening problem. Sepsis is the most frequent cause of DIC. Like a nurse: Disseminated intravascular coagulation (DIC) is an adverse effect of septic shock. This complication causes bleeding, which would occur at the intravenous catheter insertion site. Early signs of shock include full and bounding pulses and a rapid respiratory rate. Signs that shock is progressing include cool, clammy, and pale skin.

The nurse provides care for a client diagnosed with heart failure. Which client statements indicate to the nurse that medication therapy is effective? (Select all that apply.)1. "Since I've been taking captopril, my feet are not as puffy."2. "Taking spironolactone has kept my pulse less than 60."3. "Lisinopril seems to help me not be as short of breath."4. "Now that I'm taking carvedilol, I don't have palpitations."5. "Before taking valsartan, I had to stop and rest while cooking."6. "I seem to urinate more when I take digoxin."

1. "Since I've been taking captopril, my feet are not as puffy."- ACE inhibitors, such as captopril, reduce peripheral edema. This statement indicates the medication therapy is effective. 3. "Lisinopril seems to help me not be as short of breath."- ACE inhibitors, such as lisinopril, reduce pulmonary congestion, which will decrease dyspnea. This statement indicates the medication therapy is effective.5. "Before taking valsartan, I had to stop and rest while cooking."- Angiotensin II receptor blockers (ARBs), such as valsartan, decrease pulmonary congestion and improve cardiac output, which should reduce client's fatigue and dyspnea. This statement indicates the medication therapy is effective. 6. "I seem to urinate more when I take digoxin."- Cardiac glycosides, such as digoxin, improve cardiac output, which increases urine output. This statement indicates the medication therapy is effective. Think like a nurse: In evaluating effectiveness of medications used to treat heart failure, the nurse should look for manifestations indicating an improvement of cardiac output, renal function, tissue perfusion, and activities of daily living. The client is informed to report to the provider sudden or steady gain in daily weight, such as 2 to 3 lbs (0.91 to 1.4 kg) in 24 hours or 5 lbs (2.3 kg) or more in 1 week. If taking digoxin, the client should be taught how to take their pulse rate for a full minute and be aware not to take digoxin if rate is less than 60 beats/minute.

The nurse provides care for a client taking disulfiram. Which medication is important for the nurse to instruct the client to avoid?1. Over-the-counter cough syrup.2. Propranolol.3. Aspirin.4. Antacids.

1. Over-the-counter cough syrup.- Intake of any form of alcohol with disulfiram will cause a severe reaction, including flushed skin, pounding headache, tachycardia, chest pain, shortness of breath, blurred vision, and hypotension. Most over-the-counter cough/cold preparations contain varying levels of alcohol and will precipitate this reaction. Think like a nurse: The nurse teaches the client to avoid medication interactions. Using Maslow's hierarchy to evaluate physiological issues first, the nurse is most concerned when a client reports ingesting over-the-counter (OTC) medications and drugs that may interact. Alcohol is a substance in many products that consumers do not think about, including cough medications. In this case, the client is taking disulfiram, an alcohol deterrent that is prescribed to help clients abstain from alcohol. All forms of alcohol ingestion, direct and indirect, should be avoided for this client. Serious adverse effects such as chest pain may occur if the client takes an unapproved OTC medication and the prescribed medication.

The nurse reviews the importance of receiving an annual influenza vaccination with a client. Which statement indicates to the nurse that the client requires further instruction?1. "I will get the shot since I am 69 years old."2. "I had bronchitis twice last year, so I will get the shot."3. "I volunteer at a preschool, so I will get the shot."4. "I live with two large dogs, so I will get the shot."

4. "I live with two large dogs, so I will get the shot."- The client is not at risk for getting influenza from a dog. Therefore, this client statement indicates the need for further education. Think like a nurse: The annual influenza vaccination is recommended for most, if not all, people. It is particularly important for older adult clients to receive this vaccination because of a change in immunity that occurs naturally with aging. Older adults are also more likely to have chronic respiratory and cardiovascular illnesses, which would be exacerbated by an episode of the flu. Younger children are prone to contracting and transmitting bacteria and viruses, but the influenza virus is not transmitted from animals.

During a pregnant client's nonstress test (NST), the nurse observes several late fetal heart rate decelerations. Which nursing action is most appropriate?1. Reposition the client on the right side.2. Notify the health care provider for further evaluation.3. Document these results in the client's record.4. Stop the oxytocin immediately.

2. Notify the health care provider for further evaluation.- The appearance of any decelerations of the fetal heart rate during the NST should be immediately evaluated by the health care provider. Think like a nurse: A nonstress test (NST) is performed to check fetal well-being when it is determined that the fetus might be at risk for an adverse outcome. An NST might be performed when the mother has diabetes mellitus, heart disease, or hypertension. Often, an NST is performed for a post-term fetus to determine whether pregnancy can continue until natural labor occurs or whether labor induction is needed. During this test, the only stress is the baby's own movements. A decreased fetal heart rate in response to fetal movement indicates poor fetal oxygenation. This finding indicates a need to notify the health care provider and likely will result in induction of labor.

The nurse delegates tasks to an unlicensed assistive personnel (UAP) for the first time. Which action is appropriate for the nurse to implement? (Select all that apply.)1. State to the UAP how to report task completion.2. Describe to the UAP which tasks will be delegated.3. Allow the UAP to decide which client changes to report.4. Permit the UAP to decide when tasks will be completed.5. Describe to the UAP the expected task outcomes.

1. State to the UAP how to report task completion.— This is an important step when delegating tasks to the UAP.2. Describe to the UAP which tasks will be delegated.— This is an important step when delegating tasks to the UAP.5. Describe to the UAP the expected task outcomes.— This is an important step when delegating tasks to the UAP.Think like a nurse: The five rights of delegation include the right task, right circumstance, right person, right direction/communication, and right supervision. The nurse is expected to provide a hand-off to the unlicensed assistive personnel (UAP) at the beginning of the shift. This is an opportunity for the nurse to verify the UAP's experience with tasks being delegated. It is important for the nurse to be familiar with the local institutional policy and state regulations related to delegation. Matching staff skill to client and family needs highlights the difference between delegation and assignment.

The nurse provides care for a client who has been raped. Which action by the nurse is most appropriate?1. Address the immediate needs and concerns of the client.2. Refer the client for crisis counseling.3. Determine how the rape occurred.4. Determine how the client previously responded to trauma.

1. Address the immediate needs and concerns of the client.— The first action is to assist the client to identify immediate needs and concerns. The nurse should first ensure that the client is physically stable. Think like a nurse: The nurse caring for a victim of rape should mentally ask, "Which actions will convey feelings of compassion and support, and not appear judgmental?" The priority when caring for a client who is a victim of rape is to address the client's immediate needs and concerns. The client has been physically, psychologically, and emotionally violated. The nurse needs to ensure for the client's physical needs while addressing psychological and emotional needs to the best of the nurse's ability. Keep in mind though that the nurse should not perform any tasks that may harm the trail of evidence.

The nurse in the outpatient clinic has four phone messages. Which message does the nurse return first?1. An older adult client undergoing bowel prep reporting watery diarrhea.2. A client with a newborn experiencing breast engorgement. 3. A client who had a cataract extraction 3 days ago reporting nausea.4. A client with a spinal cord injury at the level of C6 reporting a headache.

4. A client with a spinal cord injury at the level of C6 reporting a headache.— A severe headache is indicative of autonomic dysreflexia in the client with a high-level spinal cord injury. Autonomic dysreflexia is associated with a dangerously high blood pressure, and, if untreated, can result in intracranial bleeding and death. The nurse should instruct the client to sit in high-Fowler position and should assess for triggers, such as bowel impaction or urinary retention. When deciding which client to call first, the nurse considers which client is at highest risk for harm by using principles such as stable versus unstable; the airway, breathing, circulation (ABCs) method; and real harm versus potential harm. The client with a spinal cord injury who is reporting a headache is likely unstable due to a circulation issue (dangerously high blood pressure that can lead to stroke and death). This client is priority over the client who is at risk for increased intraocular pressure.

The nurse discovers a pediatric client in bed clenching the teeth and making tonic-clonic movements of the extremities. Which action will the nurse implement?1. Restrain the client's movements.2. Insert an oral airway.3. Gently turn the client to one side.4. Insert a tongue blade.

3. Gently turn the client to one side.- The nurse should gently turn the client to one side to maintain a patent airway and prevent aspiration of secretions. Think like a nurse: Finding a client in a posture or performing skeletal muscle movements that are out of the ordinary requires quick thinking by the nurse. The nurse should recognize the manifestations that indicate the client is having a seizure. The nurse should immediately implement the airway, breathing, and circulation (ABCs) of emergency care, with the first action to assess and protect the client's airway. The nurse is aware of the need to gently turn the client to a side-lying position, which will help maintain the airway and decrease the risk for aspiration. The position permits the tongue to fall forward and secretions to run out of the client's mouth, preventing airway occlusion. The nurse should never attempt to insert anything into the mouth of a client with seizure activity.

The nursing manager observes a graduate nurse conduct a physical examination on a newly admitted client. Which action made by the graduate nurse requires an immediate intervention by the nursing manager?1. The nurse uses the ball of the hand to palpate for tactile fremitus.2. The nurse depresses the client's tongue slightly off center when using a tongue depressor to inspect the uvula.3. The nurse uses a stethoscope to palpate the client's abdomen, with fingers moving over the edge of the diaphragm.4. The nurse completes inspection of the client's thorax for cardiac assessment and then begins auscultation.

4. The nurse completes inspection of the client's thorax for cardiac assessment and then begins auscultation.— The correct sequence during cardiac assessment is inspection, palpation, and then auscultation.Think like a nurse: The nurse needs to mentally review the correct order of processes before conducting a physical assessment. The nurse will need to consider what each process will do to the area being assessed. When assessing the client's thorax during the cardiac assessment, the order of assessment should be inspection, palpation, and auscultation. The nurse should palpate before auscultating heart sounds. However, when assessing the abdomen, the order becomes inspection, auscultation, and palpation. Palpating the abdomen prior to auscultation can change the characteristics of, or stimulate, bowel sounds.

The nurse plans care for a client diagnosed with Grave disease. Which intervention will the nurse include in the plan of care? 1. Serve the client two meals per day.2. Provide frequent rest periods.3. Provide extra clothes for warmth.4. Offer coffee and tea with meals.

2. Provide frequent rest periods.— The nurse will provide an environment that is free of stress and activity due to the high metabolic rate. The nurse should restrict visitors and control choice of roommates to provide the client with rest and an environment with few stimuli.Think like a nurse: The nurse knows that Grave disease is another term for hyperthyroidism. Because this client's metabolic rate is high, there is a need for frequent rest periods in a non-stimulating environment. The client will need additional calories and should avoid stimulants, such as caffeine. The nurse understands the importance of monitoring dietary intake and weight, adjusting the room temperature for comfort, and reviewing lab results. If surgery is performed, the nurse should observe for postoperative complications, such as hemorrhage, thyrotoxicosis, hypocalcemia, hypothyroidism, and damage to the laryngeal nerve.

The nurse presents a teaching session to a postpartum client who just delivered her first newborn. When educating the client about breastfeeding, which action does the nurse implement?1. Instruct the client to use an antiseptic soap to cleanse her breasts.2. Remain with the client and newborn during the breastfeeding.3. Inform the client that the newborn will require breastfeeding 4-6 times per day.4. Advise the client to use only the cradle position when breastfeeding.

2. Remain with the client and newborn during the breastfeeding.— The nurse should remain with the client to assess effectiveness of the newborn's suck, swallow, and gag reflex. Observation of the breastfeeding sessions offers an excellent opportunity to evaluate effectiveness of the feeding and provide additional teaching. Think like a nurse: Observation of a newborn breastfeeding from the mother offers clues to the nurse about what further instruction might be required and opportunities to praise the new mother's efforts. Techniques and tips can be offered during this time, if needed. This is also an opportunity for the nurse to observe maternal-infant bonding behaviors and to offer the significant other, if present, ways in which to participate.

The nurse in the pediatric clinic receives a phone call from a parent who says, "My 10-year-old has a nosebleed that will not stop bleeding even though I have applied pressure." Which response by the nurse is most important?1. "Place pressure on the nose using an ice-cold washcloth."2. "How much bleeding has occurred?"3. "Instruct your child not to blow the nose."4. "How long have you applied pressure?"

4. "How long have you applied pressure?"— The nurse should assess before implementing. Initially, the parent should apply direct pressure for 5 to 10 minutes continuously. If this is ineffective, the nurse should tell the parent to take the child to the emergency department or urgent care center as the nosebleed may require treatment with silver nitrate applicator and compressed gelatin foam.Think like a nurse: The client's statement that it "will not stop" requires assessment. All blood looks like too much blood, and any time spent bleeding seems like too much, especially to the lay person worried about their child. Nosebleeds are common and are often caused by dry mucous membranes. The capillaries in the nose are fragile and may bleed easily after chronic exposure to a dry environment. Frequent or prolonged nose bleeds require further assessment, though. Occasionally, nose bleeds are caused by severe problems such as bleeding disorders or cancers and will require medical intervention.

The nurse provides care to a client diagnosed with sinus arrhythmia. The nurse uses which site to assess the client's pulse? 1. Apical.2. Radial.3. Femoral.4. Carotid.

1. Apical.- Apical pulse assessment is indicated for use during initial cardiac examination or if the client's pulse is irregular. Sinus arrhythmia, which is most common among children and young adults, refers to minor variations in pulse regularity that occur in relationship to the respiratory cycle. In infants and children up to 3 years old, the apical pulse is the routine site for cardiac assessment. Apical pulse assessment is also indicated prior to administration of certain medications, such as digoxin. 2) INCORRECT - Assessment of the radial pulse is appropriate for routine use in the client with a stable, regular pulse rate and rhythm.Think like a nurse: The nurse should stop and recall the physiology of a sinus arrhythmia. The nurse is aware that arrhythmia is characterized by a change in rhythm that is associated with the phases of the respiratory cycle. The rate will typically increase during inspiration and slow down during expiration. Because this heart rate is irregular, measurement should be completed at the apical site for a more comprehensive assessment. Using a peripheral pulse measurement may not provide the correct heart rate for this client.

The nurse on the medical/surgical unit reviews lab results. The nurse notes that a client's serum albumin level is 2.5 g/dL (25 g/L), fasting blood sugar is 110 mg/dL (6.1 mmol/L), potassium is 4.2 mEq/L (4.2 mmol/L), and sodium is 140 mEq/L (140 mmol/L). It is most important for the nurse to assess for what finding?1. Edema.2. Nausea.3. Muscle weakness.4. Blurred vision.

1. Edema.— The client has hypoalbuminemia. The normal albumin range is 3.5-5.5 g/dLThink like a nurse: The nurse reviews the lab values and identifies the client's albumin level as low. The nurse evaluates each assessment finding to identify whether it is associated with hypoalbuminemia. One reason for the development of edema is a low total body protein level. An adequate albumin level is required for fluid to stay in the vasculature. When this level decreases, fluid will shift to body tissues, causing edema. The nurse should assess the client's dietary intake, explore reasons why the client is not eating (if applicable), and collaborate with the dietitian to develop a healthy, balanced meal plan for the client.

The employee-health nurse encourages all employees to use a newly opened physical exercise and wellness area in the workplace. Which level of health promotion is the nurse demonstrating in this situation?1. Primary prevention.2. Secondary prevention.3. Tertiary prevention.4. Passive prevention.

1. Primary prevention.- This type of prevention works to precede disease and alter unhealthy behaviors.Think like a nurse: One role of the nurse is to provide health promotion and disease prevention teaching. Prior to this teaching, the nurse should recall the different levels of prevention. Primary prevention includes activities to prevent the development of disease. This would include making lifestyle adjustments such as increasing daily exercise. Secondary prevention includes activities to detect and then treat disease. Tertiary prevention includes activities to recover from disease. In this scenario, the nurse is endorsing the use of exercise facilities as a primary prevention action.

The community health nurse provides care to an older adult client who recently developed decreased hearing acuity. The client's family is concerned because the client insists on taking evening walks alone. Which recommendation by the nurse is most appropriate?1. "It's best for you to walk in the morning."2. "Consider visiting an audiologist."3. "You'll need to find a walking partner."4. "Carry a cell phone with you at all times."

2. "Consider visiting an audiologist."— Primary concerns for the older adult client include optimizing health and wellness to preserve autonomy and independence. Visiting an audiologist is the most appropriate recommendation, as the audiologist may prescribe hearing aids, which would enhance the client's autonomy and independence. Think like a nurse: The community health nurse should think, "What could I recommend that would help address the client's hearing loss and the family's concerns regarding the client's safety?" An audiologist can help assess the client's hearing loss and recommend possible solutions. Insisting that the client walk with a partner diminishes the client's independence. A client with hearing loss may not hear approaching people or vehicles, increasing the risk for client harm. This risk remains present regardless of the time of day. Carrying a cellphone enables the client to call for help should a problem arise, but it does not protect the client from harm.

The nurse provides care to clients in a skilled nursing facility. Which client requires the nurse's immediate attention?1. Recovering from a cerebral vascular accident whose prescription for warfarin expired two days ago.2. Experiencing pain after receiving morphine in an acute care facility and was transferred with a prescription for acetaminophen with codeine.3. Voiding foul-smelling, cloudy, dark amber urine associated with dysuria.4. Needing influenza immunization because of immunosuppression.

1. Recovering from a cerebral vascular accident whose prescription for warfarin expired two days ago.- The duration of warfarin therapy for the client recovering from a cerebral vascular (CVA) accident is 2 to 5 days. This client is at risk for another CVA and should be assessed first. Think like a nurse: Warfarin is routinely prescribed as a treatment for ischemic/embolic stroke. Failure to take warfarin can result in new clot formation and place the client at risk for experiencing another stroke. This is a circulatory issue and should be assessed first. The client experiencing pain when voiding foul-smelling, cloudy, dark amber urine most likely has a urinary tract infection and should be assessed second. This is a physical need, but not a circulatory need.

The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe?1. The client is experiencing delusions of messianic grandeur. 2. The client believes that the world is ending on a specific date. 3. The client is experiencing persistent pain after the resolution of herpes zoster.4. The client is experiencing blindness without an identified physical cause.

4. The client is experiencing blindness without an identified physical cause. - Conversion disorder is diagnosed when the client presents with neurologic symptoms such as blindness, deafness, or paralysis that cannot be explained by medical evaluation. Think like a nurse: The nurse understands that a conversion reaction is the development of a neurologic symptom without an identifiable reason. The client demonstrating blindness as a conversion reaction will have intact optic cranial nerve function, but will be blind. Additionally, a client diagnosed with a conversion reaction may report muscle paralysis, again, without an identifiable cause.

A client receiving a blood transfusion experiences a hemolytic reaction. Which finding will the nurse expect when assessing this client? 1. Hypotension, backache, low back pain, fever.2. Wet breath sounds, severe shortness of breath.3. Chills and fever occurring about an hour after the infusion started.4. Urticaria, itching, respiratory distress.

1. Hypotension, backache, low back pain, fever.- Signs and symptoms of a hemolytic reaction include chills, headache, backache, and dyspnea.Think like a nurse: The nurse is aware that a client should be closely monitored during a blood transfusion. A hemolytic transfusion reaction is the most severe type of reaction because the immune system breaks down red blood cells in the body due to incompatibility with the transfused blood. Manifestations of this type of reaction include a drop in blood pressure, backache, chills, headache, and a fever. The nurse should stop the transfusion immediately, administer oxygen, monitor vital signs, and contact the health care provider.

3. Death of a spouse.- According to the Social Readjustment Rating Scale, death of a spouse ranks as the highest risk factor for stress-related disorder. Think like a nurse: Holistic care takes into consideration the client's body, mind, and spirit. The nurse recognizes a problem within any of these health domains can result in disease. When stressed, the body responds by increasing the release of cortisol, the stress hormone. With prolonged stress, the body may not be able to fend off other diseases because of the constantly elevated level of stress hormone in the bloodstream. The nurse should recall that there are different types and levels of stress and should mentally ask, "What would cause the client to experience the most amount of total body discontent?" In this scenario, the one that would cause the most acute physical, mental, and emotional stress response would be the death of a spouse.

The health care provider documents in a client's medical record the statement "bizarre gesturing, decline in hygiene, and command hallucinations." Which action is most important for the nurse to take when caring for this client? 1. Note the quality and duration of the gestures.2. Offer the client a fresh change of clothing.3. Ask the client what the voices are saying.4. Administer antipsychotic medication.

3. Ask the client what the voices are saying.- The nurse must assess the nature of command hallucinations and then take appropriate safety action, as the voices may be telling the client to harm self or others. Think like a nurse: The priority for the nurse is to assess the content of the hallucinations so appropriate safety actions can be implemented. After safety needs are met the nurse can help meet the client's hygiene needs. Medications will be provided as prescribed after safety needs are met.

The health care provider removes the peripherally inserted central catheter (PICC) from a client. A portion of the catheter breaks off. Which action does the nurse take first?1. Check the client's radial pulse.2. Turn the client to the right side.3. Apply a tourniquet to the upper arm.4. Instruct the unit secretary to call for an emergent x-ray.

3. Apply a tourniquet to the upper arm.- The nurse will place a tourniquet close to the axilla. This prevents the catheter piece from advancing into the right atrium and acting as an embolism. After the tourniquet is applied, check for the presence of the radial pulse to ensure that arterial flow is not eliminated. The tourniquet will be kept in place until an x-ray is obtained and surgical retrieval attempted. Think like a nurse: With proper placement, the distal end of peripherally inserted central catheter (PICC) lies near the heart in the superior vena cava. A catheter tip embolus may be the actual tip or a portion of the catheter. The original length of the PICC should be noted in the procedure documentation. If the entire catheter is not retrieved upon removal, the nurse may apply a tourniquet to the upper arm with the hope that the catheter embolus is lodged in the arm and not in a major vessel. The health care provider, rapid response team, and PICC insertion team should be notified of the adverse event. Documentation should be completed per the organizational policy.

The nurse provides care for an older adult client after a left total hip replacement. Which finding will the nurse be most concerned about?1. The client is positioned with a pillow between the legs.2. The client moves slowly when getting out of bed.3. The client 's heels are on the bed with toes pointed upward.4. The client uses an incentive spirometer every 2 hours.

3. The client 's heels are on the bed with toes pointed upward.— This client is at an increased risk for skin breakdown. It is important to keep the client 's heels off the bed to prevent skin breakdown. Think like a nurse:The National Pressure Ulcer Advisory Panel recommends that the nurse ensure that the client 's heels are free from the bed. Additionally, the staff should use heel offloading devices or polyurethane foam dressings on individuals at high-risk for heel ulcers. The nurse should inspect all of the skin upon admission as soon as possible (but within 8 hours). Heel pressure injury can develop over a short period. When a client suffers from neuropathy (e.g., reduce leg sensation), the client may not feel pain on the injured heels.

A nurse in a rural community assesses residents for risk factors for heart disease. The nurse determines that which resident is at greatest risk to develop heart disease?1. A resident who participates in a competitive weight lifting program.2. A resident diagnosed with type 1 diabetes that is poorly controlled.3. A resident whose grandfather died of heart failure at age 72.4.A resident who drinks a glass of beer every night.

2. A resident diagnosed with type 1 diabetes that is poorly controlled.— An elevated blood glucose level places a client at risk for heart disease. Diabetes is considered a cardiovascular risk equivalent. Think like a nurse: The nurse needs to consider the connection between heart disease and other presenting factors. Which of the presenting factors have a known negative effect on the cardiovascular system? The nurse needs to remember that the complications of diabetes mellitus are divided into macro-vascular or micro-vascular changes. Both of these types of complications adversely effect the heart's function in the client with diabetes mellitus. The client with diabetes mellitus who is poorly controlled is at the greatest risk for a cardiovascular event.

The nurse is considered professionally negligent by delegating which task to the unlicensed assistive personnel (UAP)? (Select all that apply.)1. Measure a client's temperature rectally.2. Administer eye drops stored in the client's room.3. Increase a client's intravenous fluid flow rate.4. Insert a straight, intermittent urinary catheter.5. Change a peripheral intravenous site dressing.6. Administer a cleansing tap water enema.

2. Administer eye drops stored in the client's room.- Medication administration cannot be delegated to an UAP. Even multidose medications stored in the client's room, whether at bedside or locked in the client's personal medication drawer, cannot be given by the UAP. 3. Increase a client's intravenous fluid flow rate.- Regulation of IV flow rate cannot be delegated to UAP. 4. Insert a straight, intermittent urinary catheter.- Invasive procedures require knowledge of asepsis and cannot be delegated to the UAP. 5. Change a peripheral intravenous site dressing.- Changing a peripheral IV site dressing requires knowledge of asepsis and assessment of peripheral IV site, and cannot be delegated to the UAP. Think like a nurse: When delegating tasks to the unlicensed assistive personnel (UAP), the nurse must recall the scope of practice for the UAP. The nurse is responsible for medication administration, monitoring IV fluid infusions, performing invasive procedures (e.g., intermittent urinary catheterization), and changing dressings on areas that need to be assessed. Therefore, these procedures cannot be delegated. The UAP can safely measure vital signs and administer a cleansing enema after the nurse validates that the skill can be safely performed. Therefore, it is appropriate to delegate these tasks to the UAP.

The nurse teaches a group of pregnant clients about prenatal care. Which client statement requires follow up by the nurse?1. "I will avoid changing my cat's litter box."2. "I will drink 8 glasses of water a day."3. "I will put my legs up on a pillow when I lie on my back to watch television."4. "I can continue with my exercise class until I become too short of breath."

3. "I will put my legs up on a pillow when I lie on my back to watch television."- Supine hypotension syndrome, also called aortocaval compression or vena cava syndrome, may occur if the woman lies on her back. The heavy uterus compresses her inferior vena cava, reducing the amount of blood returned to her heart. Circulation to the placenta may also be reduced by increased pressure on the woman's aorta, resulting in fetal hypoxia. The nurse should instruct the client to lie on her side. Think like a nurse: The nurse should consider the health of the client and the fetus when preparing teaching material for this population. Teaching should focus on wellness activities and actions to ensure viability of both client and fetus. In this scenario, the pregnant client should be instructed to avoid the supine position. The information is based on the fact that the weight of the growing fetus compresses the client's inferior vena cava, reducing the return of blood to the heart and general circulation. Supine position also hinders the blood flow to the fetus. Lying prone is another position that adversely affects both the client and fetus and should be avoided.

An adolescent student asks the school nurse what to do when a parent has a panic attack every time the parent attempts to leave the house. Which statement is the best response for the nurse to make?1. "Have your parent practice deep breathing and relaxation techniques before leaving the house."2. "Tell your parent that this behavior is disruptive to the whole family."3. "You are concerned for your parent, but more help is needed than you are able to provide."4. "Desensitize your parent by having them get into the car and quickly leave the area."

3. "You are concerned for your parent, but more help is needed than you are able to provide."— The student is describing a phobic disorder that is treated with behavior therapy and medication that can reduce or block the panic attacks. Phobias are an extreme expression of anxiety, apprehension, or helplessness when confronted with the phobic situation or feared object. The person avoids the situation in which the symptoms have occurred and restricts life in ways that become as problematic as the original phobic object.Think like a nurse: Dealing with a parent who suffers from panic attacks is stressful, particularly for adolescent children. The nurse can assist by clarifying the situation the child is facing and acknowledging the limits of what the child can provide to help the parent. The nurse should escalate the scenario by making appropriate referrals to community-based organizations that can help the child. The nurse can offer reassurance and hope to the child. In small ways, this may help the child build resiliency.

A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice is becoming louder and angrier. Which action does the nurse take? 1. Utilize an organized team to place the client in seclusion.2. Allow time in the client's private assigned room for reflection.3. Redirect the client to a quiet activity such as journaling4. Assist the client to express feelings of anger and frustration.

4. Assist the client to express feelings of anger and frustration. — This behavior indicates increased agitation and may indicate impending violence. The nurse de-escalates the client's behavior. The nurse will help the client to verbalize feelings, avoid disagreeing with or threatening the client, and remove threatening components of the environment. Think like a nurse: When clients, visitors, or staff are angry or upset, the nurse first seeks to defuse, or de-escalate, the situation. Strategies for defusing conflict include stating objective observations, such as "you seem frustrated," rather than immediately questioning an individual about details of the situation. At the height of conflict, asking "why" may be perceived as confrontational and can exacerbate a volatile situation. Acknowledging feelings and providing appropriate validation are effective strategies to help the individual feel heard and understood, which in turn may decrease the individual's sense of frustration.

During a flood, two ambulances arrive at an emergency substation at the same time. One contains a toddler near-drowning victim on a ventilator. The other contains an older adult client with a left-sided cerebrovascular accident (CVA) who is conscious and has a blood pressure of 220/130 mm Hg. Which client does the nurse see first?1. The toddler because the client is on a ventilator.2. The older adult client because the client is hypertensive.3. The toddler because the client is a victim of the flood.4. The older adult client because of the client's age.

2. The older adult client because the client is hypertensive.- The client's blood pressure is an obvious threat to health status and is an emergent problem.Think like a nurse: A client with hypertension and suspected stroke and a toddler near-drowning victim arrive at the emergency substation at the same time. The toddler receives mechanical ventilation. The older adult has severe hypertension and left-sided weakness. The nurse should think, "Which client's condition is life-threatening, but survivable with rapid intervention?" The toddler's airway and breathing are currently supported by mechanical ventilation. The older adult has severe hypertension and left-sided weakness. If left untreated, the older adult client could suffer life-threatening consequences.

The nurse performs an assessment of a 9-month-old client. The nurse expects which findings? (Select all that apply.) 1. The client sits unsupported.2. The client pulls self to a standing position.3. The client attempts to build a two-block tower.4. The client responds to simple verbal commands.5. The client can say three to five words.6. The client hugs the parent on request.

1. The client sits unsupported.— This is an expected finding. A 9-month-old client can sit without support for a prolonged period of time. 2. The client pulls self to a standing position.— This is an expected finding. A 9-month-old client can also stand while holding onto furniture. 4. The client responds to simple verbal commands.— This is an expected finding. The client should comprehend "no-no, " for example. Think like a nurse: When preparing to assess a 9-month-old client, the nurse should stop and think, "What is appropriate behavior for a client of this age?" The nurse will need to apply the concepts of growth and development. The nurse should expect musculoskeletal and neurologic systems to be developed so the client can sit unassisted and stand while holding onto a piece of furniture or someone's hands. The client's comprehension of words is still underdeveloped; however, the client should be able to understand the word "no," and other simple commands. A client of this age is egocentric and will expect others to respond to his/her vocalizations.

The school nurse educates preschool faculty and staff about hepatitis A. Which information does the nurse include in the teaching?1. Anorexia is one of the most common symptoms of hepatitis A among children.2. The majority of young children who contract hepatitis A will develop jaundice.3. The hepatitis A vaccine is administered to clients beginning at 1 month of age. 4. Black, tarry stools often occur among children diagnosed with with hepatitis A.

1. Anorexia is one of the most common symptoms of hepatitis A among children.- Among pediatric clients, symptoms of hepatitis A often are flu-like in nature. Common symptoms of hepatitis A among young children include anorexia, fever, malaise, and lethargy. However, among children 6 years of age and younger, up to 70 percent of individuals who contract hepatitis A will be asymptomatic. Think like a nurse: Hepatitis A is a fecal-oral disease, and as such, it flourishes in areas with poor sanitation or where poor sanitation occurs, such as schools and day cares. The Centers for Disease Control and Prevention is a great resource for the public to obtain information about hepatitis A. This severe and contagious illness lasts weeks to months and includes flu-like symptoms such as fever, fatigue, and loss of appetite. Disease-specific symptoms include gray color stools, jaundice, and dark urine.

The home care nurse assesses a client who reports having diarrhea. Which client statement indicates a need for follow up by the nurse?1. "I am taking an over-the-counter probiotic pill."2. "I like to drink water that is at room temperature."3. "I am taking azithromycin."4. "I like waffles for breakfast."

3. "I am taking azithromycin."— Azithromycin, which is a macrolide anti-infective agent, may cause diarrhea, nausea, and abdominal pain. The client should be advised to consult a health care provider regarding management of diarrhea, which may include changing the medication regimen.Think like a nurse: The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects. The client is experiencing a side effect to the antibiotic. The client or nurse should notify the health care provider who may change the medication or ask the client to take an over-the-counter anti-diarrhea medication. Occasionally, gastrointestinal symptoms are too severe to continue the medication.

The school nurse teaches high school students about safe practices when it comes to loud noises and hearing. A student reports, "My parents are always yelling at me about my loud music and that I will go deaf. I tell them that when I get old, if I need a hearing aid, I will just get one. I already wear glasses." What is the best response by the nurse?1. "It sounds as though your parents really care about you."2. "Let me explain about the two main kinds of hearing loss."3. "It is not that simple. Hearing aids are quite different from glasses."4. "You seem really upset about this issue with your parents."

2. "Let me explain about the two main kinds of hearing loss."— Adolescents can think abstractly and logically, and this response provides important information from an adult outside the family. Hearing loss includes conductive and sensorineural types. The sensorineural type of hearing loss can be caused by prolonged exposure to noise, such as loud music. This type is usually permanent and is not helped with medical or surgical treatment (such as hearing aid use).Think like a nurse: The student's response about treatment for hearing loss indicates the need for teaching. The nurse should explain the types of hearing loss and which can be aided by a hearing device. Addressing the student's comment about eyeglasses does not focus on the most important issue, which is that the student does not understand the types of hearing loss, how they occur, and the methods available to treat them.

A client is tested for suspected amyotrophic lateral sclerosis (ALS). Which early symptom will the nurse expect the client to exhibit?1. Incontinence of bowel and bladder.2. Difficulty swallowing.3. Paresthesia of the face.4. Disorientation to time and place.

2. Difficulty swallowing.— ALS affects the muscles of the throat and upper respiratory tract. The client will demonstrate dysphagia, which can cause aspiration. Other early symptoms include fatigue while talking, tongue atrophy, and weakness of the hands and arms.Think like a nurse: Many of the early manifestations of amyotrophic lateral sclerosis (ALS) are related to impaired muscular coordination. Speech or swallowing difficulties, failure to accurately grasp a writing or eating utensil, gait impairments, or clumsiness may be initial symptoms. These symptoms progress rapidly over the course of less than five years, resulting in loss of all muscle control, including the muscles that control respiration. The nurse promotes client safety by offering anticipatory guidance and coping strategies to help compensate for declining muscular coordination.

The nurse provides care for a client prescribed negative-pressure wound therapy for a wound on the left lower extremity. Which is the most important action for the nurse to take prior to initiation of the therapy? 1. Check serum protein levels.2. Check serum calcium level.3. Assess capillary refill of the upper extremities.4. Check white blood cell count.

1. Check serum protein levels.— Protein is essential for wound healing. If the client's protein level is low, wound healing will be impaired and the negative-pressure wound therapy may not be helpful.Think like a nurse:Wound healing is largely dependent on the body's internal environment. The client needs adequate dietary protein or a nutrient-rich infusion to promote healing. If the client is anemic, this condition must be corrected. An adequate red blood cell (RBC) count is needed to ensure sufficient oxygen delivery to the traumatized tissue. If the client demonstrates impaired systemic oxygenation, then supplemental oxygen should be administered as prescribed. Nursing assessment includes identifying potential barriers to wound healing, including inadequate client hygiene, and educating the client about infection control.

The home care nurse makes an initial visit to a client with heart failure. The client takes digoxin 0.25 mg and furosemide 40 mg daily. It is most important for the nurse to intervene if the client makes which statement?1. "I take my digoxin either in the morning or midday."2. "I eat a dish of ice cream for dessert every night."3. "I take herbal licorice to control my stomach ulcer."4. "I take the furosemide after supper each day."

3. "I take herbal licorice to control my stomach ulcer."- Licorice can increase potassium loss and may cause digoxin toxicity and arrhythmias.Think like a nurse: The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects, in addition to monitoring for medication interactions. Using the Maslow hierarchy to evaluate physiological issues first, the nurse is most concerned when a client reports ingesting foods and drugs that may interact. Licorice increases the potassium loss that results from furosemide, a loop diuretic. Hypokalemia interacts with digoxin to result in toxicity. Digoxin toxicity causes adverse effects, including arrhythmias.

A client is discharged from the emergency department after evaluation for a concussion with loss of consciousness. Which statement by the client's spouse indicates to the nurse that further teaching is necessary?1. "I will wake my spouse up every 3 hours when he is sleeping and ask him his name, my name, and where he is."2. "If my spouse reports a headache and needs aspirin, I will give it to him no more than every 4 hours."3. "If my spouse complains of blurry vision or has difficulty walking, I will bring him to the emergency department."4. "I will talk to my spouse's friend about doing the coaching for the soccer team tomorrow."

2. "If my spouse reports a headache and needs aspirin, I will give it to him no more than every 4 hours."- The client should not receive aspirin, as it can prolong any bleeding that might occur. Acetaminophen every 4 hours as needed is what should be given for pain. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client's understanding. In the client with a head injury, any statements about taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) require the nurse to evaluate the client's understanding and reteach the information. Small amounts of intracranial bleeding often are self-limiting; however, the addition of medications that make platelets less sticky increases the chance that any bleeding will result in continued bleeding and brain injury.

The unlicensed assistive personnel (UAP) calls the nurse and states, "The client in room 218 is reporting shortness of breath." Which response by the nurse is appropriate? 1. "Call the respiratory therapist and request an arterial blood gas be performed."2. "Ask the client when the shortness of breath started."3. "Ensure the nasal cannula is in the client's nares."4. "Listen to the client's lung sounds and notify me if you hear wheezing or crackles."

3. "Ensure the nasal cannula is in the client's nares."— Ensuring the nasal cannula is in the client's nares can immediately improve oxygenation. The skill of applying (not setting or adjusting oxygen flow) and adjusting a nasal cannula can be delegated to the UAP.Think like a nurse: The nurse is aware the unlicensed assistive personnel (UAP) are able to complete routine tasks for stable clients within the identified scope of practice. Assisting with the application of nasal cannula is within the scope of practice for this level of care provider. The nurse always need to understand In delegation, the nurse retains the accountability and responsibility for assessing and evaluating the effectiveness of treatment (the nursing process). In this scenario, the UAP is performing correctly by informing the nurse of a client issue or a change in the client's status. Shortness of breath is noted without the process of assessment.

The nurse supervises the unlicensed assistive personnel (UAP). Which tasks can the nurse safely delegate to the UAP? (Select all that apply.)1.Determine a client's risk for pressure injury development.2. Anchor a nasogastric tube to a client's gown.3. Provide nasal hygiene to a client with a nasogastric tube.4. Answer questions about a patient-controlled analgesia (PCA) pump.5. Change a client's peripheral intravenous (IV) site dressing.

2. Anchor a nasogastric tube to a client's gown.- This action can be delegated to the UAP. At this point, the nasogastric tube has already been secured to the bridge of the client's nose by the nurse.3. Provide nasal hygiene to a client with a nasogastric tube.- This action can be delegated to the UAP.Think like a nurse: Unlicensed assistive personnel (UAP) do not perform assessment and evaluation of nursing care or conduct client education, as these are the responsibilities of the nurse. The UAP can take vital signs, provide comfort measures, document intake and output, assist clients with activities of daily living (e.g., bathing). In some institutions, they can draw blood and perform a 12-lead ECG. It is essential for the nurse to provide a proper hand-off to the UAP and to verify the UAP's knowledge and experience doing certain tasks. The nurse should be familiar with the UAP's job description.

The nurse provides care to a client diagnosed with acute renal failure secondary to severe kidney infection. During the oliguric phase, which assessment finding does the nurse expect to observe? (Select all that apply. )1. Urine specific gravity is 1.039.2. Azotemia.3. Pruritus.4. Nausea.5. Serum potassium (K+) is 6 mEq/L (6 mmol/L).

2. Azotemia.- Azotemia, which is a classic sign of acute renal failure, refers to the buildup of nitrogenous waste products in the bloodstream. Hallmarks of azotemia include increased serum BUN and increased serum creatinine.3. Pruritus.- With acute renal failure, pruritus (itching) may occur. Although some scientists believe a buildup of urea in the bloodstream contributes to this condition, research has not yet conclusively identified the cause of pruritus in relationship to kidney dysfunction. 4. Nausea.- With acute renal failure, the buildup of metabolic waste products in the bloodstream may cause nausea and vomiting. 5. Serum potassium (K+) is 6 mEq/L (6 mmol/L).- Normal potassium ranges from 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Acute renal failure causes impaired filtration of fluid and electrolytes. During the oliguric phase, an increase in serum potassium (hyperkalemia) is typically seen. Think like a nurse: The kidneys remove body wastes and regulate fluid and electrolyte balance in the body. When the kidneys fail, normal functioning is effected. Azotemia, itching, and nausea occur because nitrogenous waste products and urea cannot be removed from the body. The potassium level can reach dangerously high levels because the injured kidney is unable to remove excess potassium from the body.

The nurse provides care for a client diagnosed with Guillain-Barré syndrome. Which statement indicates to the nurse that the client's family member understands the diagnosis? (Select all that apply.)1. "The syndrome only lasts 1 or 2 weeks."2. "Intravenous immunoglobulins are often used for treatment."3. "The cause of the syndrome may be a virus."4. "This illness doesn't cause shortness of breath."5. "My loved one's ability to walk will be affected."6. "A feeding tube may be required for treatment."

2. "Intravenous immunoglobulins are often used for treatment."— Intravenous immunoglobulins decrease circulating antibody levels and reduce the amount of time the client is immobilized and can prevent the need for mechanical ventilation. This statement indicates correct understanding of the information presented.3. "The cause of the syndrome may be a virus."— A viral infection precipitates clinical presentation in approximately 60% to 70% of cases. This statement indicates correct understanding of the information presented.5. "My loved one's ability to walk will be affected."— Guillain-Barré syndrome is an autoimmune attack on the peripheral nerve myelin. This statement indicates correct understanding of the information presented.6. "A feeding tube may be required for treatment."— If the client cannot swallow because of bulbar paralysis, a gastrostomy tube may be placed to administer nutrients. This statement indicates correct understanding of the information presented.Think like a nurse: Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. Given that Guillain-Barré syndrome is a serious condition, the nurse should offer the client and family emotional support along with information.

The home care nurse visits a client undergoing continuous ambulatory peritoneal dialysis (CAPD) for chronic kidney disease. Which instruction does the nurse reinforce with the client? 1. "Drink distilled water."2. "Cap the catheter during dwell time."3. "Boil the dialysate 1 hour before an infusion."4. "Clean the arteriovenous fistula site with hydrogen peroxide daily."

2. "Cap the catheter during dwell time."- The most common complication is peritonitis. Use aseptic technique when caring for catheter, fluid, or tubing. Cap the catheter during the dwell time.Think like a nurse: Prior to teaching a client a specific treatment, the nurse should mentally ask, "What is the most important information that this client needs?" and "What concerns exist regarding the client's safety?" The nurse needs to consider that peritoneal dialysis is the introduction of dialysis fluid directly into the peritoneal cavity. There is a significant risk of infection during the preparation for the procedure, the introduction of the fluid, and when the fluid is drained. The nurse should emphasize practices to reduce the likelihood of the client developing an infection when performing this procedure in the home.

The nurse provides care for a pregnant client. The client reports heartburn. Which client statement requires the nurse to intervene? 1. "I sit upright for 2 hours after eating."2. "I sleep with an extra pillow."3. "I will stop smoking."4. "I eat every 6 hours."

4. "I eat every 6 hours."—The nurse should intervene. The client should eat small, frequent meals. Think like a nurse: A pregnant client may experience a variety of nuisance health problems that did not exist prior to becoming pregnant. One of these health situations is heartburn. Heartburn can be caused by changes in the client's hormone levels affecting the rate of digestion and tolerance of different foods, or heartburn may be caused by the enlarging uterus putting pressure on the stomach. One action for the mother to take to lessen the effects of heartburn is to eat small meals more frequently and to choose foods that are not spicy or irritating to the gastric lining.

The nurse receives hand-off communication from the previous shift. Which client does the nurse see first?1. Client recovering from coronary artery bypass graft surgery who is having the atrioventricular wires removed later in the day.2. Client with type 1 diabetes mellitus who is scheduled for a cardiac catheterization later today.3. Client recovering from surgery a day ago with an spinal anesthesia in place.4. Client with cardiomyopathy who is being evaluated for a heart transplant.

3. Client recovering from surgery a day ago with an spinal anesthesia in place.- Spinal anesthesia is used for pain relief. The client needs monitored for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting.Think like a nurse: The presence of an spinal anesthesia used for pain management increases the risk for respiratory depression, hypotension, and alterations in bowel and bladder function. This client should be assessed first. The client recovering from coronary surgery is stable enough to have pacer wires removed. The client with diabetes mellitus is awaiting a procedure. The client with cardiomyopathy is awaiting a transplant and does not have acute issues at this time.

The nurse provides care to a client with a cast on the left leg. Which exercise will the nurse recommend to this client?1. Passive exercise of the affected limb.2. Quadriceps setting of the affected limb.3. Active range of motion exercises of the unaffected limb.4. Passive exercise of the upper extremities.

2. Quadriceps setting of the affected limb.— Quadriceps setting is an isometric exercise. It is performed by contracting the muscle without moving the joint. This exercise maintains muscle strength while the limb is in a cast.Think like a nurse: Quadriceps setting, also known as "quad sets," is an isometric exercise that helps promote muscle maintenance in a casted extremity. Desired outcomes associated with performance of quad sets include preventing disuse syndrome, which is characterized by muscle wasting, weakness, and disability. To perform quad sets, the client sits on a flat, level surface and extends the casted leg in front of the body. The client then contracts the thigh muscles while pressing the knee toward the surface beneath the leg. The client maintains the muscle contraction for a few seconds before relaxing. The exercise is repeated for approximately 10 sets. Ideally, quad sets should be performed hourly to maintain muscle mass while the limb is immobilized.

The school nurse finds an adolescent client slumped on the floor of the bathroom with a razor blade in hand and bleeding from the wrists. Which response by the nurse is appropriate?1. "Why are you doing this to yourself?"2. "What caused you to cut yourself?"3. "Did you tell anybody about this?"4. "I will not leave you alone."

4. "I will not leave you alone."— The nurse will stay with client and convey the intent to control the current injury and the teen's self-destructive impulses.Think like a nurse: Staying with the client is the best action of the nurse. After calling for assistance, the nurse should assess the client and the environment for potential hazards. The nurse can follow the protocol of the school. It is likely that a paramedic should be called immediately. As it is a sentinel event, the nurse should participate in debriefing and root-cause analysis. The nurse also should anticipate providing support to the other students in the school who might be affected by the suicidal behavior of the client.

The nurse prepares teaching for a client receiving sulfasalazine. Which information will the nurse include in this client's instructions?1. Restrict fluids to 1500 mL per day.2. Expect that stools may become clay-colored.3. Continue the medication even after symptoms subside.4. Discontinue the medication if diarrhea occurs.

3. Continue the medication even after symptoms subside.— Sulfasalazine decreases bowel inflammation. It should be taken as prescribed.Think like a nurse: For teaching and learning, ensure a comfortable environment with adequate lighting. Prepare for the teaching activity. Determine the client's knowledge level and previous experiences with taking sulfasalazine. Allow time for discussion and questions. Stop for a break when the client indicates that one is needed. Minimize distractions and use clear, brief instructions. Clearly communicate the objectives and expectations. Determine which factors help or hinder the learning process. Evaluate the effectiveness of the teaching and learning session.

The nurse on the burn unit orients new staff to infection control issues. Which measure is most important to emphasize for this particular type of unit?1. Wear gowns, gloves, masks, as well as shoe and hair covers.2. Ensure that no equipment is shared between clients.3. Assign clients diagnosed with infection to private rooms with negative-pressure air flow.4. Wash hands using a thorough and consistent approach.

4. Wash hands using a thorough and consistent approach.— Correct and consistent handwashing is the single most effective technique for preventing infection transmission on burn units. This is the priority measure for the nurse to communicate.Think like a nurse: The nurse recognizes that any client with impaired skin integrity is at an increased risk for infection. Handwashing, in all settings, is the first line of defense against the transmission of microorganisms. When providing care to a client with a burn injury, hand hygiene should be performed according to established protocols. This includes washing the hands both before and after each instance of client contact and wound care.

The nurse provides care for a client who is one day postpartum. The client voids large amounts of urine frequently. Which action does the nurse implement?1. Assure the client that this is expected after delivery.2. Ask the client if the urine is cloudy.3. Check the urine specific gravity of the urine.4. Notify the health care provider.

1. Assure the client that this is expected after delivery.- Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Postpartum diuresis is caused by several factors, including a decrease in serum estrogen levels, the elimination of increased venous pressure in the lower extremities, and by the loss of any remaining pregnancy-induced increases in blood volume. All of these factors work together to aid the body in ridding itself of excess fluid. A urine output of 3000 mL or more each day during the first 2 to 3 days is expected. Think like a nurse: The body undergoes major physiological changes during pregnancy. Upon delivery, the body realizes that the changes needed to support the developing fetus are no longer needed, and begin sto adjust. One of the body changes in pregnancy is an increase in circulating blood volume. The extra blood is needed to support both the mother and developing fetus. Once the fetus is delivered, the extra blood is no longer needed and the body can start to remove the extra fluid from the general circulation. Evidence of the body making appropriate adjustments to the mother's fluid volume is an increase in the amount of urination. This is an expected occurrence that should be explained to the client.

The nurse reviews the medical record of a client who is 24 hours post-operative. Which assessment documented in the client's record requires an intervention by the nurse?1. A client has requested pain medicine every 6 hours since returning from surgery.2. A client's urine output is 240 mL during the previous 12-hour shift.3. A client has ambulated twice in the room.4. A client has not had a bowel movement since surgery.

2. A client's urine output is 240 mL during the previous 12-hour shift.— A urine output of less than 30 mL per hour requires further evaluation by the nurse. Once the nurse assesses the situation, the next action is to notify the health care provider.Think like a nurse: The nurse needs knowledge regarding the normal functioning of the body, and of the conditions that can alter normal functioning. Anesthesia can interrupt normal bodily functions. For the client recovering from surgery, these bodily functions may return slowly. However, renal function is rarely negatively impacted by anesthesia and should be monitored for routine function. The kidneys normally produce 30 mL of urine per hour. If the client had a urine output of 240 mL of urine over the last 12 hours, the kidneys are producing 20 mL/hour, which is less than optimal. This finding should be reported to the health care provider for the prescription of interventions.

The nurse asks the unlicensed assistive personnel (UAP) to perform soapsuds enemas for a client scheduled for a diagnostic test. Which action does the nurse expect from the UAP? 1. The UAP describes the returns from the enema. 2. The UAP observes the returns from the enemas in the bedside commode.3. The UAP asks the client to describe the returns from the enema.4. The UAP palpates the client's abdomen, noting firmness and tenderness.

2. The UAP observes the returns from the enemas in the bedside commode.— Performing an enema is a standard, unchanging procedure that can be delegated to the UAP with the responsibility and authority for performing the task. It is the nurse's responsibility to describe clear outcomes. Observing returns is a part of the task delegated and should be performed by the UAP. Think like a nurse: Before delegating a skill, the nurse needs to consider the scope of practice of the care provider. Unlicensed assistive personnel (UAP) are permitted to provide soapsuds enemas if competency on the skill is validated and the client is stable. When delegating the task, the nurse should clearly explain the expectations. For the soapsuds enemas, UAP should observe the returns and report these findings to the nurse. Remember that assessment is beyond the scope of practice for UAP.

The nurse provides care for a client diagnosed with atherosclerosis. Which client statements about clopidogrel require follow-up by the nurse? (Select all that apply.)1. "This medication may cause my blood pressure to be low. "2. "I play racquetball three times each week for exercise. "3. "I need to go back to the health care provider next year. "4. "I take my medications at the same time each day. "5. "I take this medication so I don 't have a stroke."6. "I will notify my health care provider if I notice bruises. "

1. "This medication may cause my blood pressure to be low. "— Adverse effects of clopidogrel include hypertension, so this statement requires the nurse to follow up. 2. "I play racquetball three times each week for exercise. "— Because clopidogrel increases the client 's risk of bleeding, contact sports such as racquetball should be avoided. The nurse will discuss safe exercise choices with the client. 3. "I need to go back to the health care provider next year. "— Clients taking clopidogrel will need regular medical supervision and periodic blood tests. The nurse should discuss follow-up care with the client. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client 's understanding. The client should demonstrate understanding of the medication 's therapeutic effects, side effects, and adverse effects. Clients who are prescribed antiplatelet medications (such as clopidogrel) or anticoagulant medications (such as warfarin or heparin) often require lifestyle changes, including increased health care provider visits and careful choices in activities. The client with atherosclerosis may also require blood pressure management. However, education is indicated to explain that clopidogrel is not used to decrease blood pressure.

The nurse instructs a client with gout about the disease process. Which client statement indicates additional teaching is required? 1. "I will limit my alcohol intake to one drink per day."2. "I will take a water bottle with me to work."3. "I will be able to eat mussels and clams for dinner."4. "I will skip the anchovies from my pizza toppings."

3. "I will be able to eat mussels and clams for dinner."- Shellfish, such as mussels and clams, are high in purine, which can lead to an increase in uric acid.Think like a nurse: The nurse needs to recognize that purines are substances in animal and plant foods that convert to uric acid. High levels of serum uric acid can lead to the formation of crystals that often accumulate in the joints, causing inflammation and a gout attack. The client is informed to avoid organ and glandular meats (liver, kidney, and sweetbreads), which have high purine levels. The client is advised to avoid beer, as well as distilled liquors and high fructose corn syrup. Research shows drinking more water means fewer gout flares. Low-fat dairy products may improve excretion of uric acid in the urine.

The health care provider prescribes cefdinir 190 mg in oral suspension every 12 hours. The label reads 125 mg/5mL. How many milliliters does the nurse administer for each dose? (Round at the end of the equation. Record your answer using one decimal place. )

7.6 mLRatio/Proportion:190/x mL = 125/5 mL5 ×190 = 125 mL950/125 = 7.6x = 7.6 mLDimensional Analysis:x mL = 5 × 190/125 = 950/125 = 7.6x mL = 7.6Alternate Method:125mg/5 mL = 25mg/mL190mg/25mg = 7.6 mL

The nurse provides care to a client who is experiencing dyspnea. Which symptom does the nurse expect to observe in the client?1. Tachycardia.2. Shortness of breath.3. Hemoptysis.4. High blood pressure.

2. Shortness of breath.- Dyspnea refers to a persistent feeling of inadequate ventilation, or "air hunger," and is often accompanied by difficult and labored breathing. Shortness of breath is commonly associated with dyspnea. Think like a nurse: The nurse needs to have a solid understanding of medical terminology. Any unknown term should be validated using a reliable resource. Sometimes, the nurse can break down the term to aid in interpretation ("dys" means difficult; "pnea" means breathing). The nurse must then mentally clarify what is expected when assessing a client with dyspnea. Individuals who experience dyspnea will state that they feel "short of breath" or are unable to "catch their breath." The nurse should expect the client with dyspnea to have rapid respirations. Depending upon the degree of dyspnea, the client may display anxiety. The nurse will also need to assess for signs of hypoxia.

The nurse observes the unlicensed assistive personnel (UAP) providing care for a client diagnosed with disseminated herpes zoster (shingles). Which UAP action requires the nurse to intervene ? (Select all that apply.)1. Ambulating the client to the nurses station.2. Donning gloves, a gown, and N-95 mask prior to entering the client's room.3. Refusing to enter the client's room due to a personal positive titer.4. Performing hand hygiene upon entering the client's room.5. Using the unit equipment to monitor the client's vital signs.

1. Ambulating the client to the nurses station.- The client diagnosed with disseminated herpes zoster is placed in contact and airborne isolation; therefore, ambulating the client to the nurses station increases the risk for infection to others who may not be immune. 3. Refusing to enter the client's room due to a personal positive titer.- The UAP is immune to varicella zoster (chickenpox) based on the positive titer, and the nurse will discuss this with the UAP. 4. Performing hand hygiene upon entering the client's room.- Hand hygiene will be done prior to entering a contact precaution room. 5. Using the unit equipment to monitor the client's vital signs.- Isolation rooms must have dedicated equipment to prevent hospital-acquired infections and cross-contamination of clients. Think like a nurse: Health care facilities should ensure that all health care workers have evidence of immunity to the varicella-zoster virus (VZV). This measure prevents VZV and nosocomial spread of VZV. A health care worker's immunity to VZV should be documented and readily available in the workplace. The health care worker who lacks evidence of immunity should receive teaching about the risks of possible infection and offered two doses of varicella vaccine (administered 4 to 8 weeks apart). An unvaccinated, susceptible health care worker who has been exposed to VZV is potentially contagious from days 8 to 21 after exposure, and the health care worker should be granted a leave of absence or temporarily transferred to a remote area that does not require contact with clients.

Which client on the pediatric unit requires the immediate attention of the nurse?1. A client with epilepsy who has a loose tooth.2. A client experiencing diarrhea with a sickle cell crisis.3. A client saying the arm cast feels too tight.4. A client who is blind and has a nosebleed.

3. A client saying the arm cast feels too tight.- A cast that is too tight may indicate compartment syndrome. This child has a current neurovascular status threat and is the priority patient.Think like a nurse: Prompt and accurate diagnosis of compartment syndrome is critical. Prevention and early recognition are the priorities of care. Of the four clients, the one reporting tightness of the cast requires immediate attention as it could lead to tissue hypoxia and necrosis. The client with epilepsy is not actively seizing, although the risk for aspiration from a loose tooth should be evaluated. The client experiencing symptoms of compartment syndrome requires immediate assessment and intervention to decrease the risk for a loss of limb due to circulatory compromise. While the client experiencing a sickle cell crisis with diarrhea requires assessment and treatment, there is no immediate danger. Epistaxis is rarely fatal.

The psychiatric nurse on the inpatient unit identifies which client situation as requiring the nurse's immediate attention?1. A client taking clozapine for 2 months reports having a sore throat.2. A client taking diazepam for anxiety asking for the medication on a regular basis.3. A client taking lithium carbonate for ten days being observed to have frequent urination.4. A client taking haloperidol for 4 days having a temperature of 102°F (38.9°C).

4. A client taking haloperidol for 4 days having a temperature of 102°F (38.9°C).- The fever may indicate impending neuroleptic malignant syndrome (NMS). NMS is a potentially lethal side effect of antipsychotic medications, especially high-potency drugs such as haloperidol. This is a medical emergency.Think like a nurse: The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects, in addition to monitoring for medication interactions. Using the Maslow hierarchy to evaluate physiological issues first, the nurse is most concerned when a client reports symptoms related to adverse effects, such as a high fever possibly caused by neuroleptic malignant syndrome (NMS). Neutropenia is a physiological concern too, but NMS is an emergency with high potential for quickly causing death. Ruling this out takes priority.

The nurse provides care to the client who is at 40-weeks' gestation and in labor. The nurse notes the client is having persistent late decelerations. The nurse recognizes which condition as a potential cause of persistent late decelerations?1. Umbilical cord compression.2. Impending delivery.3. Fetal head compression.4. Uteroplacental insufficiency.

1. Umbilical cord compression.INCORRECT - Umbilical cord compression typically causes variable decelerations. Late decelerations are associated with uteroplacental insufficiency. 2. Impending delivery.INCORRECT - Impending delivery is indicated by crowning of the fetal head.3. Fetal head compression.INCORRECT - Fetal head compression causes early decelerations. Uteroplacental insufficiency causes late decelerations. 4. Uteroplacental insufficiency.CORRECT— Persistent late decelerations are a manifestation of uteroplacental insufficiency.Think like a nurse: Late decelerations are the result of fetal hypoxia and subsequent fetal hypertension. Late decelerations may stem from excessive contractions, maternal hypotension or hypoxia, or poor perfusion across the placenta (placental exchange). If allowed to continue, fetal hypoxia results in sustained fetal bradycardia. The fetus cannot maintain this pattern of poor oxygenation and cardiac perfusion. Initial nursing interventions aim to increase the mother's cardiac output and oxygenation, but if these measures are not quickly successful, the fetus is delivered surgically.

The nurse provides care for an older adult client who had a stroke. Assessment findings include right-sided weakness, facial drooping, difficulty swallowing, and limited mobility. The nurse recognizes which sites are appropriate for use when assessing the client's temperature? (Select all that apply.)1. Axillary.2. Oral.3. Tympanic membrane.4. Rectal.5. Temporal artery.

Answer:1. Axillary.3. Tympanic membrane.5. Temporal artery.1. Axillary.CORRECT- Axillary temperature measurement is safe, noninvasive, and appropriate for use with the client who has had a stroke. Oral and rectal temperature measurements are not the best option for this client, due to facial drooping and the client's potential difficulty with assuming a side-lying position, which is necessary for assessment of rectal temperature. 2. Oral.INCORRECT - Due to facial drooping and difficulty swallowing, the oral cavity is not the best site for temperature assessment in the client who has had a stroke.3. Tympanic membrane.CORRECT- The tympanic membrane is an appropriate site for use in temperature assessment with the client who has sustained a stroke, as this site is easily accessible and does not require client repositioning. 4. Rectal.INCORRECT - Rectal temperature measurement is not ideal for the client who demonstrates limited mobility (including the client whose mobility is impaired due to a stroke), as maintaining a side-lying position may be challenging. Rectal temperature assessment provides no significant advantages over other routes of temperature assessment.5. Temporal artery.CORRECT- The temporal artery is an appropriate site for measurement of temperature in the client who has had a stroke, as this route is safe and easily accessible. However, use of this method requires specialized equipment that may not be available to the nurse.Think like a nurse: For the client who has experienced a stroke or cerebrovascular accident (CVA), measurement of vital signs requires certain precautions. The nurse will avoid taking an oral temperature due to facial paralysis. Nerves that control facial muscles are damaged and it is not completely safe or accurate to obtain an oral temperature under these circumstances. If the stroke resulted in hemiplegia, blood pressure measurements are obtained on the unaffected side of the client's body. Changes in muscle tone make obtaining a blood pressure on the affected side inaccurate and unsafe.

The nurse discovers an older adult client on the floor of the waiting room in the outpatient clinic. The client is unconscious and not breathing but has a pulse. Which action does the nurse implement next?1. Lift the back of the client's neck and check the airway.2. Move the lower jaw backward and push the tongue to the side.3. Turn the client's head to one side and shake the client firmly.4. Tilt the client's head back and lift the chin.

4. Tilt the client's head back and lift the chin.— This opens the airway. The nurse should place a hand on the client's forehead, applying backward pressure. The nurse should place the fingers of the other hand under the client's chin and lift forward.Think like a nurse: The nurse understands that the first step of cardiopulmonary resuscitation (CPR) is to determine client responsiveness by tapping or shaking the client's shoulder and asking, "Are you okay?" If the client does not respond, the nurse knows to check for breathing while simultaneously performing a carotid pulse check for at least 5 seconds, but for no more than 10 seconds. For the pulseless client, the nurse understands the importance of high-quality CPR and early defibrillation if the client's cardiac rhythm is ventricular fibrillation or pulseless ventricular tachycardia.

The nurse provides care for the client diagnosed with gastroesophageal reflux disease (GERD). Which information does the nurse include when educating the client about strategies to help decrease nighttime GERD symptoms?1. Lie down within 30 minutes after meals.2. Increase fluid intake prior to bedtime.3. Elevate the head of the bed on 6-inch blocks.4. Eat a snack every night at bedtime.

3. Elevate the head of the bed on 6-inch blocks.- For the client with GERD, when lying in a supine position, elevating the head of the bed helps decrease the risk for regurgitation of stomach acid into the esophagus.Think like a nurse: The nurse must provide information to the client diagnosed with gastroesophageal reflux disease (GERD). Interventions to treat GERD serve one of two purposes: (1) decreasing stomach acid production, or (2) decreasing reflux of stomach acid through the lower esophageal sphincter (LES). Certain foods cause the stomach to produce additional acid and should be avoided, such as fatty meals. Oatmeal and rice are filling foods that do not cause reflux. Strategies to reduce pressure on the LES include maintaining a healthy weight, avoiding tight-fitting clothing, staying upright after a meal, eating smaller meals, not smoking, and elevating the head of the bed at night.

The nurse instructs a client prescribed hydralazine as treatment for hypertension. Which client statements indicate to the nurse that the teaching is effective? (Select all that apply.)1. "I will take my hydralazine with my breakfast."2. "I will call my health care provider before taking ibuprofen."3. "I need to have my blood drawn twice a week."4. "I will feel hungry while on this medication."5. "I will sit on the edge of my bed for 2 minutes before I get out of bed."

1. "I will take my hydralazine with my breakfast."- Hydralazine should be taken with food to increase bioavailability of the medication.2. "I will call my health care provider before taking ibuprofen."- Over-the-counter medications should be avoided when taking hydralazine unless otherwise directed by the health care provider. 5. "I will sit on the edge of my bed for 2 minutes before I get out of bed."- Orthostatic hypotension is a possible adverse effect of hydralazine. The client should be instructed to sit on the edge of the bed prior to standing to prevent this effect. Think like a nurse: During client teaching, the nurse uses the teach-back method to evaluate the client's understanding. The nurse ensures the client understands the indications for hydralazine administration, as well as health management related to the hypertension. Dizziness, which is a potential adverse side effect of hydralazine, may increase the client's risk for falls. Adverse effects such as fainting, tachycardia, edema, or chest pain require immediate care. Dietary recommendations include a low-sodium diet. Reinforce the importance of adhering to the prescribed medication regimen. Educate the client about health risks associated with ineffective management of hypertension, including stroke and heart attack.

The nurse provides discharge teaching to a client with multiple sclerosis. Which instruction is most important for the nurse to include? 1. Ambulate as tolerated every day.2. Avoid overexposure to heat or cold.3. Perform stretching and strengthening exercises.4. Participate in social activities.

Answer:AVOID OVEREXPOSURE TO HEAT OR COLD1. Ambulate as tolerated every day.INCORRECT— Although the client should be encouraged to ambulate as tolerated, this is not the most important instruction. 2. Avoid overexposure to heat or cold.CORRECT— Overexposure to heat or cold may cause damage related to the changes in sensation. Extremes in temperature can also exacerbate multiple sclerosis symptoms. 3. Perform stretching and strengthening exercises.INCORRECT— The client should be encouraged to participate in an exercise program that includes range-of-motion (ROM), stretching, and strengthening exercises, but this is not the most important instruction.4. Participate in social activities.INCORRECT— The client should be encouraged to continue usual activities as much as possible, including social activities. However, this is not the most important instruction.Think like a nurse: Extremes in temperature can cause an exacerbation of symptoms in the client with multiple sclerosis. This is the most important area for the nurse to focus. Ambulation, exercise, and social activities are important; however, they do not help reduce the severity or exacerbation of symptoms.

The nurse in the long-term care facility provides care for clients during an outbreak of Legionnaire disease. The nurse recognizes that which client is most at risk to develop the disease?1. A 95-year-old client diagnosed with a fractured right hip.2. An 85-year-old client diagnosed with a right- sided cerebrovascular accident.3. A 75-year-old client diagnosed with Alzheimer disease.4. A 65-year-old client diagnosed with end-stage kidney disease.

4. A 65-year-old client diagnosed with end- stage kidney disease.— Clients diagnosed with Legionnaire disease develop pneumonia caused by Legionella pneumophila. Risk factors include advanced age (50 years or greater), end-stage kidney disease, immunosuppression, diabetes, smoking, and pulmonary disease. The client has two risk factors: advanced age and end-stage kidney disease. This client is at highest risk of developing the disease.Think like a nurse: When evaluating the risk of disease development, the nurse will consider the risk factors for the disease and the number of risk factors that the client possesses. After counting the risk factors for each client, the nurse determines that the client most at risk for developing Legionnaire disease is the one with both advanced age and end-stage kidney disease. An additional risk factor for Legionnaire disease, though not applicable in this case, is recent travel with an overnight stay from the home. The nurse knows to monitor the client for signs of Legionnaire disease, which include fever, body aches, and cough.

The nurse notes that a toddler has honey-colored crusts, vesicles, and reddish macules around the mouth. Which statement is accurate when providing education to the client's parent?1. "Your child has developed an irritation because of using a pacifier."2. "Your child has an infection that can be treated with antibiotics."3. "Your child has a food allergy and needs a restricted diet."4. "Your child has been exposed to a sick child and should be isolated for a few days."

2. "Your child has an infection that can be treated with antibiotics."— The client is experiencing the skin eruptions found with impetigo. Symptoms of impetigo include reddish macules that become vesicles and then develop crusts. This infection is caused by bacteriaThink like a nurse: Impetigo is caused by either streptococcus or staphylococcus. Often these bacteria enter the body when the skin has already been irritated or injured because of other skin problems such as eczema, poison ivy, insect bites, burns, or cuts. Raw skin that develops under the nose (due to a cold or allergies) also increases the child's risk for developing impetigo. However, impetigo also can develop in completely healthy skin. The parents should be taught about strict adherence with antibiotic treatment and preventing the spread of infection among the child's contacts at home or in the community.

The nurse provides postoperative care for a client after an ileal conduit procedure. Which observation most concerns the nurse?1. There is bleeding from the stoma when the appliance is changed.2. The skin under the ostomy pouch is irritated.3. The client has abdominal pain and a temperature of 100.4°F (38°C).4. Bowel sounds are absent in all four quadrants.

3. The client has abdominal pain and a temperature of 100.4°F (38°C).- Fever, abdominal rigidity and pain are indications of peritonitis. Urine may have entered the peritoneal cavity from anastomosis site leakage or from separation of the ureter from the ileal segment (the conduit). The health care provider should be notified at once, as this requires immediate medical intervention. This poses the greatest risk of harm to the client and is the highest priority.Think like a nurse: The nurse needs to consider the procedure performed and then ask what could be causing the client to have the presented manifestations. Abdominal pain and an elevated temperature after surgery to place an ileal conduit can indicate contamination of the peritoneal cavity by urine that could have occurred during or after the procedure. The health care provider needs to be immediately contacted to report the findings and prescribe appropriate treatment.

The nurse instructs a client with right-sided weakness how to use a cane. Which client behavior indicates to the nurse that teaching is successful?1. The client holds the cane in the right hand, moves it forward followed by the right leg, and then the left leg.2. The client holds the cane in the right hand, moves the cane forward followed by the left leg, and then the right leg.3. The client holds the cane in the left hand, moves the cane forward followed by the right leg, and then the left leg.4. The client holds the cane in the left hand, moves the cane forward followed by the left leg, and then the right leg.

3. The client holds the cane in the left hand, moves the cane forward followed by the right leg, and then the left leg.— The cane acts as support and aids in weight-bearing for the weaker right leg. The elbow should be flexed 30 degrees and the tip of cane should be 15 cm lateral to the base of the fifth toe.Think like a nurse: A cane is used to provide stability when ambulating. The client who uses a cane needs to have adequate strength to remain upright and be able to advance the cane to support the weaker limb. To begin teaching on the use of a cane, identify the weak limb. The cane is placed on the opposite side as a support to the weaker limb. When walking with the cane, the cane is advanced first, followed by the weak limb, and then the stronger limb is brought forward. This process ensures stability for the weak limb and maintains the client's balance. The handle of the cane should be at the client's wrist so when it is grasped, the elbow is flexed no greater than 30 degrees. The cane is advanced to accommodate the client's step length.

The nurse provides care for a client who had a hypophysectomy. The client reports being thirsty and having to urinate frequently. Which action does the nurse take?1. Assess for glucose in the urine.2. Increase fluid intake.3. Assess urine specific gravity.4. Document the client's concerns.

3. Assess urine specific gravity.— After this procedure, diabetes insipidus can temporarily occur because of an antidiuretic hormone deficiency.Think like a nurse: The nurse should first mentally review the type of surgery the client had, the reason for the procedure, expected manifestations, and any possible indications of complications. A hypophysectomy is the removal of a part or the entire pituitary gland, which controls specific hormones. One hormone is the antidiuretic hormone, which controls fluid balance. After surgery and due to the lack of this hormone, the client will have increased urine output, which is indicative of the complication diabetes insipidus. The nurse should expect to find low urine specific gravity due to high urine output and high serum sodium (hypernatremia) due to low fluid volume.

The unlicensed assistive personnel (UAP) reports to work on the oncology unit with a cough, runny nose, and an elevated temperature. The UAP reports having no sick leave and being the breadwinner of the family. Which response does the nurse provide to the UAP? 1. "Did you receive a flu shot?"2. "Can you work at the desk and help the unit secretary with the medical records?"3. "I will call one of the other units where clients are less vulnerable."4. "I am sorry, but you will have to go home."

4. "I am sorry, but you will have to go home."- During community outbreaks of the flu, it is responsible management to exclude staff with febrile infections from caring for high-risk clients. - If the UAP stayed on the unit in a non-patient caring role, Influenza is spread by droplets, and even though the UAP will not be caring for clients, the UAP will still come in contact with other staff members. Oncology clients are immunocompromised. Think like a nurse: Nurses on a bone marrow transplant or oncology unit are, rightly so, protective of the clients in their care and avoid exposing them to infections that could prove lethal in the immunocompromised population. A cough and runny nose with fever is too symptomatic to work, especially with this client population. Often, if a staff member has only a low grade fever or sore throat, they might continue to work while wearing a mask, but even this is not wise to do when caring for clients with decreased immune systems in which simple infections have serious consequences.

The nurse provides care for a client who is having an anaphylactic reaction. The client is hypotensive and in respiratory distress. The nurse notes the client has swollen lips and tongue. Which intervention should the nurse perform first?1. Be prepared to administer intravenous (IV) epinephrine.2. Start an IV immediately and run normal saline.3. Apply oxygen using a high-flow, non-rebreather mask.4. Ensure that intubation and tracheotomy equipment is ready.

3. Apply oxygen using a high-flow, non- rebreather mask.— When a client is having an anaphylactic reaction, oxygen should immediately be applied to ensure there is adequate oxygenation helping to prevent hypoxia, dysrhythmia, shock, and cardiopulmonary arrest.Think like a nurse: A client demonstrating the symptoms of an anaphylactic reaction needs immediate respiratory support. The nurse should follow the airway, breathing, and circulation (ABCs) system and begin with establishing an airway. The client's tongue and lips are swollen; however, the client is still breathing. A source of oxygen should be provided immediately. The nurse should stay with the client, monitor respiratory rate and blood pressure, and call for help in the event the client's condition deteriorates. Epinephrine will be administered to assist in reducing airway edema after the oxygen is applied.

During a well-child checkup, the parent of two children (2 and 4 years of age) appears tired and frustrated. The parent states, "I feel like I have been on a whirlwind for over a year. I never thought two children could be so much work. If I have to discipline my kids one more time, I think I will scream!" Which response does the nurse implement with the parent? 1. "Tell me about the types of limits you are setting for each child."2. "Have you thought about preschool for your children?"3. "As they grow, you will miss these busy days with them."4. "Do you and your spouse agree on the use of time-out?"

1. "Tell me about the types of limits you are setting for each child."- This is an open-ended question that allows the parent to talk more about the limits for each child. This will open further discussion about options. Think like a nurse: Since the parent is tired and frustrated, the nurse may be able to help the parent with the situation. However, before offering suggestions, the nurse needs to assess what the parent means by "discipline." The best way to assess for this information is to use an open-ended question. Once the discipline and limits are identified, the nurse can proceed with strategies or alternatives for the parent to effectively deal with the toddler and preschool age children's behaviors.

A client is admitted to the medical unit for evaluation of headaches, epigastric pain that is relieved by food, anorexia, nausea and vomiting, and periods of both constipation and diarrhea. The health care provider prescribes several diagnostic tests. Which test does the nurse schedule first?1. Upper gastrointestinal series.2. Small bowel series.3. Lower gastrointestinal series.4. Lumbar puncture.

3. Lower gastrointestinal series.— This is often referred to as a barium enema examination. It is a radiographic visualization of the large intestine and encompasses the rectum, sigmoid, descending, transverse, and ascending colon going to the ileocecal valve. The barium is administered through a rectal catheter, which has an inflatable balloon. When both upper and lower GI series are ordered, the lower GI series should be done first in order to avoid the barium from the upper GI exam traveling down the GI tract and interfering with the results of the lower GI series.Think like a nurse: The nurse needs a solid understanding of diagnostic test procedures along with knowledge about anatomy and physiology. When considering the scheduling of multiple diagnostic tests, the nurse should understand the importance of avoiding future test site "contamination" with the elements of previous tests. Tests used to diagnose a gastrointestinal disorder often include barium. Because barium that is ingested will interfere with a lower gastrointestinal examination, the lower gastrointestinal test should be scheduled first.

The nurse receives report on a group of clients at the beginning of the shift. Which client does the nurse assess first?1. A client drinking contrast for an abdominal CT scan who reports nausea and abdominal pain.2. A client with a respiratory rate of 24 breaths per minute and an oxygen saturation of 93% on room air.3. A client reporting frequent small amounts of watery diarrhea with abdominal cramping and nausea.4. A client whose family member threatened to sue the hospital if the nurse does not talk with the family immediately.

3. A client reporting frequent small amounts of watery diarrhea with abdominal cramping and nausea.— Frequent and small amounts of diarrhea may indicate a possible bowel obstruction that can be life-threatening if the bowel perforates. The nurse needs to assess this client so interventions can be implemented quickly.Think like a nurse: Untreated intestinal obstruction can lead to life-threatening complications, including bowel infarction and infection secondary to peritonitis. The resulting inflammation in bowel obstruction can lead to fluid sequestration, increased capillary permeability, and severe reduction in circulating blood volume. The nurse should think of preventing hypovolemic shock in clients with suspected bowel obstruction. The nurse needs to assess this client first in order to escalate interventions, such as an emergency exploratory laparotomy or aggressive fluid resuscitation.

A pregnant client tells the nurse about receiving a toy that requires walking as a present for the unborn child. The client asks the nurse when this toy would be appropriate for the child. Which response by the nurse is appropriate?1. "That toy is good for a 3-month-old child."2. "That toy is good for a 6-month-old child."3. "That toy is good for a 12-month-old child."4. "That toy is good for an 18-month-old child."

4. "That toy is good for an 18-month-old child."— The child would be able to enjoy the toy at 18 months, as the child will be able to walk and begin to coordinate movementsThink like a nurse: Part of the nurse's role in working with parents of children is to provide objective information on childhood development and what to expect at each stage. A baby may begin to walk by 12 months of age. The ability to coordinate movements is expected to develop by 18 months of age. The nurse will want to ensure that the mother understands when the toy may be best used, to avoid safety risks or frustration. Teach the parents that age-appropriate toys during the first few months of life include mobiles (maintained at 8- to 10-inch distance from face), rattles, and a cradle gym.

The nurse provides care to a client diagnosed with Paget disease. Which findings are anticipated by the nurse as characteristic of this disorder? (Select all that apply.)1. A vitamin D deficiency.2. An elevated serum alkaline phosphatase.3. A pathologic fracture.4. A loss of total bone mass and substance.5. An abnormal remodeling and resorption of bone.

Answers: 2. An elevated serum alkaline phosphatase.3. A pathologic fracture.5. An abnormal remodeling and resorption of bone.2. An elevated serum alkaline phosphatase.- An elevated serum alkaline phosphatase level occurs in advanced forms of the disease.3. A pathologic fracture.- Pathologic fractures are the most common complication of the disease.5. An abnormal remodeling and resorption of bone.- Abnormal remodeling and resorption of bone occurs, and the new bone is larger, disorganized, and structurally weaker.Think like a nurse: The nurse knows bone remodeling is an essential and continual process. In Paget disease, a localized area of bone does not correctly go through the cycle of bone breakdown and building, which results in odd and fragile bone formations. Paget disease has no known cause, and risk factors are not well understood, but the disorder may include a genetic component. While manifestations of Paget disease are often painful and interfere with daily living, some clients diagnosed with this disorder are asymptomatic. The same medications (but different doses) used for osteoporosis are used for treatment of clients with Paget disease. These medications slow bone turnover and help to lay down normal new bone.

The nurse auscultates 40 bowel sounds in 1 minute when assessing the abdomen of a client with pain, nausea, and vomiting. Which statement will the nurse use when documenting this assessment finding? 1. "Absent bowel sounds on auscultation."2. "Hypoactive bowel sounds heard on auscultation."3. "Normal bowel sounds heard on auscultation."4. "Hyperactive bowel sounds heard on auscultation."

1. "Absent bowel sounds on auscultation."INCORRECT— Absent bowel sounds mean that no sounds are heard over 3-5 minutes. 2. "Hypoactive bowel sounds heard on auscultation."INCORRECT— Hypoactive bowel sounds mean that one or two sounds are heard over 2 minutes. 3. "Normal bowel sounds heard on auscultation."INCORRECT— Normal bowel sounds mean that 5-30 sounds are heard per minute.4. "Hyperactive bowel sounds heard on auscultation."CORRECT— Hyperactive bowel sounds mean that more than 30 sounds are heard over 1 minute. Think like a nurse: Hearing 40 bowel sounds in 1 minute upon auscultation indicates bowel hyperactivity and should be documented as such. This amount of sounds would be expected because of the client's symptoms of pain, nausea, and vomiting. Five to 30 bowel sounds is considered normal. Hearing no sounds for 3 to 5 minutes indicates absence of bowel activity.

The nurse provides teaching for a client diagnosed with heart failure. Which client statement indicates to the nurse that teaching is effective?1. "Low-fat cottage cheese is a good snack."2. "I can continue using prepared salad dressings."3. "I will increase the amount of celery I eat every day."4. "I will continue to eat my favorite canned green peas."

3. "I will increase the amount of celery I eat every day."— Two stalks of celery contain 62 mg of sodium, making them an appropriate snack for a low-sodium diet. The nurse should encourage the client to choose fresh vegetables, which are low in sodium.Think like a nurse: The client with heart failure should be instructed to reduce sodium intake. This reduces fluid volume, improves pumping action of the heart, and prevents fluid from accumulating in the lungs and extremities. It is essential for nurses to able to recognize appropriate food choices for clients who have a restricted sodium intake. Celery has a low amount of sodium, which makes it an ideal choice for a snack.

4. "It is best to start your child on the usual diet right away, offering food as tolerated."— Once rehydration has occurred, or if dehydration is not evident, the child's normal diet should be resumed. Continued feeding or early reintroduction of nutrients as in a normal diet is without adverse effects, decreases the duration and severity of the illness, and improves weight gain compared to gradually reintroducing foods.Think like a nurse: A client recovering from acute gastroenteritis should resume a normal diet once rehydration has occurred to ensure adequate nutritional intake.

The nurse provides care for a client receiving chemotherapy. The medication is an alkylating agent. Which actions will the nurse implement to minimize adverse effects? (Select all that apply.)1. Prevent ileus formation by encouraging frequent ambulation.2. Administer anti-emetics prophylactically and as needed.3. Offer frequent high fat meals to prevent weight loss.4. Teach client to use saline mouth rinse before and after meals.5. Encourage client to increase fluid intake for the next 3 days.6. Educate client about the benefits of exercise to manage fatigue.

1. Prevent ileus formation by encouraging frequent ambulation.INCORRECT- Ileus formation is not a common side effect of chemotherapeutic medications.2. Administer anti-emetics prophylactically and as needed.CORRECT - Nausea and vomiting are common and should be prevented if possible.3. Offer frequent high fat meals to prevent weight loss.INCORRECT- A high protein, nutrient-dense, high calorie diet is recommended to prevent weight loss. Clients should not choose high fat items solely for their fat content, unless the items also contain necessary nutrients, such as the calcium found in ice cream.4. Teach client to use saline mouth rinse before and after meals.CORRECT - Stomatitis is a common adverse effect of chemotherapy, and it may be prevented or minimized with meticulous oral care. Salt water, usually mixed with baking soda, is used to rinse the mouth after every meal as a way to reduce particles and reduce oral acidity.5. Encourage client to increase fluid intake for the next 3 days.CORRECT - Cystitis occurs with many chemotherapeutic agents and may be prevented with increased fluid intake.6. Educate client about the benefits of exercise to manage fatigue.CORRECT - Mild to moderate exercise, along with frequent rest periods, will help to manage the fatigue often experienced during chemotherapy.Think like a nurse: Chemotherapy with alkylating agents can be particularly caustic to the body's mucous membranes. Stomatitis can be minimized by a saline mouthwash. Urinary tract irritation can be reduced by ingesting more fluid. Since chemotherapy can irritate the gastrointestinal tract and cause nausea and vomiting, anti-emetic medications are recommended. Mild to moderate exercise while receiving chemotherapy helps reduce fatigue and enhance general well being.

The nurse instructs a client diagnosed with genital herpes about acyclovir. Which client statement indicates that teaching has been effective? 1. "If I miss a dose of medication, I can double up the next dose."2. "I should avoid sexual contact while I have lesions."3. "I'm glad this medication will cure me."4. "I must take this medication with food."

2. "I should avoid sexual contact while I have lesions."- This statement indicates correct understanding of the information presented. Acyclovir is an antiviral medication that is used to treat recurrent genital herpes and localized cutaneous herpes zoster. The client is considered contagious and should refrain from sexual contact while the lesions are present. Think like a nurse: Prior to administering a newly prescribed medication, the nurse instructs the client on the mechanism of action, expected effects, any precautions, and possible adverse effects. Acyclovir (Zovirax) is an antiviral, used to treat the genital herpes virus, and does not cure the virus, but helps reduce the symptoms and promotes the healing of lesions. The nurse should emphasize the importance of refraining from sexual contact while the lesions are present to prevent the transmission of the virus to the client's sexual partner. The nurse uses the art of listening to determine if the client has a correct understanding about the prescribed medication and treatment regimen.

The nurse supervises the care of a client receiving enteral feedings through an NG tube. Which observations indicate to the nurse that the care being provided by the unlicensed assistive personnel (UAP) is appropriate for this client? (Select all that apply.) 1. Aspirates and measures the amount of the gastric aspirate.2. Elevates the head of the bed 30 degrees.3. Warms the feeding to room temperature.4. Measures the pH of the gastric aspirate.5. Infuses the intermittent feeding in 20 minutes.6. Clamps the proximal end of the feeding tube at the end of the feeding.

Answers:2. Elevates the head of the bed 30 degrees.3. Warms the feeding to room temperature.6. Clamps the proximal end of the feeding tube at the end of the feeding.Explanations:1. Aspirates and measures the amount of the gastric aspirate.INCORRECT - Aspiring and measuring the amount of gastric aspirate verifies placement of the tube and should be performed by the nurse. 2. Elevates the head of the bed 30 degrees.CORRECT— Elevating the head of the bed prevents aspiration and indicates appropriate care by the UAP. 3. Warms the feeding to room temperature.CORRECT— Warming the feeding to room temperature prevents cramping and indicates appropriate care by the UAP. 4. Measures the pH of the gastric aspirate.INCORRECT - Measuring the pH of gastric aspirate should be performed by the nurse. 5. Infuses the intermittent feeding in 20 minutes.INCORRECT - The feeding should be infused over a minimum of 30 minutes. 6. Clamps the proximal end of the feeding tube at the end of the feeding.CORRECT— Clamping the proximal end of the feeding tube at the end of the feeding prevents air from entering the stomach and indicates appropriate care by the UAP. Think like a nurse: When supervising client care, the nurse first considers the scope of practice of the care provider. The unlicensed assistive personnel (UAP) is able to provide nasogastric tube feedings if the skill has been deemed appropriate and safe to provide to a stable client. However, the UAP cannot perform assessment or evaluation, such as checking the amount or pH of the gastric aspirate. The nurse then considers the safety of the actions provided by the UAP. When administering a nasogastric tube feeding, the head of the bed should be elevated to prevent aspiration. Warming the feeding to room temperature prevents gastric cramping and distress. And clamping the nasogastric tube at the conclusion of the feeding prevents air from entering the gastrointestinal tract. These actions are appropriate for UAP to perform.

The nurse provides care for a preschool-age client diagnosed with epiglottitis. Which action is appropriate for the nurse to implement?1. Ask the unlicensed assistive personnel (UAP) to take the child to radiology. 2. Use a padded tongue blade to assess the child's gag reflex.3. Obtain a blood culture and ABGs as prescribed by the health care provider. 4. Apply a pulse oximeter, and start an IV infusion.

4. Apply a pulse oximeter, and start an IV infusion.- Treatment for epiglottitis includes moist air and IV antibiotics to decrease epiglottal swelling. A pulse oximeter measures oxygen saturation to determine the need for supplemental oxygen. Think like a nurse: The nurse needs to review the manifestations and risks associated with the client's diagnosis. The nurse will plan care with the understanding that epiglottis is an acute inflammation and swelling of the upper region of the throat. Because of the location of the swelling, the client is prone to developing an occluded airway. The nurse will apply the principles of airway-breathing-circulation (ABCs) in formulating a plan of care. The client's oxygen saturation level should be monitored to evaluate effectiveness of respirations. Additional treatment includes fluid replacement and medication to address the infection which is causing the health problem.

The nurse discusses skateboard safety with a group of parents. Which statement is most important for the nurse to include?1. "If your children are younger than 5 years of age, always observe them while they are skateboarding."2. "Carefully check the surface where your child will be skateboarding."3. "It does not matter what type of skateboard you get for your child."4. "Instruct your child to keep as close to the curb as possible."

Answer:2. "Carefully check the surface where your child will be skateboarding."Explanations:1. "If your children are younger than 5 years of age, always observe them while they are skateboarding."INCORRECT - Children younger than 5 years of age should not skateboard. Developmentally, they have difficulty protecting themselves from injury.2. "Carefully check the surface where your child will be skateboarding."CORRECT— The parents should check for holes, bumps, rocks, and debris that may cause an accident.3. "It does not matter what type of skateboard you get for your child."INCORRECT - Skateboards are designed for various uses (slalom, freestyle, or speed). The parents should know how the child plans to use the skateboard.4. "Instruct your child to keep as close to the curb as possible."INCORRECT - The child should never ride a skateboard in the street and should not be close to the curb.Think like a nurse: Bicycling, riding scooters, skateboarding, and inline skating are common activities of school-age children. Laws in some states require a helmet for riding bikes and scooters. In addition, when skating or skateboarding, school-age children should wear a helmet, knee pads, and elbow pads.

The nurse plans care for a client diagnosed with meningitis due to Haemophilus influenza. It is important for the nurse to include which intervention in the client's plan of care?1. Place the client in isolation until cerebrospinal fluid culture results are normal.2. Monitor vital signs and perform neurological checks every 6 hours.3. Dim the room lights, turn off the television, and reduce the noise level.4. Encourage oral fluids and administer intravenous fluids as needed.

Answer:3. Dim the room lights, turn off the television, and reduce the noise level.Explanations:1. Place the client in isolation until cerebrospinal fluid culture results are normal.INCORRECT - The client is placed on droplet precautions until 24 hours after culture-specific antibiotics are started. Some institutions may have varying guidelines, but ending isolation will not depend on the culture results.2. Monitor vital signs and perform neurological checks every 6 hours.INCORRECT - The nurse assesses for increasing ICP and shock. Neurological checks are done frequently in acute meningitis, at least every 4 hours, and more frequently as indicated. Ideally, continual monitoring of vital signs is desired.3. Dim the room lights, turn off the television, and reduce the noise level.CORRECT— Reducing environmental stimuli is essential to reducing complications. Meningeal irritation causes headache, light sensitivity, and seizures.4. Encourage oral fluids and administer intravenous fluids as needed.INCORRECT - The client may be on fluid restriction due to increased ICP or may be neurologically unable to safely drink, but dehydration is carefully avoided by use of continuous, low-volume IV fluids.Think like a nurse: The client diagnosed with meningitis will be subject to isolation for a short period. The nurse's primary concerns are preventing increases in intracranial pressure and managing symptoms of meningitis, such as headache, photophobia, disorientation, and seizures. Fluid management, administration of prescribed medications (including anti-infective agents, steroids, and analgesics) are essential to this client's care. Non-pharmacological measures to promote a calm, peaceful environment are also important to avoid overstimulating the client.

The client takes beclomethasone by metered dose inhaler (MDI). Which statement made by the client indicates that teaching is successful?1. "I know it is time to have the prescription refilled when the canister floats in water."2. "I will rinse my mouth and throat with water after each dose."3. "I will be sure not to shake the canister before I use it."4. "If the dose does not help, I will take extra and let the health care provider know the results."

2. "I will rinse my mouth and throat with water after each dose."- Beclomethasone is a corticosteroid. Inhaled corticosteroids can predispose the client to fungal oropharynx infection (candidiasis). Rinsing the mouth and gargling with warm water when each treatment is completed is imperative to remove residual medication and prevent the onset of infection. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client 's understanding. This client has a few misconceptions about using the inhaler but is correct that rinsing after its use is essential, as this prevents infection. The nurse will assess the source of the client 's other statements and provide corrected information.

The emergency department triage nurse has a limited number of open beds. Which client does the nurse place in an emergency bed? (Select all that apply.)1. 17-year-old client who intentionally ingested 15 acetaminophen tablets prior to arrival.2. 24-year-old client who reports dental pain, rating pain 10/10 on pain scale.3. 63-year-old client who reports a severe, localized headache with no history of headaches.4. 77-year-old client who has had generalized weakness for the past day.5. 88-year-old client who has a rash, and whose spouse is being treated with permethrin cream.6. 92-year-old client who is requesting suture removal, with dehiscence noted at site.

1. 17-year-old client who intentionally ingested 15 acetaminophen tablets prior to arrival.- This client requires activated charcoal and possible administration of acetylcysteine. Therefore, the nurse places this client in an emergency bed. 3. 63-year-old client who reports a severe, localized headache with no history of headaches.- This client requires a head CT to rule out hemorrhage. Therefore, the nurse places this client in an emergency bed. 4. 77-year-old client who has had generalized weakness for the past day.- This client requires assessment and diagnostic work-up to exclude myocardial infarction, electrolyte imbalance, and stroke. Therefore, the nurse places this client in an emergency bed. Think like a nurse: Maslow's hierarchy of needs can be used to make decisions regarding the acuity of the clients. An attempted suicide places the client at high risk for self-harm and needs immediate intervention. A severe localized headache could represent a cerebral hemorrhage and needs immediate assessment. Generalized weakness could indicate a cardiac, neurologic, or electrolyte imbalance problem and requires immediate assessment.

1. Nausea may be linked to the mother 's acceptance of the pregnancy.CORRECT - Ambivalence about, or rejection of, the pregnant state may cause nausea. 2. Nausea should diminish by the 14th week of pregnancy.CORRECT - Nausea begins about 4 weeks after the last menstrual period, and usually improves by the end of the 14th week of pregnancy. Nausea is associated with an increase of human chorionic gonadotropin (hCG) levels in early pregnancy. 3. Eating a dry carbohydrate immediately upon arising is recommended.CORRECT - Eating a dry carbohydrate upon waking up in the morning may help decrease nausea. 4. Decreasing the intake of protein in the evening meal may help.INCORRECT - Eating more protein at night may help with nausea5. Avoid fried, spicy, and greasy foods.CORRECT - Avoiding fried, spicy, and greasy foods can help. Think like a nurse: The nausea ( "morning sickness ") that many women experience during the first trimester of pregnancy is the result of hormonal changes. Human chorionic gonadotropin (hCG), is produced at higher levels during the first trimester than at any other time during pregnancy. The nurse explains to the client the difference between typical "morning sickness " and hyperemesis gravidarum, which is a complication of pregnancy that is characterized by severe nausea and vomiting over an extended period. Before teaching, the nurse should first assess the client 's baseline knowledge. The teach-back method is used to verify the client 's understanding.

The nurse develops a brochure on health promotion. Which example of primary prevention health promotion does the nurse include in the brochure?1. Attending a stress management class.2. Performing a testicular examination.3. Having a blood test for diabetes.4. Taking an analgesic for a headache.

1. Attending a stress management class.- Primary prevention aimed at health promotion includes activities that may prevent the disease from developing. These activities include health education programs, immunizations, and physical and nutritional fitness activities.Think like a nurse: The fight or flight response is designed to boost the body's ability to act in an emergency. Long-term stress results in chronic activation of the sympathetic nervous system, which leads to a continually elevated heart rate, blood pressure, and blood glucose level. Uncontrolled stress increases the risk for developing heart disease, cancer, and other health alterations. Increasing daily activity, taking purposeful deep breaths, eliminating distractions during certain hours, sleeping adequately, and taking time to enjoy healthy, balanced meals are all healthful strategies to combat stress.

The nurse provides care for the family of a client who died 30 minutes ago. Which action is most important for the nurse to take?1. Provide a private place for family members.2. Explain to the family that the client is now in heaven.3. Notify the family members individually.4. Prevent the family from spending time with the client.

1. Provide a private place for family members.— This provides a private place to grieve. This shows compassion and understanding by the nurse.Think like a nurse: The nurse needs to recognize the family needs because the client's death just occurred. The family needs a private place to grieve if the client is in a room with another client. The nurse needs to carefully assess the needs of both clients assigned to the room. Being present during a death and family grieving can cause unnecessary stress for a roommate, and the roommate may not be able to safely leave the room. If the client is in a private room or the roommate is out of the room for a diagnostic test or other reason, the family can stay at the bedside to begin the grieving process. This is the best approach to support the family during this difficult time.

The parent of an infant client with tetralogy of Fallot (TOF) is pumping her breasts at the client's bedside. The unlicensed assistive personnel (UAP) says to the nurse, "She should breast feed that baby instead of pumping all the time. What's wrong with her?" Which is the best response for the nurse to make? 1. "You sound upset about what you observed."2. "Why don't you ask her why she is pumping?"3. "What do you understand about her baby's illness?"4. "It's not our business to judge the decisions of others."

3. "What do you understand about her baby's illness?"- This is a non-judgmental response and provides opportunity and a starting point for needed staff teaching. Infants with congenital heart diseases, including TOF, are weak, fatigue easily, and need to be fed carefully and with the least amount of required effort on their part. Think like a nurse: "What do you understand about her baby's illness?" is a question that explores the UAP's knowledge about the client. The nurse may use this opportunity to educate or correct misconceptions. The nurse should also consider including key information during hand-off communication with the UAP and providing rationale for why the baby must be fed carefully.

The nurse evaluates tasks delegated to the staff. Which observation indicates that the care provided to a client who is positive for human immunocompromised virus (HIV) is appropriate? 1. LPN/LVN applies a gown when entering the room.2. Nursing assistive personnel uses sterile linen to make the bed.3. Nursing staff wear gloves when exposed to secretions.4. Family members wear gown, gloves, and mask when entering the room.

3. Nursing staff wear gloves when exposed to secretions.— Standard precautions are used when caring for this client. This observation indicates appropriate care. Think like a nurse: Standard precautions are used when caring for a client who is positive for human immunocompromised virus (HIV). A gown does not need to be worn when entering the room. Sterile linens are not required when changing the bed. There is no reason for family to wear personal protective equipment upon entering the client's room.

When providing care to a group of postoperative clients, which interventions does the charge nurse delegate to the LPN/LVN? (Select all that apply.)1. Palpating the suprapubic area of a client who has not voided in 6 hours.2. Changing the gauze dressing for a client who had a hip pinning yesterday.3. Teaching the client how to self- administer enoxaparin injections.4. Titrating oxygen administration according to prescribed parameters.5. Following up on a report of a 100.6 F (38.1 C) temperature in a client after an appendectomy.6. Auscultating the abdomen of a client who is nauseated after eating broth.

2. Changing the gauze dressing for a client who had a hip pinning yesterday.- The LPN/LVN may change dressings, so the nurse can delegate this task. 4. Titrating oxygen administration according to prescribed parameters.- An LPN/LVN may titrate O2 within specified parameters. Therefore, the nurse can delegate this task. Think like a nurse: When delegating to the LPN/LVN, the nurse recalls the scope of practice for this member of the health care team. The LPN/LVN can safely collect data, implement the plan of care, and report changes in client conditions to the nurse. Changing a dressing and adjusting oxygen flow according to a prescribed plan of care fall within the LPN/LVN's scope of practice. The nurse will not delegate tasks or skills that include assessment and teaching.

The nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment is most critical for the nurse to perform before the procedure?1. Height and weight.2. Baseline peripheral pulse rates.3. Intake and output.4. Allergy to shellfish or iodine.

4. Allergy to shellfish or iodine.- This is a vital assessment because an allergy to the radiopaque dye used in the procedure may cause anaphylaxis.Think like a nurse: The nurse is aware that cardiac catheterization (e.g., coronary angiogram) requires the use of iodine-based contrast media. Clients who are allergic to shellfish may not get the iodine-based contrast media or require premedication with diphenhydramine IV prior to the procedure. It is also essential for the nurse to inform clients taking metformin to hold the medication 2 days before or after coronary angiogram to prevent kidney damage since metformin is nephrotoxic and the iodine-based contrast media is cleared by the kidneys. The nurse should review the client's baseline blood urea nitrogen (BUN) and creatinine. Typically, clients with acute or chronic kidney injury do not have procedures requiring contrast media due to the risk for kidney failure.

The nurse in the outpatient clinic receives a phone call from an adolescent who states, "There is no reason to live. I am going to shoot myself." Which response by the nurse is best?1. "Do you have access to a gun?"2. "Why do you want to shoot yourself?"3. "Think about how this will affect your family."4. "Share with me what happened to you today."

1. "Do you have access to a gun?"- The nurse should first ensure the client's safety by determining if the client has a plan and the means to carry out the plan. Think like a nurse: Because the adolescent client specifically said "shoot myself," the nurse needs to immediately assess if the client has access to a firearm. This is one instance when it is appropriate and necessary to ask the client a direct "yes/no" question since it is paramount to determine the lethality of the client's statement. Ongoing assessment, communication, and interventions will depend upon the client's response.

The nurse assesses a client's reflexes. Which finding indicates to the nurse an expected response? 1. Extension of the leg when the patellar tendon is tapped.2. Spreading of the toes when the lateral part of the sole of the foot is stroked.3. Flexion of the hips and knees when the neck is quickly flexed.4. Rapid alternating flex and extension of the ankle after holding the foot in a flexed position.

1. Extension of the leg when the patellar tendon is tapped.- To elicit the patellar reflex, strike the patellar tendon just below the patella. The client can be sitting or lying if the leg being tested hangs freely. The normal response is extension of the leg with contraction of the quadriceps.Think like a nurse: The nurse needs knowledge of assessment skills and the meaning of assessment findings. A complete neurologic examination includes assessment of the cranial nerves, cognition, sensory and motor function, gait, and reflexes. Of these areas to assess, reflexes may be the most challenging. Typically, musculoskeletal reflexes are assessed with the use of a reflex hammer. After positioning, the area being assessed is gently struck with the rubber hammer in order to elicit a musculoskeletal response. The response is outside of conscious control and typically includes some sort of "kick" if the knee is used for this assessment.

The nurse overhears the unlicensed assistive personnel (UAP) discussing a client's medical condition and test results with other clients. Which response by the nurse is appropriate? (Select all that apply.)1. "Don't worry others yet. The tests will be repeated tomorrow."2. "Stop discussing the client's condition."3. "I think the client will improve with this new medication."4. "Read the medical record silently, please."5. "Only those with a 'need to know' should be informed of the client's test results."

2. "Stop discussing the client's condition."- This response immediately stops the violation of client privacy. Medical information is used only for the purpose of diagnosis and treatment. Other clients are not involved in a client's treatment plan. 5. "Only those with a 'need to know' should be informed of the client's test results."- This response provides an explanation to the UAP as to why the action is wrong. It also provides further instruction of maintaining a client's privacy. Think like a nurse: The privacy and confidentiality of protected health information (PHI) is federally mandated by the Health Insurance Portability and Accountability Act (HIPAA). All members of the health care team are required to protect client privacy and confidentiality. Given that the UAP works under the nurse's supervision, if a breach of privacy and confidentiality is observed, the nurse intervenes to correct the breach and reinforce understanding of the requirement to protected health information data. Additional action may be indicated based on the organization's disciplinary guidelines. As a rule, staff members should have access only to confidential or sensitive information that is necessary to perform their jobs. This means staff should not review electronic files or paper records of clients for whom they are not assigned to provide care.

The nurse provides care to a client with an above-the-knee amputation (AKA). Which information is appropriate for the nurse to review with the client regarding how to care for the residual limb?1. Apply cream to the residual limb every day.2. Cover the amputation site with a nylon sock while awake.3. Keep the residual limb elevated on a pillow at night.4. Expose the amputation site to air daily.

4. Expose the amputation site to air daily. - Exposing the amputation site to air facilitates healing of the area. This also allows the client to inspect the incision site daily for pressure areas, dermatitis, and blisters. Think like a nurse: Proper residual limb bandaging fosters shaping and molding for eventual prosthesis fitting. A compression dressing is typically ordered to reduce edema, support soft tissues, and promote limb shrinkage and maturation. The delayed prosthetic fitting may be the best choice for clients who had above the knee or below the elbow amputations, older adults, debilitated individuals, and those with infections. For appropriate wound healing at the amputation site, the nurse should ensure the amputation site stays clean and dry, and teach the client to avoid placing any creams or non-cotton fabric on the site.

The nurse reviews newly written prescriptions for clients who are on a telemetry unit. Which finding does the nurse report to the health care provider?1. The client who has congestive heart failure (CHF) and has been prescribed intravenous (IV) morphine while receiving a continuous IV infusion of dopamine.2. The client who has atrial fibrillation (AF) and renal insufficiency (RI) and has been prescribed a low-molecular-weight heparin.3. The client who had coronary artery bypass graft surgery (CABG) 4 hours ago, has had 800 mL of serosanguineous chest tube drainage since surgery, and has been prescribed enoxaparin.4. The client who has coronary artery disease (CAD) and has been prescribed warfarin while receiving a continuous IV infusion of heparin.

3. The client who had coronary artery bypass graft surgery (CABG) 4 hours ago, has had 800 mL of serosanguineous chest tube drainage since surgery, and has been prescribed enoxaparin.— Chamber one of the chest tube drainage system collects the fluid draining from the client. This fluid is measured hourly during the first 24 hours. Notify the care provider if more than 100 mL/hr of drainage occurs. Since there is active bleeding, enoxaparin, a synthetic heparin, may be contraindicated.Think like a nurse: Prior to making a decision, the nurse should stop and think, "Which client situation is the most likely to indicate complications?" The client with a chest tube after cardiac surgery is having bloody drainage that is averaging 200 mL/hr. This is twice the acceptable amount, and the nurse should recognize the possibility of active bleeding. Of additional concern is the fact that the client is also prescribed an anticoagulant, which has the potential of making the bleeding become worse. The nurse should assess the client's vital signs and then report the findings to the health care provider for additional evaluation and prescriptions for further treatment.

The client is prescribed 1 unit of red blood cells (RBCs). The transfusion is started at 0945. At 1003, the client reports chills and back pain rated at 5 of 10. The client's skin is flushed, blood pressure is 98/66 mm Hg, and pulse rate is 108 beats/min. In which order does the nurse implement these nursing interventions? (Please arrange in order. All options must be used.)- Assess blood pressure, HR and RR- Begin 0.9% sodium chloride infusion- Call the healthcare provider- Hang a new IV infusion set- Obtain blood and urine specimens- Stop the blood transfusion

- Stop the blood transfusion- Hang a new IV infusion set- Begin 0.9% sodium chloride infusion- Call the healthcare provider- Assess blood pressure, HR and RR- Obtain blood and urine specimens- The client has signs and symptoms that suggest a hemolytic reaction. The nurse should first stop the blood transfusion to prevent worsening the client's reaction. Next, the nurse should hang a new intravenous infusion set to allow for the administration of 0.9% sodium chloride. This will provide additional hydration to promote perfusion and to flush the kidneys to reduce the risk of acute kidney injury from the hemolytic reaction. The nurse should then notify the health care provider of the reaction and assess to see whether the client's condition has improved. The nurse has a set of current vital signs in the stem of the question, so there is no need to reassess the vital signs prior to notifying the health care provider. Finally, the nurse should obtain blood and urine specimens for laboratory confirmation of the hemolytic reaction.Think like a nurse: Because a hemolytic reaction is a medical emergency, the nurse must act quickly to decrease the risk of the client progressing to cardiovascular collapse. The nurse prioritizes discontinuation of the blood transfusion, changing IV infusion set, and administration of isotonic IV fluid to promote filling of the client's dilated blood vessels and expanded intravascular space. If a standing prescription allows for administration of steroids or an antihistamine, these medications are administered next. If the client's condition worsens, notifying the rapid response team (RRT) would be the next step. Ideally, the nurse would delegate reassessment of vital signs to a nurse colleague during this period.

A client is placed on NPO status because of an esophageal mass. A family member gives the client juice, which is vomited immediately. Which are appropriate nursing actions? (Select all that apply.)1. Suction the client 's mouth with an oral suction.2. Elevate the head of the bed to 45 degrees.3. Notify the health care provider immediately.4. Auscultate the client 's breath sounds frequently.5. Draw blood for arterial blood gas assessments.

1. Suction the client 's mouth with an oral suction.— This is an appropriate nursing action. Suctioning with oral suction can clear secretions and vomitus from the mouth, decreasing the risk of aspiration or reducing the amount of aspirate. 2. Elevate the head of the bed to 45 degrees.— This is an appropriate nursing action. Elevating the head of the bed 30 to 45 degrees or higher can prevent or reduce aspiration that can occur with vomiting. 3. Notify the health care provider immediately.— Once the nurse has implemented bedside interventions and performed a focused assessment, the health care provider should be informed that the client may have aspirated juice, vomitus, or both. 4. Auscultate the client 's breath sounds frequently.— This is an appropriate nursing action. Adventitious sounds may indicate aspiration of food/vomitus. Think like a nurse: Symptoms of esophageal cancer often include dysphagia, which indicates esophageal occlusion. In many cases, by the time of diagnosis, the esophageal tumor is large. Regurgitation of a thin liquid is a sign of a complete esophageal obstruction. The client who experiences any degree of esophageal obstruction is at high risk for aspiration, which may lead to airway obstruction, pneumonia, and other serious consequences. In the event of known or suspected aspiration, priorities of care include ensuring airway patency and adequate breathing. After implementation of priority interventions, the health care provider should be promptly notified of the client 's status. Instruct family and visitors to refrain from offering the client food or drink until further diagnostics can be performed.

The nurse counsels a client about the West Nile virus during an outbreak. Which client statement requires follow up by the nurse?1. "I will get an immunization for the West Nile virus."2. "I will limit my time outside between dusk and dawn."3. "I will wear long sleeves and pants when I go outside."4. "I will use a mosquito repellent that contains DEET."

1. "I will get an immunization for the West Nile virus."- There is no immunization for the West Nile virus infection.Think like a nurse: Depending upon the place of residence, some clients may be prone to developing diseases caused by insect bites or stings. One such illness is the West Nile virus. The nurse should recall the mode of transmission of the virus (the vector is a specific type of mosquito) and recommend actions to prevent the client from contracting the disease. The client should understand the use of DEET-based insect repellent and the importance of keeping the skin covered when in areas where the possibility of exposure is high. The nurse should also remind the client that there is no immunization against this disease so precautions must be taken at all times.

The nurse provides care for a client who had a hypophysectomy. The nurse observes clear drainage coming from the client's nostril. Which action does the nurse take immediately?1. Test the drainage for glucose.2. Document the drainage.3. Lower the head of the bed.4. Obtain a culture of the drainage.

1. Test the drainage for glucose.— A possible complication of a hypophysectomy is a cerebrospinal fluid (CSF) leak. CSF contains glucose. This test will determine if the drainage is CSF.Think like a nurse: If a cerebral spinal fluid (CFS) leak is suspected, the nurse can simply test the drainage for sugar content (CSF has a high glucose content). The nurse should also conduct a thorough neurological assessment. The nurse may also assess for the "halo" sign of the suspected CSF leak. The halo sign is a classic image traditionally taught as a method for determining whether bloody discharge from the ears or nose contains CSF. If there is CSF leak, a "double-ring" appearance on the gauze used to dab the drainage is observed. The nurse anticipates sending the client with CSF leak for a CT of the head. The nurse understands that a CSF leak puts the client at risk for infection, a serious complication following surgery on the brain.

The nurse in the pediatric clinic provides care for a school-age client diagnosed with infectious mononucleosis. Which statement does the nurse expect the child to make?1. "My left ear hurts."2. "I have a cough that won't go away."3. "My nose is runny all the time."4. "I just have no energy to do anything."

4. "I just have no energy to do anything."— Mononucleosis is an infectious disease caused by the Epstein-Barr virus. Besides extreme fatigue, other indications include malaise, fever, headache, epistaxis, and severe sore throat. Think like a nurse: The nurse knows that infectious mononucleosis presents with a sore throat, headache, malaise, and fatigue. Malaise and fatigue tend to be the hallmarks of the condition, whereas other symptoms may or may not be present. The fatigue is extreme and persists for up to 6 weeks. Though rare, tonsillar enlargement could potentially obstruct the client's airway, so periodic airway assessment is warranted.

The nurse provides care to a client with suspected influenza. To promote infection control, the nurse ensures implementation of which precautions? (Select all that apply.)1. Standard precautions.2. Neutropenic precautions.3. Contact precautions.4. Droplet precautions.5. Airborne precautions.

1. Standard precautions.- Standard precautions, the first line of infection control, are used during the provision of care to all clients, regardless of the source of infection. Second line precautions (such as airborne, droplet, and contact) are initiated as transmission-based precautions, based on the infectious agent. 4. Droplet precautions.- Droplet precautions are required for clients with infections, such as influenza or meningococcus, to prevent transmission of infected respiratory or pharyngeal secretions. Think like a nurse: One of the nurse's roles is to implement safety and infection control when providing client care. An action to ensure that both client and care provider are protected is the use of standard precautions, these precautions are those used by all care providers for all clients regardless of diagnosis. However, in the event of an illness that can be spread via droplets, the nurse may need to add additional precautions. In this scenario the client has influenza, which is a viral infection spread through respiratory secretions. It is appropriate to implement standard and droplet precautions when caring for this client.

The charge nurse makes rounds on the psychogeriatric unit. Which situation requires immediate intervention by the charge nurse?1. The dietary aide removes a full breakfast tray untouched by a client with major depression who is still in bed wearing night clothing.2. The unlicensed assistive personnel (UAP) makes the bed while a client with schizophrenia is sitting in the bedside chair shaving with a disposable razor and mirror.3. The LPN/LVN assigned to medication administration argues loudly with a client with bipolar disorder who is refusing to take prescribed medication.4. The UAP places personal care items in reach of a client with Alzheimer disease and then leaves to fill the wash basin with water.

4. The UAP places personal care items in reach of a client with Alzheimer disease and then leaves to fill the wash basin with water. - The client with Alzheimer disease is at risk for choking on inedible items such as soap, lotions, and caps of sample bottles. Think like a nurse: Persons with Alzheimer disease face safety challenges. In working with this population, the nurse should scan the immediate surroundings for potential safety hazards. Preventing choking hazards is a priority. Depending on the client 's stage of Alzheimer disease, the nurse can determine the level of supervision required. Another important safety measure is to watch the temperature of water and food. It may be difficult for the person with dementia to tell the difference between hot and cold.

he nurse provides instructions to a pregnant client who is 28 weeks' gestation. The client is prescribed a 1-hour oral glucose tolerance test (GTT). Which instruction does the nurse include in the teaching?1. "You will be diagnosed with gestational diabetes if the blood sugar at 1 hour is greater than 140 mg/dL (7.8 mmol/L)."2. "This test requires you to be connected to a glucose drip."3. "This test will determine if you have gestational diabetes."4. "You can continue to eat your normal diet prior to test day."

4. "You can continue to eat your normal diet prior to test day."- The client should continue to consume a normal diet until the day of the test.Think like a nurse: Client teaching is essential when providing care to the pregnant client. The nurse must adequate prepare the client regarding what is expected during the different stages of pregnancy along with diagnostic testing that will occur. Clients who are in the second trimester of pregnancy will be prescribed a glucose tolerance test (GTT) to assess for gestational diabetes mellitus. The nurse provides information to the client and then evaluates understanding through the teach-back method. If the nurse determines inadequate understanding of the information presented, the nurse must re-teach the material allowing the client to obtain adequate understanding.

The nurse teaches a client about a new medication for hypertension. Which client statement indicates that further teaching is needed? (Select all that apply.)1. "I should not take acetaminophen with this medication."2. "I will get up slowly from sitting or lying down while taking this medication."3. "I will check with my health care provider before taking herbal supplements."4. "I do not need to stop smoking now that I have this medication."5. "I need to continue to monitor my blood pressure."

1. "I should not take acetaminophen with this medication."- There are no interactions noted between acetaminophen and antihypertensives. 4. "I do not need to stop smoking now that I have this medication."- Smoking can reduce the effects of antihypertensives as smoking causes vasoconstriction. Think like a nurse: Antihypertensives do not interact with acetaminophen and can be safely taken together. Smoking cessation efforts should be encouraged because nicotine constricts blood vessels, which counteracts the effects of the antihypertensive medication. The effectiveness of all medication should be routinely evaluated.

The nurse provides care to a client with a peripherally inserted central catheter (PICC) for treatment of metastatic cancer. Which findings will the nurse expect 4 days after the catheter placement? (Select all that apply.)1. Feels no resistance when flushing the catheter with saline.2. Observes dried blood at the insertion site under the transparent dressing.3. Notes the insertion site is on the client's left chest.4. Measures the exposed (nontunneled) portion of the catheter as being 18 cm for the past 2 days.5. Notes a vesicant medication is prescribed to be administered through the catheter.6. Learns during hand-off communication that the client showered for morning care.

1. Feels no resistance when flushing the catheter with saline.- Feeling no resistance when flushing the catheter is a normal finding.4. Measures the exposed (nontunneled) portion of the catheter as being 18 cm for the past 2 days.- A PICC can be up to 60 cm in length, including the tunneled portion. The nurse should measure the exposed length each shift to ensure the catheter has not migrated. 5. Notes a vesicant medication is prescribed to be administered through the catheter.- Irritating and vesicant medications may be infused through a PICC. 6. Learns during hand-off communication that the client showered for morning care.- The insertion site and dressing may be covered with a transparent semipermeable dressing during bathing. If the sterile dressing becomes loose or damp during the shower, a new dressing should be applied. Think like a nurse: A peripherally inserted central catheter (PICC) is a long-term IV access device. PICCs often have multiple lumens, which allow for simultaneous infusion of multiple medications into the fast, voluminous flow of the superior vena cava. Nothing smaller than a 10 mL syringe is used when flushing (unless the syringe is specially designed to generate low pressure) or administering medications through this device, as the pressure will damage the tip, potentially causing a catheter embolism or causing the catheter to collapse. Frequent normal saline flushing is required to maintain patency.

The nurse discovers the IV infusion tubing disconnected from a peripherally inserted central catheter, and the client has tachycardia, chest pain, and shortness of breath. In which position will the nurse place the client? 1. Supine with the head of bed elevated 30 to 45 degrees.2. Left side-lying Trendelenburg.3. Right lateral decubitus.4. Reverse Trendelenburg.

2. Left side-lying Trendelenburg.- The client exhibits signs and symptoms of an air embolism. Therefore, the nurse should position the client on the left side in the Trendelenburg position to trap the air in the lower portion of the right ventricle.Think like a nurse: Before considering the best action to take, the nurse needs to recall the anatomical location of the peripherally inserted central catheter. The treatment of this access site should be the same as if the catheter was placed in a central location. And, because of the type of device, the client's symptoms indicate an air embolism. Treatment of these symptoms should begin with positioning the client on the left side. This forces the air embolism to move to the right side of the heart. The Trendelenburg position helps contain the embolism to the right ventricle. The goal of this nursing intervention is to prevent the air embolism from entering the lungs or brain, which can cause life-threatening complications.

An older adult client takes dexamethasone 1.5 mg by mouth three times a day. Which client statement causes the nurse concern?1. "I take my medication with meals."2. "I have this little sore on my leg that won't go away."3. "I should take a brisk walk several times a week."4. "I avoid public places during the flu season."

2. "I have this little sore on my leg that won't go away."- Dexamethasone, a cortiosteroid, suppresses the immune response. A non-healing sore should be reported to the health care provider and further assessed.Think like a nurse: Impaired wound healing is just one dermatologic adverse reaction associated with cortiocosteroid use. Other adverse reactions include acne, allergic dermatitis, dry scaly skin, ecchymoses, petechiae, erythema, increased sweating, rash, striae, suppression of reactions to skin tests, thin fragile skin, thinning scalp hair, and urticaria. An open sore that is not healing warrants further evaluation based on the current medication prescription of dexamethasone.

The nurse answers a call light for a client who reports pain at the intravenous (IV) access site. Upon assessment, the nurse notes the IV insertion site is pale, cool to the touch, and mildly swollen. It is most important for the nurse to take which action?1. Slow the infusion rate and monitor the client's response.2. Stop the infusion and notify the health care provider.3. Remove the IV catheter and apply a pressure dressing.4. Remove the IV catheter and place the client's arm on a pillow.

4. Remove the IV catheter and place the client's arm on a pillow.— The client is experiencing an infiltration of the IV access site. The nurse will remove the IV catheter and elevate the extremity to increase the rate of reabsorption of the fluid.Think like a nurse: An intravenous site that is painful, edematous, and cool to the touch indicates an infiltration. The catheter should be immediately removed and the extremity elevated to reduce edema and increase absorption of the fluid. Slowing the infusion rate will exacerbate the infiltration.

The nurse assesses a client at 10 weeks' gestation. Which finding does the nurse expect to observe?1. Fundus at the umbilicus.2. Fetal heart rate heard with Doppler.3. Fetal movement felt with palpation.4. Ballotment.

2. Fetal heart rate heard with Doppler.— The nurse should be able to hear the fetal heart rate at 110 to 160 beats/min with Doppler at 10 to 12 weeks of gestation.Think like a nurse: The nurse is aware a fetus undergoes many developmental stages. At first, the product of fertilization is identified as an embryo. During this stage, the body organs and structures are in rudimentary development. At the end of the first trimester of pregnancy, all major development has occurred and the embryo is then referred to as a fetus. During the second and third trimesters, body systems mature and the fetus grows physically. One of the body systems that is developed and begins functioning early is the heart. At the end of the first trimester of pregnancy, a heartbeat may be heard with the help of electronic enhancement.

The nurse provides care for a client taking oral contraceptives. While taking the client's history, the nurse learns that the client smokes a pack of cigarettes per day. Which observation most concerns the nurse?1. Weakness.2. Irritability.3. Chest pain.4. Abdominal cramping.

3. Chest pain.— Smoking while taking oral contraceptives places the client at increased risk for cardiovascular or thromboembolic disease. The nurse should immediately assess this client for a myocardial infarction. This is a life-threatening circulatory concern and requires immediate intervention. This is the priority assessment.Think like a nurse: Oral contraceptives are contraindicated in the client who smokes because of the risk of developing blood clots. Because of this fact, the nurse should mentally ask, "What symptoms would indicate that the client is having adverse reactions related to this medication and lifestyle?" Chest pain could indicate a myocardial infarction or pulmonary embolism, both of which can be life-threatening. This client needs further assessment and may require immediate medical attention.

The nurse plans care for a client with toxic shock syndrome. Which client statement causes the nurse the most concern?1. "I am very frightened of doctors and hospitals. "2. "I vomited 12 times in the past 24 hours. "3. "I have abdominal pain and pressure. "4. "I use extra-absorbent tampons. "

2. "I vomited 12 times in the past 24 hours. "— Vomiting 12 times during the last 24 hours addresses the client's physical status. This amount of vomiting could lead to fluid volume deficit. Symptoms of toxic shock syndrome include a sudden onset of fever, hypotension, and rash. Think like a nurse: Toxic shock syndrome (TSS) is a toxin-mediated acute life-threatening illness, usually precipitated by infection with either staphylococcusaureus or group A s treptococcus (GAS), also called streptococcus pyogenes. It is characterized by high fever, rash, hypotension, multiorgan failure, and desquamation, typically of the palms and soles, 1 to 2 weeks after the onset of acute illness. Due to risk for hemodynamic compromise, the nurse should anticipate close monitoring of the client's hemodynamic parameters such as central venous pressure. The nurse should also assess for the potential cause of the client's TSS.

The parents sit at the bedside and discuss a bicycle accident involving their older son who was riding his bicycle and accidentally hit their school-age daughter, who experienced a concussion. Which statement made by a parent validates the nursing diagnosis of dysfunctional family process? 1. "Our daughter never watches where she's going. She doesn't pay attention."2. "It was an accident. I don't want to hear that our son has always been jealous of her."3. "This would not have happened if you had not stopped at the bar on the way home."4. "We are going to have to talk to our son about bicycle safety."

3. "This would not have happened if you had not stopped at the bar on the way home."- Blaming a spouse for the accident combined with potential substance abuse indicates a dysfunctional family process. Substance abuse is a primary cause of dysfunctional family systems.Think like a nurse: Evidence of a dysfunctional family includes blaming and using substances or alcohol to cope with stressful life situations. Planning to talk with a child about bicycle safety is evidence of a well-functioning family unit.

After insertion of a central venous catheter (CVC), a client suddenly starts coughing. The nurse observes that the client is pale and dyspneic, and has tachycardia. Which action does the nurse take first?1. Turn the client to the left side and lower the head of the bed.2. Notify the health care provider.3. Administer oxygen.4. Instruct the client to do the Valsalva maneuver.

1. Turn the client to the left side and lower the head of the bed.— The client's symptoms are consistent with an air embolism, which can occur with CVC insertion. Placing the client in the left lateral position prevents the air embolism from entering the right atrium and pulmonary artery, which would create a right ventricular outflow obstruction (air lock) and stop the heart. The client should be kept in this position for 20-30 minutes. Think like a nurse: During the insertion of a central venous catheter, there is a risk that an air embolism may be introduced into the circulation. The client's symptoms indicate an air embolism has occurred in this situation. Because the pulmonary arteries are located on the right side of the heart and the nurse wants to minimize the air occluding the pulmonary arteries, the client should be turned onto the left side with the head lowered. Supplemental oxygen should be provided until the symptoms subside.

The nurse performs discharge teaching for an older adult client diagnosed with peripheral artery disease. It is important for the nurse to include which instruction?1. "Soak in a tub of warm water twice per day or perform foot soaks."2. "Maintain a warm environment by using blankets or loose, layered clothing."3. "Elevate your legs above the level of your heart four times per day."4. "Sit for a total of 6 hours per day with your feet resting on the floor."

2. "Maintain a warm environment by using blankets or loose, layered clothing."— Keeping warm, to the client's comfort level, will cause vasodilation of the extremities and is safer than placing direct heat on the extremities. Think like a nurse: Peripheral artery disease (PAD) is characterized by decreased blood flow to the limbs due to narrowing or occlusion of peripheral blood vessels. The client diagnosed with PAD experiences muscle pain with activity, as impaired blood flow limits the delivery of oxygen to muscles and prevents adequate exchange of glucose and lactate. Additional effects of PAD may include delayed wound healing and cool extremities due to impaired circulation. Interventions emphasize maximizing blood flow to and from the extremities by engaging in mild to moderate exercise. To promote capillary dilatation and blood circulation, the client is advised to stay warm by dressing in non-constricting layers of clothing.

The nurse provides care for a client diagnosed with pneumonia and acute respiratory distress syndrome (ARDS). The client asks about the benefits of pulmonary rehabilitation. Which results of the rehabilitation program will the nurse include in the teaching? (Select all that apply.)1. Improved exercise capacity.2. Decreased anxiety.3. Decreased depression.4. Increased oxygen needs.5. Decreased hospitalizations.

Answers:1. Improved exercise capacity.2. Decreased anxiety.3. Decreased depression.5. Decreased hospitalizations.Explanation:1. Improved exercise capacity.- The program will help improve endurance and oxygenation.2. Decreased anxiety.- Decreased anxiety is one of the major anticipated goals of the program. 3. Decreased depression.- Decreased depression is one of the major anticipated goals of the program. 5. Decreased hospitalizations.- Decreased hospitalizations is one of the major anticipated goals of the program. Think like a nurse: Recovery from acute respiratory distress syndrome (ARDS) could take time and requires pulmonary rehabilitation. This is partly because the fibrotic changes in the lung tissue may cause lasting damage, leading to chronic hypoxia. Exercise, diet, and health maintenance activities, such as influenza and pneumonia vaccination and avoiding contact with sick persons, are warranted. If the client requires home oxygen therapy, oxygen handling safety is reviewed with the client and caregiver. The nurse should use the teach-back method in all educational encounters, giving the client and caregiver an opportunity to ask questions.

A client with a serum potassium level of 2.4 mEq/L (2.4 mmol/L) is to receive 40 mEq of potassium chloride (KCl) intravenously. The available supply is 10 mEq KCl in 100 mL sodium chloride in each premixed bag. After hanging the first bag, the nurse sets the pump to infuse at how many milliliters per hour? (Do not round. Record your answer using a whole number.)

100 mL/hr- KCl administration must not exceed the rate of 10 mEq per hour. Because the 10 mEq bag holds 100 mL, 40 mEq will need to be administered at 100 mL per hour over 4 hours.Think like a nurse: Standard potassium chloride (KCl) IV infusion must not exceed the rate of 10 mEq per hour. This is done to prevent rapid correction that might lead to hyperkalemia, or phlebitis if the KCL is infused via a peripheral line. The nurse should also check the client's magnesium level. Magnesium and potassium have a direct relationship. When one is low, it is likely that the other also will be low. The nurse should assess the client for signs and symptoms of hypokalemia, such as muscle weakness, muscle cramps, nausea and vomiting, abdominal cramping, and dysrhythmia.

The nurse teaches a group of adolescent parents about infant nutrition and feeding. Which point does the nurse include in the teaching?1. Sweeten foods with honey, not sugar.2. Introduce fruit juice at age 4 months.3. Avoid use of no-spill cups that require sucking.4. Introduce strained, pureed, or mashed meats at 6 months of age.

3. Avoid use of no-spill cups that require sucking.- The use of no-spill cups that requiring sucking is not recommended because they do not encourage the infant to learn to drink from a cup. Additionally, they allow juice or milk to be in constant contact with the teeth, increasing the risk for dental caries. Think like a nurse: Nutrition and feeding guidelines change over time, requiring the nurse to remain current on published evidence. Additionally, recommendations from health care providers differ based on personal experience and interpretation of guidelines. For example, one health care provider may suggest starting foods at 4 months while another may suggest waiting until 6 months of age. Parents should also be taught to watch their child for readiness cues related to food and use of eating and drinking equipment.

The nurse provides care for clients on the medical-surgical unit. The nurse notes that a client is anxious and in respiratory distress. In which position does the nurse place the client?1. Flat on back with thighs flexed and legs abducted.2. Lying with the head of the bed elevated 15 ° to 45°.3. Lying on the left side with legs bent.4. Lying with the head of the bed elevated 60 ° to 90°.

4. Lying with the head of the bed elevated 60 ° to 90°.- The high-Fowler position allows optimal pulmonary expansion. It also decreases venous return, which assists in lowering the ventricular output and pulmonary congestion. Think like a nurse: A simple maneuver to assist a client improve lung expansion in the event of respiratory distress is to sit the client up. The nurse should simultaneously obtain a full set of vital signs, perform a focused respiratory assessment, and apply supplemental oxygen as needed. Depending on the individual scenario, the nurse may activate the rapid response team (RRT). The nurse should not leave the client alone.

The charge nurse in the emergency department receives a call from paramedics who are en route with four patients involved in a motor vehicle accident (MVA). Which client does the nurse plan to see first based on paramedic report?1. An adult with an obvious deformity to the left knee, weak pedal pulses bilaterally, and reports of pain.2. An adult with a decreased level of consciousness, a heart rate of 126 beats/min, and no obvious injuries.3. A child with an obvious deformity to the right forearm, a strong radial pulse, and reports of pain.4. A child, crying uncontrollably, with an abrasion on the forehead and a heart rate of 112 beats/min.

2. An adult with a decreased level of consciousness, a heart rate of 126 beats/min, and no obvious injuries.— This client may be experiencing hypovolemic shock related to an unknown hemorrhagic injury and therefore takes priority.Think like a nurse: When deciding which client to assess first, the nurse utilizes the integrated processes that enhance critical thinking and clinical judgement. The nurse first initiates the concepts of airway-breathing-circulation (ABCs), which are key to survival. The clients with obvious deformities, reporting pain, or crying have an adequate airway. They may have issues with bleeding and circulation; however, at this time, seeing these clients can be delayed. The client with decreased level of consciousness, a rapid heart rate, and no obvious signs of injuries is demonstrating hypovolemic shock possibly caused by internal bleeding injuries. The change in level of consciousness could be from inadequate oxygenation caused by a low circulating blood volume. The rapid heart rate is caused by insufficient amount of blood to support organ function.

The nurse instructs the unlicensed assistive personnel about the care of an older adult client diagnosed with presbycusis. Which client characteristic will the nurse include in the teaching?1. Often distracted.2. Has middle ear changes.3. Responds to low-pitched tones.4. Develops excessive earwax.

3. Responds to low-pitched tones.- The older adult client diagnosed with presbycusis (age-related hearing loss) has difficulty hearing high-frequency sounds. Think like a nurse: The nurse needs to recall the normal age-related changes that can occur in the older client, and acknowledge these changes can affect the client sensory status, particularly hearing. When reviewing the changes that occur with hearing, the nurse needs to remember that higher-pitched tones are the first to be altered, making them difficult to hear. To ensure that an older client is able to hear effectively, nursing staff should use lower-pitched tones when communicating.

The nurse delegates tasks to the unlicensed assistive personnel (UAP). For which UAP action does the nurse intervene? (Select all that apply.)1. Decreases the flow rate of oxygen from 4 L/minute to 2 L/minute for a client being titrated off oxygen therapy.2. Reapplies the nasal cannula for a client who displaces the oxygen tubing.3. Reports a decrease in a client's systolic blood pressure to the health care provider.4. Reports an abnormal capillary blood glucose value to the nurse.5. Assists a healthy, multiparous, postpartum client to the bathroom for the first time following childbirth.

Answers:1. Decreases the flow rate of oxygen from 4 L/minute to 2 L/minute for a client being titrated off oxygen therapy.3. Reports a decrease in a client's systolic blood pressure to the health care provider.5. Assists a healthy, multiparous, postpartum client to the bathroom for the first time following childbirth. Explanation:1. Decreases the flow rate of oxygen from 4 L/minute to 2 L/minute for a client being titrated off oxygen therapy.- Titrating an oxygen flow rate requires the nurse to assess the client's tolerance to a lower amount of oxygen. This action should only be done by the nurse. 3. Reports a decrease in a client's systolic blood pressure to the health care provider.- Only the nurse should report a change in client status to the health care provider (HCP). The HCP may want to provide new prescriptions, which the UAP cannot accept, since this is beyond the scope of practice. 5. Assists a healthy, multiparous, postpartum client to the bathroom for the first time following childbirth.- Since the client has just delivered, the nurse may need to provide teaching such as perineal cleansing. The nurse should assist the client to the bathroom to assess tolerance to activity and urine output. This task is not appropriate to delegate to the UAP. Think like a nurse: The nurse needs to consider the scope of practice of the UAP before deciding to intervene. The UAP may not administer or adjust prescribed therapies, such as oxygen. The UAP is responsible for following the chain of command and reporting any abnormal findings to the nurse. In considering whether the UAP may perform a task such as ambulation, the nurse considers whether the client is stable or whether the client has just experienced a change that may require assessment by the nurse. Just as the first set of vital signs upon admission or post-surgery should be performed by the nurse, the first ambulation to the bathroom post-delivery should also be done by the nurse.

The nurse is teaching a client diagnosed with type 1 diabetes mellitus (DM) about disease management during an illness. Which client statement indicates to the nurse that further teaching is needed?1. "I will monitor my blood glucose levels every 2 to 3 hours."2. "I should contact the health care provider if I am unable to eat for more than 24 hours."3. "I should stop taking insulin during the time I am sick."4. "I should notify the health care provider if I have vomiting and diarrhea for more than 24 hours."

3. "I should stop taking insulin during the time I am sick."— The nurse will provide further teaching. The client with type 1 DM does not have any endogenous insulin, which means that glucose cannot be transported into the cell without the prescribed insulin. The client should take the usual dose of insulin and substitute easily digested foods and fluids to provide adequate nutrition and prevent dehydration.Think like a nurse: Clients with diabetes should be instructed on "sick day rules," which include taking medication as prescribed. An illness stresses the body. The stress causes the release of cortisol, which leads to increased blood glucose levels. It is essential for the client to ingest adequate food and fluids to ensure nutritional status and prevent dehydration.

The nurse provides care to oncology clients. Which clients require further intervention from the nurse? (Select all that apply.)1. The client receiving chemotherapy treatment for breast cancer who reports "always feeling tired."2. The client receiving a chemotherapeutic alkylating agent intravenously via an implanted port with redness on the chest.3. The client with bladder cancer reporting that "nothing tastes good" and who drinks four cans of nutritional supplement daily.4. The client receiving radiation for lymphoma who reports there are handfuls of hair on the pillow every morning.5. The client diagnosed with bone cancer who is receiving chemotherapy and is afebrile but has a productive cough.6. The client who reports frequent bouts of diarrhea but states the nausea is manageable with occasional sips of fluid.

Answers: 2. The client receiving a chemotherapeutic alkylating agent intravenously via an implanted port with redness on the chest.5. The client diagnosed with bone cancer who is receiving chemotherapy and is afebrile but has a productive cough.6. The client who reports frequent bouts of diarrhea but states the nausea is manageable with occasional sips of fluid.Explanation: 2. The client receiving a chemotherapeutic alkylating agent intravenously via an implanted port with redness on the chest.— Alkylating agents can cause tissue necrosis if extravasation occurs. This client needs immediate intervention.5. The client diagnosed with bone cancer who is receiving chemotherapy and is afebrile but has a productive cough.— Clients receiving chemotherapy may not have fever even though they are ill because of bone marrow depression. This client needs immediate intervention. 6. The client who reports frequent bouts of diarrhea but states the nausea is manageable with occasional sips of fluid.— This client is at great risk for dehydration due to frequent diarrhea and reduced oral intake. The nurse will intervene immediately.Think like a nurse: Clients with an implanted infusion port should be monitored closely for signs of central line-associated bloodstream infection (CLABSI). Due to immunosupression, the client receiving chemotherapeutic agents should be monitored for overt and covert signs and symptoms of infection. The nurse should check the client's complete blood count (CBC) result daily. Assess a client's hydration and ability to take adequate nourishment, which can be compromised due to nausea, vomiting, and diarrhea. All chemotherapeutic agents may potentially cause serious skin and mucus membrane damage if extravasated.

The nurse receives a report on clients who reside on the psychiatric unit. Which actions, if performed by the off-going nurse, require follow-up by the nurse? (Select all that apply.)1. The nurse assessed a suicidal client every 15 minutes.2. The nurse administered ziprasidone to a violent client.3. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal.4. The nurse allowed a suicidal client to remain in street clothes.5. The nurse initiated a signed PRN prescription for physical restraints.

Answers:1. The nurse assessed a suicidal client every 15 minutes.3. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal.4. The nurse allowed a suicidal client to remain in street clothes.5. The nurse initiated a signed PRN prescription for physical restraints.Explanations:1. The nurse assessed a suicidal client every 15 minutes.- The suicidal client must have one-on-one supervision at all times. The client could attempt suicide in a 15-minute interval. 3. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal.- Seclusion is never punitive. This intervention is only to be used to achieve the goal of client and others ' safety. 4. The nurse allowed a suicidal client to remain in street clothes.- All clothing and personal belongings are secured to minimize the potential for self-harm. Clients are placed in hospital gowns only. 5. The nurse initiated a signed PRN prescription for physical restraints.- Restraints are never a PRN prescription. The nurse uses alternative measures prior to the use of restraints (such as reorientation, family involvement, frequent assistance with toileting). Think like a nurse: The Joint Commission requires all health care providers to implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions. The scenario described offers several opportunities for the oncoming nurse to verify the clients ' plans of care, to reinforce adherence to protocol and procedure, and to ensure delivery of evidence-based practice. Situational crisis calls for the application of TeamSTEPPS ®, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety. This evidence-based framework aims to improve communication and collaboration among health care team members by promoting effective use of information, personnel, and resources for the purpose of achieving optimal client outcomes.

The nurse on the long-term care unit identifies a higher than expected incidence of impaired skin integrity among the clients. The nurse calls a staff meeting to obtain input about the problem. Which suggestion indicates that the staff member feels empowered to solve the problem?1. The nursing assistive personnel states the facility's sheets are irritating and suggests home sheets be requested or donated by employees.2. A practical nurse states that incontinence during the night is the main factor and suggests that fluids be restricted after the evening meal.3. A practical nurse states that shearing force is a factor and suggests that the nursing assistive personnel be more gentle when repositioning clients. 4. The registered nurse states that clients are left sitting for too long and announces that from now on clients will be repositioned every hour.

1. The nursing assistive personnel states the facility's sheets are irritating and suggests home sheets be requested or donated by employees.- Empowerment involves innovation in problem solving, resulting in a sense of accomplishment and feeling of worth. This staff member highlighted a possible problem and proposed a potential, workable solution. Think like a nurse: The suggestion offered by the staff indicates a willingness to act. Feeling empowered is critical in nursing practice. The lack of empowerment will lead the staff to rely heavily on rigid bureaucratic structures rather than their own professional power to guide, practice, or create a solution. Although most of nursing's effort to enhance professional practice is through structural empowerment, it is also important for staff to value psychological and social empowerment.

The nurse develops a teaching plan for a pregnant client. A goal of the plan is to promote cardiac output during pregnancy. Which instruction is most important for the nurse to tell the client? 1. "Take frequent rest periods."2. "Modify your regular aerobic exercise as pregnancy progresses."3. "Lie on your left side when sleeping or resting."4. "Elevate feet whenever sitting."

3. "Lie on your left side when sleeping or resting."- In the supine position, particularly during the second half of pregnancy, the weight of the gravid (pregnant) uterus partially occludes the vena cava and the aorta. This reduces cardiac output and can lead to the development of supine hypotensive syndrome. Lying on left side takes the weight of the uterus off the vena cava and increases blood return to the heart, which will promote cardiac output.Think like a nurse: Before selecting the most appropriate teaching to support the pregnant client's cardiovascular status, the nurse needs to stop and recall the physiological process of pregnancy. As the uterus enlarges, the client's internal organs become compressed or displaced. This includes the descending aorta within the abdominal cavity. To maximize cardiovascular functioning, the nurse should instruct the client to lie on the left side, which prevents compression of the descending aorta. Elevating the lower extremities may further press the gravid uterus onto the aorta if the client does not shift the abdomen to the side.

The nurse supervises the unlicensed assistive personnel (UAP) who provides care for a client diagnosed with a cervical spinal cord injury (C7-C8). Which action by the UAP requires intervention by the nurse?1. The UAP elevates the head of the bed 30 degrees when assisting with meals.2. The UAP firmly massages the client's lower back and buttocks with lotion.3. The UAP instructs the client to shift weight every 15 minutes when sitting.4. The UAP positions the client in a 30-degree lateral turn position in bed.

2. The UAP firmly massages the client's lower back and buttocks with lotion.- Providing a firm massage can damage tissue, increasing the risk for skin breakdown. This client is already at risk for skin breakdown due to immobility. This action requires immediate intervention by the nurse. Think like a nurse: The nurse supervises the unlicensed assistive personnel (UAP). When a breach in proper procedure is observed, the nurse should take this opportunity to teach the UAP the correct actions. The nurse can use the "sandwich" method in giving feedback. First, the nurse should point out the positive (focusing on the stren

The nurse provides care for the client after abdominal surgery, and the client reports gas pains. Which action by the nurse is appropriate?1. Encourage the client to increase intake of vegetables.2. Instruct the client to ambulate frequently.3. Show the client how to splint the abdomen.4. Position the client on the right side.

2. Instruct the client to ambulate frequently.— Frequent ambulation increases the return of peristalsis and facilitates the expulsion of flatus. This is the best way to relieve the gas pain. Think like a nurse: The impact of early mobilization on perioperative comorbidities and length of stay (LOS) has shown benefits in medical-surgical sub-specialties. For clients recovering from abdominal surgeries, ambulation can promote return of peristalsis and prevent post-operative ileus. The nurse should assess the client's hemodynamic stability for ambulation and offer use of assistive devices such as a walker. Secondary gains from early ambulation include reduced respiratory decompensation and reduced risk of pneumonia, deep venous thrombosis, pulmonary embolism, and urinary tract infections.

The nurse provides care for a client in the emergency department (ED) who is shaking and crying after witnessing a friend being shot with a gun. The nurse observes the client to be severely anxious. Which interventions does the nurse include in the client's plan of care? (Select all that apply.)1. Remain with the client.2. Contact the police to interview the client.3. Administer prescribed lorazepam 1 mg orally.4. Encourage client to describe the incident.5. Provide privacy for the client.6. Write down important information.

Answers:1. Remain with the client.3. Administer prescribed lorazepam 1 mg orally.5. Provide privacy for the client.6. Write down important information.Explanation:1. Remain with the client.- Since the client is severely anxious, the nurse should remain with the client. Through use of therapeutic communication, the nurse should assist the client to clarify thoughts and feelings. 3. Administer prescribed lorazepam 1 mg orally.- Administering the prescribed lorazepam, an anti-anxiety medication, will help the client cope with the anxiety. 5. Provide privacy for the client.- Since the client is anxious, it is important to provide privacy from the activities in the ED, which may overstimulate the client. 6. Write down important information.- The client may have difficulty listening to and understanding information if anxiety is severe. Therefore, it is important for the nurse to write down essential information. Think like a nurse: The nurse understands that witnessing a traumatic event can be overwhelming to a client's psychological balance. For the client who observed such an event with a family member or friend, the client may demonstrate behaviors consistent with panic. The nurse needs to assess for client needs and plan client care accordingly. The client should not be left alone, and should be placed in an environment with limited stimulation in order to keep calm. Additionally, if the client is not able to understand instructions, the nurse will need to have information repeated or provided in another format. If the reaction to the stress is severe, a sedative may be prescribed to help reduce the effects of the stress on the body.

The nurse teaches the parent of an infant who is two months of age about the Haemophilus influenzae type B (Hib) vaccine. The parent asks the nurse why the vaccine is necessary. Which response by the nurse is accurate?1. "It prevents hepatitis B, which can cause liver failure."2. "It prevents Hib disease, which can cause meningitis, brain damage, and deafness."3. "It prevents Hib disease, which can cause sickle cell disease."4. "It reduces the risk for human immunodeficiency virus."

2. "It prevents Hib disease, which can cause meningitis, brain damage, and deafness."—Before the Hib vaccine, Hib disease was the leading cause of bacterial meningitis in children younger than age 5 years. Hib disease can also cause pneumonia, sepsis, and death. Think like a nurse: The nurse is aware that upon birth, a newborn's immune system is immature. Even though the client may be protected somewhat by the mother's immunity, there is at risk for developing an infection or illness. Because of this, the baby should receive vaccinations according to an identified schedule. One such vaccination, the Haemophilus influenzae type B (Hib) vaccine, prevents the development of bacterial meningitis, which can lead to death. The nurse should review the purpose of the vaccination with the parent and encourage the parent to be sure the infant receives all immunizations as recommended.

The nurse prepares to discharge a client after an abdominal cholecystectomy with a T-tube in place. Which statement by a client indicates to the nurse a need for further teaching?1. "It will be great to finally get home, take a shower, and wash my hair."2. "If the amount of drainage increases over the next several days, I should call my health care provider."3. "I can resume swimming laps three times a week in my pool."4. "I will check the skin around the tube once a day to see how it is doing."

3. "I can resume swimming laps three times a week in my pool."- A client should avoid strenuous exercise for up to 6 weeks. Due to the chance of bacteria entering the incision and tube, the T-tube should not be immersed in water. Swimming and tub baths are not permitted.Think like a nurse: Clients are often sent home with drains or tubes that they must care for. Therefore, the nurse provides instruction on how to keep these devices clean and dry, how to monitor drainage and the site for infection, how to empty and drain the device, and how to document the amount and color of drainage. Reasons for leaving a drain in place after surgery include allowing the wound to heal, reducing pain by preventing fluid collection, preventing fluid collection that might lead to infection, and minimizing tissue damage.

The nurse provides care to a newly-admitted client for whom the use of hand restraints is prescribed. When delegating client care, the nurse assigns which activity to the unlicensed assistive personnel (UAP)?1. Applying the restraints.2. Identifying the reason for the use of restraints.3. Selecting the restraints.4. Determining the effectiveness of the restraints.

1. Applying the restraints.- The nurse may delegate the application of prescribed restraints, as well as their temporary removal to allow for skin monitoring, to the UAP who has been trained in the use and monitoring of restraints. The nurse is responsible for assessing the underlying cause or behavior that is the basis for restraint application, determining the appropriateness of the use of restraints, selecting the proper type of restraints, evaluating the effectiveness of the restraints, and assessing for potential complications related to their use. Think like a nurse: Prior to delegating a task to unlicensed assistive personnel UAP, the nurse needs to recall the scope of practice and identify tasks that are routine and have a predictable outcome. The nurse is aware the application of wrist restraints is within the scope of practice of the UAP. However, the nurse retains responsibility for identifying the reason for the restraint, selecting the restraint to be applied, evaluating the effectiveness of the restraint, assessing the client's skin condition, and assessing the client's response to restraint use. Assessment actions are beyond the UAP's scope of practice.

The nurse provides care for clients at risk for colorectal cancer. Which client does the nurse identify as being at highest risk for the development of colorectal cancer?1. Caucasian client with a family history of adenomatous polyposis, consumes 2 servings of red meat per week, avoids alcohol, and is physically active.2. African American client with a history of gastrectomy, consumes diet high in fruits and vegetables, avoids red meats, and is physically active.3. African American client with a history of inflammatory bowel disease, smokes cigarettes, consumes 12 alcoholic beverages per week, and avoids red meats.4. Caucasian client with a body mass index of 32, avoids alcohol, smokes cigarettes, and has a first-degree relative with a diagnosis of colorectal cancer.

3. African American client with a history of inflammatory bowel disease, smokes cigarettes, consumes 12 alcoholic beverages per week, and avoids red meats.- This client has four risk factors, which include being African American, having a history of inflammatory bowel disease, smoking, and having an alcohol intake of >4 drinks per week. This client is at highest risk for developing colorectal cancer. Think like a nurse: Colorectal cancer has been identified as a pathologic condition that can be avoided if caught early through screening and symptom identification. The nurse should recall the etiology of this health problem, specifically modifiable and non-modifiable risk factors. Non-modifiable risk factors cannot be changed and include age, gender race, and family history. Modifiable risk factors are those that can be changed and include lifestyle, alcohol intake, smoking history, dietary intake, and body weight. Of the clients being assessed, the nurse should identify the client with the most risk factors as having the highest risk for developing the disorder.

The nurse plans care for a client with cystic fibrosis. Which dietary requirement will the nurse consider for this client? 1. High-protein, low-sodium diet.2. High-protein, high-calorie diet.3. Low-protein, low-carbohydrate diet.4. Low-protein, high-sodium diet.

2. High-protein, high-calorie diet.- Impaired intestinal absorption due to the cystic fibrosis necessitates a diet higher in protein and calories.Think like a nurse: A client with cystic fibrosis will have alterations in the metabolism of certain nutrients because of a deficiency in select enzymes required for digestion. Due to this, the client is prone to developing nutritional deficiencies and should ingest a diet high in calories and protein. There is no reason to restrict sodium, carbohydrate, or protein intake.

The nurse receives several telephone messages when performing triage. Which client will the nurse direct to come to the health facility immediately? 1. Multipara client at four weeks' gestation reporting unilateral, dull abdominal pain.2. Primigravida client at five weeks' gestation having vaginal spotting and some cramping.3. Multigravida client at six weeks' gestation reporting frank, red vaginal bleeding with moderate cramps.4. Primipara client at seven weeks' gestation reporting an increase in whitish vaginal secretions.

1. Multipara client at four weeks' gestation reporting unilateral, dull abdominal pain.-The client reporting unilateral dull abdominal pain needs to be evaluated immediately for an ectopic pregnancy. Think like a nurse: The client experiencing dull pain on one side of the abdomen can be experiencing an ectopic pregnancy and should be assessed immediately. Vaginal bleeding during the early weeks of pregnancy could indicate a threatened or spontaneous abortion. These clients need to decrease activity and count the number of pads that are saturated. The nurse recognizes that white vaginal secretions can occur during an early pregnancy. This does not indicate an infection or other disease process.

The nurse assess a client who is at 24 weeks' gestation. Which finding causes the nurse to be most concerned?1. Fetal heart rate of 130 to 140 beats per minute.2. Fundal height at three fingers below the umbilicus.3. Fetal movements felt faintly on lower part of abdomen.4. The woman reports backache and leg cramps when sleeping.

2. Fundal height at three fingers below the umbilicus.- The fundus is expected to reach the umbilicus around 20 weeks and should be increasing in height above the umbilicus after 20 weeks. A fundal height of three fingers below the umbilicus indicates a fetal problem and would be a priority concern.Think like a nurse: There are various measurements for the nurse to use when assessing a pregnant client. Before beginning an assessment, the nurse should recall the physiological changes that occur in pregnancy, the findings that should be expected, and those that should be further investigated. One physiological change occurs to the uterus. As the fetus grows, the height of the uterus will increase. A general rule of thumb is that the height of the uterus should be at the level of the client's umbilicus at the 20th week of gestation. Since this client's fundal height is below this expectation, fetal growth is not progressing as expected, and requires further investigation.

The nurse observes an unlicensed assistive personnel (UAP) provide care for clients. Which observation by the nurse requires an intervention?1. A small pillow is placed under the thighs of a client diagnosed with shortness of breath, and the head of the bed is elevated 60 degrees.2. A pillow is placed under the head and neck of a client who is lying on the right side after a liver biopsy.3. A client diagnosed with hemiplegia lies prone with the lower legs placed on a pillow.4. A client diagnosed with a sacral pressure injury lies on the left side with the right leg extended and resting on the mattress.

4. A client diagnosed with a sacral pressure injury lies on the left side with the right leg extended and resting on the mattress.- This action is to be avoided by having the upper leg mildly flexed and resting on a pillow from groin to feet. A potential trouble area of the side-lying position is hip joints that are internally rotated, adducted, and unsupported. Think like a nurse. The nurse should identify client postures that could damage joint and motor function. When placing a client in the side-lying position, the upper leg should be flexed with the hip supported. A small pillow under the knees when in the high-Fowler's position prevents sliding towards the foot of the bed. A small pillow under the head when in the side-lying position prevents neck flexion. A pillow under the legs when in the prone position keeps pressure off of the toes.

An adolescent client with a fractured tibia asks the nurse what can be done to relieve itching under the cast. Which response by the nurse is accurate?1. Apply cool air under the cast with a blow-dryer.2. Use sterile applicators to scratch the itch.3. Insert crushed ice under the cast.4. Apply hydrocortisone cream under the cast using sterile applicator.

1. Apply cool air under the cast with a blow- dryer.- Itching underneath a cast can be relieved by directing a blow-dryer, set on the cool setting, toward the itchy area.Think like a nurse. The nurse is aware a cast is applied to immobilize a bone while healing occurs. The integrity of the cast must be maintained and the client should be instructed on how to protect the cast from water (bathing) and damage from impact. Even if the cast is classified as "waterproof," the client needs to be aware of the parameters for acceptable water exposure. The nurse needs to provide teaching regarding the management of cast-related discomfort associated with excoriated skin and itching. It is important to reinforce that nothing should ever be introduced under a cast. In this scenario, the nurse should suggest that the client use a hair dryer on the cool setting to blow air gently under the cast.

The nursing student asks the nurse, "What are Good Samaritan laws?" Which response by the nurse is accurate?1. "Good Samaritan laws require health care facilities to provide material to clients about rights."2. "Good Samaritan laws provide clients with the right to be free from chemical restraints."3. "Good Samaritan laws limit the liability of professionals in emergency situations."4. "Good Samaritan laws require the reporting of threatened suicide or harm to others."

3. "Good Samaritan laws limit the liability of professionals in emergency situations."- This response accurately describes Good Samaritan laws. If the client subsequently develops complications as a result of a professional's actions, the professional is immune from liability as long as the professional acted without gross negligence.Think like a nurse. Any care provider might find themselves in a situation in which someone is in need of care that is outside of the employing organization. As a nurse, it is difficult to turn away from someone in need of physical, psychological, or emotional care. Even though nurses are licensed, there still needs to be some provision that protects the nurse's actions in the event that the care offered and provided is outside of what the person eventually needs. For this reason and many others, the federal government created a law that protects care providers who may be offering care in a situation in which the provider is not protected through the auspices of an employing organization.

The nurse performs a physical assessment on a client diagnosed with bulimia nervosa. Which finding warrants an immediate referral to the health care provider?1. Bilateral parotid gland enlargement.2. A hoarse voice that is barely audible.3. Grey to black eroded teeth with foul odor.4. Multiple papulopustular skin eruptions.

2. A hoarse voice that is barely audible.- The client with a hoarse voice is at high risk for tracheoesophageal fistula from esophageal tear secondary to forceful vomiting. Laryngitis is a danger sign.Think like a nurse. Bulimia nervosa is a type of feeding disorder that starts in adolescence and presents a variety of symptoms from recurrent vomiting that begins in the oral cavity and may reach down to the larynx, causing laryngeal and voice disorder alterations. Nurses should consider bulimia as one of the causes of clinical pictures similar to gastroesophageal reflux disease (GERD). Although not all voice changes in clients with bulimia nervosa are life-threatening, the nurse should refer the client for further evaluation for tracheoesophageal fistula.

The nurse provides care for a client diagnosed with laryngeal cancer who is scheduled for a laryngectomy. Which action does the nurse implement to assess the client's laryngeal nerve function?1. Observe for excessive salivating.2. Check the ability to swallow.3. Assess the amount of neck edema.4. Tap the neck and observe for facial twitching.

2. Check the ability to swallow.- This effectively demonstrates the ability of the nerve to support the esophageal functions. Think like a nurse. The nurse applies knowledge of anatomy and physiology and evaluates laryngeal nerve function by assessing the client's ability to swallow. A laryngoscopy or bronchoscopy may be required for definite diagnosis. Concurrent injury to the laryngeal nerves may cause difficulty breathing. Laryngeal cancer can damage the laryngeal nerve. However, laryngeal nerve damage has also been seen in thyroidectomies, endotracheal intubation, and viral infection affecting the laryngeal nerves.

The nurse supervises hospice care for a client who practices orthodox Judaism. Which observation best indicates to the nurse that the care of this client is appropriate?1. The client is given a wafer which is placed on the tongue.2. The client has a continuous intravenous morphine infusion.3. The client is turned to face east as signs of death appear.4. The client is provided the sacrament of

2. The client has a continuous intravenous morphine infusion. - Pain management is appropriate for many clients at the end of life. Some members of the orthodox Jewish faith may wish for all of the following from caregivers at the end of life: facilitating lucidity, maximizing function, pain management, providing peace, and respecting dignity. Therefore, pain management with a continuous morphine infusion is considered appropriate care. Think like a nurse. When providing culturally sensitive care at the end of life, the nurse must be aware of his or her own personal beliefs, values, and behaviors regarding pain and pain management. The nurse must also be open to the cultural effects regarding how clients perceive and react to pain. To develop an effective and caring relationship with the client from a different culture, the nurse respects the client, respects the client's response to pain, and avoids stereotyping.

The nurse prepares to assess an adolescent during a visit to the clinic for a sports physical examination. Which developmentally appropriate intervention does the nurse include with an adolescent?1. Allow time for questions without the parent present in the room.2. Expose the entire body to allow for a quick examination.3. Allow adolescent females to keep their bra on during the examination.4. Remain in the examination room while the adolescent undresses.

1. Allow time for questions without the parent present in the room.-The nurse allows time for questions without the parent present in the room. This intervention gives the adolescent an opportunity to ask sensitive questions that they might not feel comfortable asking in front of a parent.Think like a nurse: An adolescent client must have time alone with the nurse and health care provider to discuss health care needs privately and for the nurse to be able to teach about important issues (such as sexuality) without embarrassing the client. Certain sex-related issues are protected topics between the health care team and the client. The nurse can make no assumptions about the adolescent-parent relationship. While some clients will be comfortable discussing private issues with parents present, most will not be comfortable. To optimize the client's health care visit, the nurse must ensure an opportunity for private conversation with the adolescent client.

The nurse receives a call from a client who is 37 weeks' gestation and reports that, "The baby has not moved much in the past 24 hours." The health care provider prescribes a nonstress test (NST). Which client statement indicates that client teaching about the nonstress test was successful?1. "My blood will be checked one hour after drinking a glucose solution."2. "The test is looking for the baby's heart beat to increase with activity."3. "An infusion of oxytocin will start contractions to see how the baby's heart beat reacts to the stress."4. "A good score for the nonstress test is at least a 7 out of 10."

2. "The test is looking for the baby's heart beat to increase with activity."— A nonstress test looks for an acceleration of the fetal heart rate (FHR) in relation to fetal activity. A favorable result is 2 or more FHR accelerations of 15 bpm lasting 15 seconds over a 20-minute interval. This statement indicates that client teaching about the nonstress test was successful.Think like a nurse: A non-stress test (NST) provides an indirect measurement of uteroplacental function. The NST is currently recommended twice weekly, after 28 weeks' gestation for clients with diabetes and other high-risk conditions, such as preeclampsia. The nurse should explain the procedure to the client, using the teach-back method. The nurse should also be ready to explain or reinforce the client's understanding of the NST result.

The nurse prepares a client for an intravenous pyelogram. Which client statement causes the nurse the most concern?1. "I really cleaned out my bowels last night. "2. "My face flushes when I eat shrimp. "3. "I missed my morning cup of coffee. "4. "They are going to be taking x-rays at multiple intervals. "

2. "My face flushes when I eat shrimp. "— Facial flushing when eating shrimp can indicate a sensitivity to iodine. The contrast medium used for an intravenous pyelogram contains iodine. If used, the client may develop anaphylaxis. The nurse should assess for an allergy to shellfish, iodine, chocolate, eggs, and milk. Think like a nurse: Clients with allergies to shellfish may potentially develop an adverse reaction to iodine-based contrast media. The client should be screened thoroughly for risk factors for adverse effects. Clients at risk for adverse effects include client with diabetes mellitus who are prescribed metformin. Typically, metformin has to be held 2 days before and 2 days after a procedure that involves an iodine-based dye. The client should be informed that he or she might feel warm during the dye infusion, as this is an expected finding.

Answers:2. May occur with removal of duodenum.3. Associated with chronic blood loss.4. Most common type of anemia.Explanation:2. May occur with removal of duodenum.— Removal of the duodenum results in the malabsorption of iron. 3. Associated with chronic blood loss.— Chronic blood loss causes a loss of iron. 4. Most common type of anemia.— More cases of iron-deficiency anemia occur than other types of anemia. Think like a nurse: There are many types of anemia. However, underlying causes of anemia typically fall into three main categories: acute blood loss, decreased red blood cell (RBC) production, and increased RBC destruction. Iron is needed to make hemoglobin, which is the component of the RBC that carries oxygen. The duodenum is the main site of iron absorption. If the client has undergone surgical removal of the duodenum (duodenectomy), iron supplementation will likely be needed. Because oral iron supplements are not well absorbed by the gastrointestinal tract, intravenous iron infusions may be prescribed.

The charge nurse notes problematic nurse-client interactions when the nurse is assigned a client who is a survivor of sexual abuse. The charge nurse learns that the nurse was sexually abused as a child. The charge nurse takes which action when making assignments?1. Organize the nurse's assignments to include clients who have been sexually abused to promote a therapeutic environment.2. Create the nurse's assignments as is normally done and request that the nurse begin outpatient counseling.3. Assign the nurse to clients who do not have a history of sexual abuse so that the nurse is able to interact therapeutically.4. Inform the nurse that clients with a psychiatric diagnosis will no longer be assigned due to the history of sexual abuse.

3. Assign the nurse to clients who do not have a history of sexual abuse so that the nurse is able to interact therapeutically.— Assign the nurse to clients who the nurse is able to deal with in a therapeutic way.Think like a nurse: While nurses are expected to deliver quality, non-judgmental client care, nurses are also humans who deserve reasonable accommodations when a conflict arises. In this case, situation-specific problematic behaviors have been noted. The charge nurse's responsibilities include making fair, reasonable client assignments. When determining a nurse's suitability to provide client care to a specific client, factors that must be considered are both technical and psychosocial in nature. For example, the nurse whose parent recently passed away due to lung cancer may be emotionally overwhelmed by caring for a client who is diagnosed with end-stage lung cancer. Likewise, ethical considerations have an impact on client assignments. For example, a nurse who objects to administering chemotherapy to aid in a nonviable pregnancy termination is not assigned to provide care to a client undergoing this procedure.

The nurse provides care for a client after a left below-the-knee amputation. Which observation by the nurse requires immediate follow-up?1. The client eats about half the food on the meal tray.2. The client expresses an inability to concentrate when reading a book.3. The client's pulses are palpable above the operative site.4. The client reports persistent pain after receiving pain medication.

4. The client reports persistent pain after receiving pain medication. — Persistent pain after receiving pain medication may indicate a complication related to circulation, inflammation, or infection. This finding requires immediate follow-up by the nurse. Think like a nurse: Pain re-assessment is expected after the administration of pain medicine. Typically, the client should be re-assessed 30 minutes after parenteral pain medications and 60 minutes after an oral pain medication. Guidelines for pain management include the use of non-opioid therapies to the extent possible, identifying and addressing co-existing mental health conditions (e.g. depression, anxiety, PTSD), focusing on functional goals and improvement, and engaging clients actively in their pain management.

The nurse notes that the output for a client diagnosed with chronic kidney disease was not documented for the previous shift. Which action will the nurse take first?1. Call the assigned nurse and request the information.2. Complete an incident report.3. Ask the client to provide the amount of output.4. Notify the immediate supervisor of the incident.

1. Call the assigned nurse and request the information.— The goal is to make every effort to retrieve the data. Knowledge of the client 's output is used to support decision making about fluid balance. Since nurses often carry notes home or store work sheets in lockers, this approach seeks a possible source for the missing data. Think like a nurse: One action that is essential when providing client care is thorough and accurate documentation. However, accidental omissions of documentation do occur. The nurse may have been distracted with another client's care needs or an emergency situation. Even so, the nurse observes that the medical record of a client with a health problem that relies on the accurate measurement and documentation of urine output is missing vital information. The best action is for the nurse to contact the nurse who provided care to the client during the shift in question to find out what the output was, especially since the information is vital for continuity of care and disease management.

The nurse assesses a newborn immediately after birth. Which APGAR assessments cause the nurse to assign a score of less than 2 for an area? (Select all that apply.)1. Weak cry.2. Actively moving the arms and legs.3. Body is pink, but extremities are blue.4. Heart rate is 86.5. Grimaces when a probe is placed into the nasal cavity.

Answers:1. Weak cry.3. Body is pink, but extremities are blue.4. Heart rate is 86.5. Grimaces when a probe is placed into the nasal cavity.Explanation:1. Weak cry.— The baby should have a vigorous cry to receive a score of 2.3. Body is pink, but extremities are blue.— The baby should be completely pink at birth to receive a score of 2. Blue extremities are not uncommon and are not a cause for great concern. The baby needs to be warmed. 4. Heart rate is 86.— The baby's heart rate should be over 100 to receive a score of 2. 5. Grimaces when a probe is placed into the nasal cavity.— The baby should actively move from the stimulation to receive a score of 2. Think like a nurse: The Apgar score is an assessment method to determine a newborn's physiologic response to extra-uterine life. The score is based upon observations of the newborn's cry, body color, heart rate, and activity when stimulated. To receive a maximum score of 2 for each of the parameters, the newborn should have a lusty cry, have pink skin color, have a heart rate within normal limits for a newborn, and actively avoid stimulation. The nurse needs to be aware that the first score is not expected to be a 10. As with all screening tools, the nurse knows that screening is helpful in recognizing real or potential problems, and the tool should be used appropriately and with discrimination.

A client returns to the care area following abdominal exploratory surgery. Once the nurse measures vital signs, which action will the nurse perform next?1. Position on left side, supported with pillows.2. Check the medical record and determine the status of the fluid balance from surgery.3. Check the abdominal dressing for any evidence of bleeding.4. Monitor the incision and pulmonary status for the presence of infection.

3. Check the abdominal dressing for any evidence of bleeding.-The surgical dressing should be assessed upon arrival to the care area and frequently for the next several hours. Think like a nurse: Upon receiving a client immediately following abdominal exploratory surgery, the nurse's priority is to assess for ABC (airway, breathing, circulation). This is typically done while a full set of vital signs are taken and monitored in frequent intervals. The surgical site should be assesses and re-assessed closely. The nurse should note the integrity of the dressing, swelling, bleeding, and the presence of any drainage collection devices. Another priority assessment is pain. The nurse should document a comprehensive pain assessment during the peri-operative period.

The nurse notes a client recovering from a pancreatectomy has minimal drainage from the nasogastric tube. Which action will the nurse take next?1. Replace the nasogastric tube.2. Increase the intravenous fluids.3. Check the tubing for kinks.4. Notify the health care provider.

3. Check the tubing for kinks.— Assessing the tube checks for kinks and ensures the tubing is in a dependent position.Think like a nurse: The nurse should stop and recall the physiology of the abdomen and the pancreas. For a surgery where the pancreas is being removed, a nasogastric tube will be inserted in order to keep the stomach decompressed and to prevent stress on the surgical wound. If the tube is not draining, the first action is to try and determine "why." The nurse should perform the easiest assessment first by checking to see if the tube is kinked. If present, removing the kink should resume the flow of drainage through the tube. However, if the tube is not kinked, further assessment is needed. Other concerns may include an obstructed drainage tube or a malfunction of the drainage system. Some drainage systems work on the principle of suction. If this is the case, the nurse should make sure that drainage suction mechanism is activated. An obstructed drainage tube will involve notifying the health care provider for additional directions.

The parent of a toddler asks the pediatric clinic nurse, "Do you have any suggestions for what I can say to get my child to go to bed without a fuss?" Which suggestion by the nurse is best?1. Ask your child, "Do you want to go to sleep now?"2. Say to your toddler, "After we read this story, it will be time for sleep."3. Say to your toddler, "It is time to go to sleep."4. Ask your child, "Would you like to take your bear or elephant to bed with you?"

1. Ask your child, "Do you want to go to sleep now?"INCORRECT - Giving the toddler a choice about bedtime is inappropriate, as the child must go to sleep. Asking whether they would like to go to sleep now offers a false choice and can create mistrust if the child is then taken to bed after saying "no". 2. Say to your toddler, "After we read this story, it will be time for sleep."CORRECT— This statement avoids asking the toddler's permission to go to sleep. It sets clear and reasonable limits and allows time for adjustment. Having a clear routine builds trust when the parent follows through. Bedtime is paired with an enjoyable, calming activity and provides a ritual, which will cue the toddler that it is time to sleep. 3. Say to your toddler, "It is time to go to sleep."INCORRECT - While this statement avoids asking the toddler's permission to go to sleep and sets a clear limit, it does not allow time for adjustment. The parent should pair bedtime with an enjoyable and relaxed activity done beforehand to provide positive reinforcement of the desired behavior. 4. Ask your child, "Would you like to take your bear or elephant to bed with you?"INCORRECT - This question does allow appropriate and limited choices for the toddler. However, the parent should first create a sufficient ritual or transition time. Think like a nurse: Setting time limits has little meaning for the toddler-aged client, but the child must learn bedtime limits and have a preparatory transition to bedtime. An older child might be instructed that they have 15 more minutes, but the young child cannot understand the concept of time. Having a favorite story read at bedtime helps the child know how long until bedtime, offers a habitual transition, and respects their need to understand what is happening.

The nurse assesses a 10-year-old client during a well-child visit. Which statements will the nurse expect the client to make? (Select all that apply.)1. "I am allergic to strawberries. Whenever I eat one my lips get real big."2. "I have a kitten. I love having an animal."3. "This is my sword!" while holding a pen.4. "A child in my class has hurt feelings when teased by others."5. "I would love to have an extra eye on my hand, so I could see around corners with it!"

1. "I am allergic to strawberries. Whenever I eat one my lips get real big."CORRECT - According to Piaget's concrete operational stage, inductive logic is appropriate at this age. 2. "I have a kitten. I love having an animal."CORRECT - According to Piaget's concrete operational stage, reversibility thinking is appropriate at this age. 3. "This is my sword!" while holding a pen.INCORRECT - This is appropriate for Piaget's pre-operational stage, which occurs before the client reaches the age of 10. 4. "A child in my class has hurt feelings when teased by others."CORRECT - According to Piaget's concrete operational stage, children should be able to take on the perspective of others. 5. "I would love to have an extra eye on my hand, so I could see around corners with it!"INCORRECT - This is appropriate for Piaget's formal operational stage, which occurs before the client reaches the age of 10. Think like a nurse: Based on Piaget's stages of cognitive development, concrete operational development occurs among school-age children (7 to 11 years of age). When providing care to the school-age client during a well-child visit, the nurse expects certain behaviors based on the stage of cognitive development. During the concrete operational stage, the child learns by manipulating concrete objects, lacks the ability to think abstractly, learns that certain characteristics of objects remain constant, understands the concept of time, starts collecting items, understands relationship among objects, and can reverse thought processes.

The nurse develops a client teaching brochure on health promotion. Which interventions will the nurse include as examples of primary health promotion? (Select all that apply.)1. Attending a stress management class.2. Performing a testicular self-examination.3. Determining glycated hemoglobin (HbA1C) level.4. Taking an analgesic for a headache.5. Determining foods low in cholesterol.

1. Attending a stress management class.- Primary prevention aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. 5. Determining foods low in cholesterol.- Primary prevention aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Think like a nurse: Primary prevention activities promote health and protect against exposure to risk factors that lead to health problems (e.g., immunization). Secondary prevention focuses on activities to stop or slow the progression of disease (e.g., annual screening test). Tertiary prevention includes actions to prevent the progression of negative consequences of chronic conditions, reduce disability, and minimize suffering, as well as preventing complications and deterioration (e.g., cardiac rehabilitation). Before teaching, the nurse should first assess the client 's baseline knowledge. The teach-back method is used to verify the client 's understanding. The nurse assesses a client 's risk and then screens the client for the condition.

The nurse plans to assess cranial nerve (CN) III in a client. Which item does the nurse use to test cranial nerve III?1. Coffee.2. Cotton ball.3. Penlight.4. Sugar and salt.

3. Penlight.— A penlight is used to assess CN III (the oculomotor nerve). To test this nerve, assess the pupils for size, equality, and reactivity to light.Think like a nurse: There are many cranial nerve mnemonics to help nurses remember the cranial nerves. Cranial nerves I, II, and III are the "O" nerves: olfactory (I), optic (II), and oculomotor (III). The olfactory nerve is tested using strong smells such as coffee, peppermint, or peanut butter. The optic nerve may be tested via a Snellen chart for visual acuity and by plotting visual fields, which assess how far the peripheral vision extends. The oculomotor nerve is tested by observing for equal pupil reaction to light and observing the client's ability to smoothly move the eyes to track a moving object.

The perioperative nurse is evaluating a group of clients for risk factors that may lead to postoperative complications. Which clients are at high risk for developing respiratory complications following surgery? (Select all that apply.)1. A 76-year-old nonsmoker who underwent an open cholecystectomy one day ago.2. A 34-year-old smoker who underwent a left ankle repair 2 days ago.3. A 60-year-old nonsmoker who underwent carpal tunnel surgery 3 hours ago.4. A 48-year-old nonsmoker who had coronary artery bypass graft (CABG) surgery 48 hours ago.5. A 42-year-old nonsmoker who had a chest tube removed 2 hours ago.

Answers:1, 2, 4 & 5Explanation:1. A 76-year-old nonsmoker who underwent an open cholecystectomy one day ago.- Aging increases the risk for respiratory complications, as mucociliary clearance ability diminishes with age. Following abdominal surgery, splinting and pain also may lead to shallow breathing, atelectasis, and decreased mucociliary clearance. 2. A 34-year-old smoker who underwent a left ankle repair 2 days ago.- Smoking increases the risk for postoperative complications, including respiratory problems, due to impaired mucociliary clearance. 4. A 48-year-old nonsmoker who had coronary artery bypass graft (CABG) surgery 48 hours ago.- Thoracic surgery leads to a decreased ability to cough and inhale deeply, and decreased mucociliary clearance. 5. A 42-year-old nonsmoker who had a chest tube removed 2 hours ago.- Lung trauma, including trauma due to procedures or surgery, increases the risk for developing respiratory complications. Think like a nurse: Risk factors for post-operative complications include increased age, history of smoking, certain surgical procedures, and lung trauma. The client post-cholecystectomy is of advanced age and is at risk. The client with a history of smoking is at risk for developing respiratory problems post-operatively. The client post-CABG is at risk because the incision location may hinder the ability to breathe deeply and cough. The client who had a chest tube recently removed is at risk because of lung trauma.

The nurse completes an admission for a client diagnosed with depression to the psychiatric unit. It is important for the nurse to take which action?1. Give the client a brief orientation to the unit.2. Explain the activities available to the client.3. Introduce the client to the nursing staff.4. Ask the client to choose activities in which to participate.

1. Give the client a brief orientation to the unit.— The client experiencing depression will benefit from a brief orientation to the unit upon admission. A more in depth orientation can occur at a later time. Think like a nurse: Routine admission procedure to the psychiatric unit includes orientation to the unit. However, the nurse should keep information simple and not overwhelm the client. The nurse should be cognizant of possible low self-esteem of the client and changes in self-care behavior. The nurse should be alert for signs of self-destructive behavior, help client to reduce anxiety and decisiveness, and support self-esteem.

The nurse reviews circumcision site care with the parents of a newborn client. The newborn was circumcised with a clamp. Which statement by the parent to the nurse indicates that teaching is successful?1. "I will wipe off any discharge that appears using warm water and a gentle circular motion."2. "I will put petroleum jelly on a gauze pad and put that over the penis before I diaper him."3. "I will be sure the diaper fits snugly, but not too tightly, and that it is changed when wet."4. "I understand that it is normal for the first few days for the penis to look red or swollen."

1. "I will wipe off any discharge that appears using warm water and a gentle circular motion."INCORRECT - Yellowish-white exudate appears on the second day. This is part of the granulation process. Do not remove or disrupt during cleaning of the are2. "I will put petroleum jelly on a gauze pad and put that over the penis before I diaper him."CORRECT - A small gauze pad with either petroleum jelly or medicated ointment is placed on the circumcision site as a dressing. This prevents the wound from adhering to the dressing or diaper. Dressing changes continue for 3 days after the procedure. 3. "I will be sure the diaper fits snugly, but not too tightly, and that it is changed when wet."INCORRECT - The diaper should be loosely fastened to prevent friction, rubbing, or pressure against the tender penis, but it should be changed when wet. 4. "I understand that it is normal for the first few days for the penis to look red or swollen."INCORRECT - These are signs of infection. Penile edema can cause urinary obstruction. This is reported to the health care provider immediately. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess understanding. That understanding is clear when the parents of the client state a plan to take measures to reduce friction and prevent further injury to the skin, such as using a lubricating ointment. The goal of post-circumcision care is to allow healing, which means keeping the site clean and protecting the penis from irritation.

The home care nurse visits an older adult client living with an adult child. Which observations, if made by the nurse, may indicate elder abuse?1. Poor nutritional status and hygiene.2. Difficulty with short-term memory.3. Dirty laundry found in the client's room.4. Client is recovering from a fractured hip.

1. Poor nutritional status and hygiene.- Poor nutrition and poor hygiene may indicate elder abuse. Other signs include absence of needed dentures and glasses, dehydration, urine burns, excoriation, and pressure injuries.Think like a nurse: Manifestations of elder abuse may be subtle or overt. The most common symptoms of this type of abuse include poor nutrition and hygiene. The client's daily oral intake and frequency of performing hygiene should be assessed. Alteration in short-term memory can occur with a variety of health problems. Dirty laundry is not an indication of abuse. The most common cause for a fractured hip in an older client is a fall. It is unlikely that a hip fracture occurred from abuse.

A client who regains consciousness after passing out while jogging reports seeing and talking with a deceased spouse. Which response is the most appropriate for the nurse to make? 1. "Because your wife died 5 years ago, I don't think you really saw her."2. "You were probably in a dream state, but everything is fine now."3. "I'll get the psychiatrist to speak with you about this."4. "Tell me how you feel about what just happened."

4. "Tell me how you feel about what just happened."- An open-ended response allows the client to explore and express thoughts and feelings. This is the most therapeutic response for the nurse to make. Think like a nurse: The client experienced a visual hallucination or dream that occurred while unconscious. The nurse needs to use therapeutic communication techniques and first assess how the experience affected the client.

The nurse provides care for a client hospitalized for treatment of uncontrollable aggressive impulses. Which observation does the nurse record before beginning a behavior modification plan for the aggressive impulses?1. The client tells each nurse that she is his favorite nurse.2. The client is flirtatious with female members of the staff.3. The client threatened to hit two other clients within 2 hours.4. The client appears insincere and superficial in his interactions.

3. The client threatened to hit two other clients within 2 hours.- Concrete evidence of aggressive behavior must be documented. The nurse intercedes early, continues nonthreatening behavior toward the client, but will restrain the client when necessary to protect self and others. Think like a nurse: Thorough and accurate documentation is essential when caring for a client demonstrating aggressive behavior. Threatening to hit others is an objective observation of aggressive behavior and warrants a behavior modification plan.

The nurse provides care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) and cutaneous Kaposi sarcoma. Which assessment confirms this new diagnosis?1. Swelling in the legs.2. Reddish blue lesions all over the skin.3. Swelling in the genital area.4. Punch biopsy of the cutaneous lesions.

1. Swelling in the legs.INCORRECT — The late disease progresses to this enlargement of the lower extremities.2. Reddish blue lesions all over the skin.INCORRECT — This condition begins as the macules described on the lower legs that then change into plaques that open and drain.3. Swelling in the genital area.INCORRECT — The late disease can progress to swelling of the penis and scrotum.4. Punch biopsy of the cutaneous lesions.CORRECT — A punch biopsy is the procedure by which a definitive diagnosis is made.Think like a nurse: The client who is positive for human immunodeficiency virus (HIV) is at risk for developing acquired immune deficiency syndrome (AIDS). The nurse should mentally review the pathophysiological process of AIDS and the types of opportunistic infections that can develop. The nurse is aware the client with AIDS has a compromised immune system that is unable to prevent specific diseases from occurring. One such disease is Kaposi sarcoma, which can only be diagnosed definitively by a biopsy of a lesion. Other symptoms may develop as the disease progresses.

The nurse provides care for a client who has a pulmonary injury. Which clinical manifestation indicates to the nurse that the client is experiencing a tension pneumothorax? 1. Tracheal deviation.2. Hypertension.3. Flattened neck veins.4. Bradycardia.

1. Tracheal deviation.CORRECT - Tracheal deviation toward the unaffected (i.e. uninjured) side is a late sign of tension pneumothorax. Breath sounds may be diminished or absent over the affected lung. Shifting of the heart and great vessels will cause decreased cardiac output and hypotension. Additional manifestations of tension pneumothorax include tachycardia and distended neck veins. Tension pneumothorax is a life-threatening medical emergency that requires immediate treatment. Interventions may include needle decompression to release air trapped in the pleural space and chest tube insertion. 2. Hypertension.INCORRECT - Manifestations of tension pneumothorax include hypotension, not hypertension. 3. Flattened neck veins.INCORRECT - Distended neck veins, not flattened neck veins, are a sign of tension pneumothorax. 4. Bradycardia.INCORRECT - Tension pneumothorax causes tachycardia, not bradycardia. Think like a nurse: The nurse needs to recall the pathophysiology of a tension pneumothorax and mentally ask, "What is occurring in the thorax when this problem develops?" The nurse recognizes that a pneumothorax develops when the pressure inside of the lung is the same as the pressure outside of the lung. The lung collapses and can no longer support body tissue oxygenation. In a tension pneumothorax, the structures within the thorax are shifted towards the inflated lung, or away from the collapsed lung. This is because free air in the thoracic cavity increases the pressure in the thorax and moves the organs away from the collapsed lung. One structure that shifts is the trachea.

A client with a history of diabetes mellitus (DM) and asthma takes high-dose corticosteroids. Which dermatologic complications will the nurse assess in this client? (Select all that apply.)1. Delayed wound healing.2. Skin pigmentation changes.3. Alopecia.4. Erythematous plaques on legs.5. Decreased subcutaneous fat over extremities.

Answers:1, 4, 5Explanation:1. Delayed wound healing.CORRECT- Corticosteroids delay wound healing. 4. Erythematous plaques on legs.CORRECT- Erythematous plaques on the legs is related to diabetes mellitus. 5. Decreased subcutaneous fat over extremities.CORRECT- Decreased subcutaneous fat in the extremities is related to both diabetes mellitus and corticosteroids. Think like a nurse: Long-term steroid therapy may be prescribed for treatment of clients with various conditions, including chronic asthma or autoimmune disorders, such as lupus or rheumatoid arthritis. Both long-term systemic steroid therapy and Cushing syndrome result in multisystem effects of cortisol. Cortisol causes catabolism, altering the strength of tissues such as muscles and blood vessels. Collagen and elastic fibers in the epidermis are ruptured, resulting in decreased skin elasticity. While systemic steroid therapy does not typically cause changes in skin pigmentation, integumentary changes can include fragile skin, easy bruising, dry skin, acne, stretch marks, or infection. Topical corticosteroid cream misuse can cause integumentary effects such as skin thinning and telangiectasia

The nurse provides care for a client diagnosed with paranoid schizophrenia. The client's spouse states that the client has not slept in 3 nights. Which action by the nurse is most appropriate?1. Assign the client to straighten up the day room.2. Establish a trusting nurse-client relationship.3. Encourage the client to sleep and offer a sleep aid.4. Introduce the client to other clients on the unit.

2. Establish a trusting nurse-client relationship.— The client diagnosed with paranoid schizophrenia views the world as hostile and threatening, so the nurse's priority is promoting trust. Trust is promoted by establishing the nurse-client relationship. Think like a nurse: Establishing rapport is essential in therapeutic communication. The nurse should speak calmly and clearly and maintain eye contact with the client. It is very important not to challenge the client's beliefs or delusions. They are very "real" to clients who experience them, and there's little point in arguing with them about their delusions or false beliefs. Instead, move the conversation along to areas or topics upon which both the nurse and the client agree.

The nurse teaches the client about preventing recurrent urinary tract infections. Which statement by the client indicates to the nurse that teaching is effective? (Select all that apply.)1. "I should bathe in the tub rather than shower."2. "Coffee and alcohol are good for my bladder."3. "Vitamin C will help by acidifying my urine."4. "I should void every couple of hours during the day."5. "I should wipe back to front after urinating."

3. "Vitamin C will help by acidifying my urine."— Vitamin C (ascorbic acid) 1000 mg daily, or cranberry juice, may help prevent recurrent urinary tract infections by acidifying the urine.4. "I should void every couple of hours during the day." — Voiding frequently prevents over-distention of the bladder and compromised blood supply to the bladder wall.Think like a nurse: Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including any literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. The nurse should explain to the client various self-management activities to prevent urinary tract infection (UTI).

The nursing staff at the pediatric hospital discuss instituting a community education program regarding intellectual disabilities, particularly prevention. It is most beneficial for the nurses to emphasize which area?1. Alcoholism treatment.2. Phenylketonuria (PKU) screening.3. Nutritional supplementation.4. Prenatal classes.

1. Alcoholism treatment.- Alcohol is recognized as the leading cause of preventable intellectual disability. This is included in the fetal alcohol syndrome (FAS) complex of symptoms. Think like a nurse: In many cases of intellectual disability, the exact cause is unknown. Prenatal exposure to alcohol or other drugs can be a cause. Prenatal errors in central nervous system development also may be responsible. Public health efforts to prevent intellectual disability should be geared toward adequate prenatal care that emphasizes abstinence from alcohol and other teratogens. In assessing clients with intellectual disability, the nurse should keep in mind that the most sensitive early indicator is delayed language development due to the extent of cognition required to understand and produce speech.

The triage nurse is prioritizing adult clients to be evaluated in the emergency department. Which client does the nurse assess first?1. A client with a temperature of 100°F (37.8°C).2. A client reporting arm pain after falling off a chair.3. A client reporting vomiting for the past several hours.4. A client with a persistent nosebleed.

4. A client with a persistent nosebleed.- Compromised circulation takes precedence over the other client needs. Think like a nurse: The client experiencing prolonged epistaxis requires assessment to ensure stability of airway, breathing, and circulation (ABCs). Persistent bleeding into the oropharyngeal cavity may compromise airway patency. Further assessment is needed to allow for estimating the client's blood loss and to determine the presence of circulatory compromise. If the client's vital signs and respiratory status are stable, the health care provider may attempt a tamponade in an effort to promote hemostasis. A severe nosebleed may be reflective of a serious pathophysiological condition and will require careful assessment.

The nurse plans care for assigned clients. In which order will the nurse prioritize the care for these clients? (Please arrange in order. All options must be used.) - Child diagnosed with sickle cell crisis reporting priapism- Child requiring observation following an acute asthma attack- Child whose temperature has risen to 103.8 degrees F (39.9 degrees C)- Infant who is vomiting and has frothy oral secretions

- Infant who is vomiting and has frothy oral secretions- Child requiring observation following an acute asthma attack- Child whose temperature has risen to 103.8 degrees F (39.9 degrees C)- Child diagnosed with sickle cell crisis reporting priapismThink like a nurse: The nurse needs to consider which client is most unstable and at greatest risk. The nurse makes this determination by using knowledge about ABCs (airway, breathing, circulation) and Maslow to set priorities. The client with frothy oral secretions is at risk for airway compromise and should receive care first. The client recovering from an acute asthma attack is still at risk for airway occlusion. The client with an elevated temperature may have an infection and is at risk for dehydration. Priapism, while uncomfortable, is not a life-threatening condition.

The nurse recognizes that which lifespan consideration may impact the care of older adult clients? 1. Older adults have a decreased sense of thirst.2. Sensitivity to odors increases with aging.3. Older adults have decreased total body fat.4. Gastrointestinal motility increases with aging.

1. Older adults have a decreased sense of thirst.- Sense of thirst is decreased among older adults. With aging, sense of smell becomes less acute and gastrointestinal mobility decreases. Total body fat increases with aging. Think like a nurse: In this scenario, the nurse should mentally review the age-related changes that are considered normal and expected. The older adult client will experience changes in sensory perception, digestion, and body composition. Regarding sensory perception, one primary change that should be addressed is the sense of thirst. Older adult clients will have a decline in the ability to detect thirst, which can lead to dehydration. When planning the care of an older adult client, the nurse should ensure for an adequate oral fluid intake. The nurse will provide client teaching about the importance of maintaining a normal fluid intake and the health issues associated with low fluid intake.

The nurse admits a client to the psychiatric unit. During the interview, the client frequently changes the subject. Which response by the nurse is appropriate?1. Remind the client about the care goals.2. Focus the interview on the client's symptoms.3. Recognize the client's behavior relieves discomfort.4. Ask the client to choose a topic for discussion.

3. Recognize the client's behavior relieves discomfort.— The client appears anxious and is having difficulty focusing. The nurse keeps environmental stresses to a minimum.Think like a nurse: In communicating with the client who frequently changes the subject, the nurse can use the sharing observation technique. The nurse can comment on how the other person is acting, looking, or sounding. Stating observations often helps a client communicate without the need for extensive questioning, focusing, and clarification.

The nurse instructs a client who is newly diagnosed with type 1 diabetes mellitus (DM) about proper foot care. Which client statement indicates to the nurse that additional teaching is needed?1. "I should cut my toenails straight across."2. "I should not go barefoot."3. "I should inspect my feet once a week."4. "I should bathe my feet daily in warm water."

3. "I should inspect my feet once a week."— The client should inspect feet daily for blisters, sores, ingrown nails, and cuts. This statement indicates that additional teaching is needed. Think like a nurse: When caring for a client with type 1 diabetes mellitus (DM), the nurse needs to apply knowledge about factors that can negatively impact the client's health and wellbeing. Because of the risk for foot wounds caused by changes in peripheral nerve sensation, the client with diabetes mellitus should be instructed to examine the feet every day. This can be accomplished by having the client hold a mirror up to the bottom of the foot to conduct a complete inspection.

The unlicensed assistive personnel (UAP) reports that a client scheduled for surgery has a temperature of 102.5°F (39.1°C). Which action will the nurse take first?1. Document the finding in the medical record.2. Notify the health care provider immediately.3. Administer acetaminophen per rectum, as prescribed.4. Verify the temperature measurement.

4. Verify the temperature measurement.- The nurse should first verify the client's temperature to ensure accuracy before intervening. By doing so, the nurse prevents unnecessary intervention should the reported finding be in error. Think like a nurse: The nurse recognizes that an elevated temperature in a client being prepared for surgery can be an issue. The client could have an infection, which would need to be managed before the surgery. Prior to contacting the health care provider about the elevated temperature and plans for the surgery, the nurse should validate the measurement. Should the measurement be valid, the surgery will most likely be postponed, and the client will undergo testing to determine the source of the infection and receive treatment.

The unlicensed assistive personnel (UAP) reports to the nurse that a client diagnosed with type 1 diabetes mellitus states, "The room is spinning around me." Which is the priority responseby the nurse?1. "Did the client eat breakfast?"2. "Has the client experienced episodes of vomiting?"3. "Is the client in bed?"4. "Has the client had this problem before?"

3. "Is the client in bed?"- The priority is client safety. The client should sit down or lie down to prevent falling. Think like a nurse: When caring for a client, the nurse's priority action is to always ensure the safety of a client. A client who is experiencing dizziness is at high risk for a fall and injury. The most important response is to ask if the client is sitting down or lying in bed. The nurse must first assure that any contributing factor to the client's safety is addressed. Additional assessment can occur once the client's safety is ensured.

The nurse admits a school-age client diagnosed with an open wound that tests positive for methicillin-resistant Staphylococcus aureus (MRSA). Which room assignment is appropriate for this client?1. A semiprivate room with a toddler diagnosed with respiratory syncytial virus.2. A semiprivate room with a preschool client diagnosed with acute respiratory virus.3. A private room that is close to the nurse's station.4. Any private room that is available.

4. Any private room that is available.- A private room is best for this client, as a client with MRSA can only room with another client who is also MRSA positive. There is no indication that the client requires close monitoring.Think like a nurse: It is ideal to place a client with a transmissible infection in a private room, even when it is not an infection that requires transmission precautions. The client on transmission precautions is never placed with a client who is immunocompromised or infected with a different transmission precaution illness. For example, a client with methicillin-resistant Staphylococcus aureus (MRSA) and a client with vancomycin-resistant enterococci (VRE) should never be assigned to the same room, and, preferably, are never assigned to the same nurse. Cross-contamination of antibiotic-resistant organisms can have lethal consequences.

The client is to begin treatment with metformin. Which client statement requires immediate intervention by the nurse?1. "I will be sure to carry a chocolate candy bar with me at all times."2. "If I get abdominal cramps and a metallic taste in my mouth, I will call the health care provider."3. "I am glad this medication will not cause me to gain weight."4. "I will take the medication when I first get up and just before I go to bed."

4. "I will take the medication when I first get up and just before I go to bed."- The client should take metformin with meals to reduce the side effects of the medication. Side effects may include nausea, vomiting, anorexia, and abdominal cramps. Think like a nurse: During client teaching, the nurse uses the teach-back method to evaluate the client's understanding. Key topics of education include the medication's purpose, therapeutic effects, side effects, adverse effects, and administration instructions. Metformin decreases production of glucose by the liver and increases cellular sensitivity to insulin. Metformin also delays glucose absorption, which helps prevent sharp elevations in blood glucose. Metformin is most effective when taken with food.

The nurse receives a phone call from a client at 29 weeks ' gestation who is experiencing heartburn throughout the day. Which suggestion does the nurse provide to the client to assist with heartburn?1. Instruct the client to lie on her left side for 30 minutes after each meal.2. Suggest the client add two slices of bacon to her breakfast meal.3. Recommend the client drink two 16-ounce glasses of water with each meal.4. Tell the client to eat six to eight small meals per day.

4. Tell the client to eat six to eight small meals per day. - The nurse should suggest that the client eat small, frequent meals throughout the day to facilitate gastric emptying and decrease heartburn. Think like a nurse: Slowed gastric emptying combined with relaxation of the esophageal sphincter and pressure from the enlarging uterus allows reflux into the esophagus, which causes heartburn during pregnancy. To reduce heartburn during pregnancy without hurting the fetus, the client is advised to eat slowly; avoid fried, spicy, or fatty foods; and avoid any foods that seem to cause relaxation of the lower esophageal sphincter and increase the risk of heartburn. Over-the-counter antacids will also help relieve symptoms, but the client should first consult with the health care provider.

The hospital has just received word that a major disaster has occurred and a large influx of clients is expected in less than 1 hour. The nurse considers which current client is most appropriate for immediate discharge?1. An older adult client admitted 4 days ago with a diagnosis of a stage 3 pressure injury.2. An older adult client admitted 12 hours ago with a diagnosis of pyelonephritis.3. An older adult client 4 days postoperative after a total hip replacement.4. An adult client 24 hours postoperative after a vaginal hysterectomy.

3. An older adult client 4 days postoperative after a total hip replacement.— This is the most stable client. Clients post-total hip replacement are typically discharged on postoperative day 2 to 3 to a rehab facility or home.Think like a nurse: In response to a disaster, the hospital activates its emergency operations plan (EOP). Planning for coordinated care of clients into and out of the hospital is an essential component of the EOP. This involves identifying which clients can be discharged or transferred to another facility to make beds readily available for an influx of clients. Hip replacement surgery commonly requires 2 to 3 days of hospitalization; this client has been hospitalized for 4 days. A stage 3 pressure injury requires aggressive treatment. Treatment for pyelonephritis requires a course of IV antibiotics to prevent progression to sepsis. After a vaginal hysterectomy, the client typically remains hospitalized for 48 hours due to the risk for bleeding.

A client diagnosed with type 2 diabetes mellitus (DM) is treated for hypertension with propanolol. The history reveals that the client is diagnosed with glaucoma and is allergic to sulfa. Which prescribed medication requires an immediate intervention by the nurse?1. Glycerin.2. Pilocarpine.3. Acetazolamide.4. Timolol maleate.

3. Acetazolamide.— This medication is contraindicated. Clients with a sulfa allergy should not take acetazolamide, as an allergic reaction may occur. Think like a nurse: The nurse should review the medication list and assess for those that may interfere with a current health problem or create a new one. Acetazolamide is contraindicated in clients with an allergy to sulfa. This is the medication that the nurse should question before administering to the client.

The nurse teaches an adult female client with a family history of hypertension. Which recommendation does the nurse include in client education? (Select all that apply.)1. Limit sodium intake to 2 grams or less daily.2. Exercise at least twice weekly.3. Avoid use of tobacco products.4. Limit alcohol consumption to one serving per day.5. Limit coffee consumption to two servings daily.

Answers: 1, 3, 4Explanation:1. Limit sodium intake to 2 grams or less daily.- Excessive sodium intake (greater than 2 grams daily) increases the risk for hypertension. 3. Avoid use of tobacco products.- Smoking or the use of other tobacco products increases the risk for hypertension. 4. Limit alcohol consumption to one serving per day.- Excessive alcohol intake is linked to hypertension. For adult females, no more than one serving of alcohol per day is recommended. Think like a nurse: Risk factors for the development of hypertension include excessive sodium intake, a sedentary lifestyle, use of tobacco products, and excessive alcohol intake. Sodium increases the amount of body fluid, which can cause a subsequent increase in blood pressure. A sedentary lifestyle encourages hemo-stagnation in the extremities, which weakens blood vessels. Tobacco and nicotine directly effect the blood vessels, causing constriction. Alcohol alters fluid balance, which affects all body systems.

Answers:1, 2, 3Explanation:1. Client reports pain is 8 out of 10.— A pain level of 8 out of 10 indicates pain that is unrelieved by the current medication prescription and requires follow-up by the nurse. The client may need an increased dose or change in pain medication.2. Assesses respiratory rate as 8 breaths per minute.— A respiratory rate of 8 breaths per minute is a sign of over-sedation. The client's prescribed medication dose may need to be altered by the health care provider. 3. Notes petechiae on the client's abdomen and forearms.— Petechiae are a sign of an allergic reaction and should be reported to the health care provider. Think like a nurse: When providing care to a client who is prescribed opioid analgesics, the nurse needs to closely monitor the client for potential adverse drug reactions such as respiratory depression and allergic reaction. Naloxone should be readily available when administering opioid medications, as naloxone is prescribed to counteract the adverse reaction of respiratory depression. While monitoring the client for adverse reactions, the nurse must also assess for pain relief. This is typically done 30 to 45 minutes after the medication is administered. Unrelieved or worsening pain warrants further assessment and collaboration with the health care provider.

The nurse provides care to a client who reports nervousness, hunger, tremors, and sweating. Which action will the nurse take first?1. Obtain a capillary blood sample for blood glucose testing.2. Obtain an arterial blood sample for an ABG analysis. 3. Administer glucagon subcutaneously, as prescribed.4. Administer a rapidly-absorbed oral carbohydrate.

1. Obtain a capillary blood sample for blood glucose testing.- The nurse should first obtain a capillary blood sample for blood glucose testing to confirm that hypoglycemia is the cause of the client's symptoms.Think like a nurse: Before acting, the nurse should think about the client's symptoms and consider reasons for them occurring together. Nervousness, hunger, tremors, and sweating are cardinal manifestations related to some sort of metabolic imbalance. The nurse should recognize that this group of symptoms are likely indicative of a low blood glucose level. The action that the nurse should take first involves use of the nursing process. The nurse would use assessment by determining this client's capillary blood glucose level. Depending upon the result, treatment with food or other oral source of glucose would alleviate the symptoms. If the glucose level is within normal limits, additional assessment would be required to identify the source of the symptoms.

The nurse provides home care for an older adult client diagnosed with impaired hearing. Which action is most appropriate for the nurse to implement based on this data?1. Checking expiration dates on food packages.2. Providing large-print reading material.3. Teaching the importance of changing position.4. Obtaining an amplified telephone for the client.

4. Obtaining an amplified telephone for the client.— An amplified phone helps with hearing and provides a means for communicating more easily with others.Think like a nurse: When providing home care, the nurse needs to be concerned with client safety in the home environment. If a client has a sensory disorder, special interventions should be identified and implemented. A client with a hearing disorder may have difficulty hearing a doorbell or not be able to hear when using a telephone. In this situation, a special telephone, or a device attached to the telephone, can amplify the sound. Other actions may be required if the client has a vision disorder, but this is not the case in this scenario.

A newly admitted client receives a lithium prescription for treatment of bipolar disorder. The client's serum lithium level is 1.7 mEq/L (1.7 mmol/L). Which action does the nurse take first?1. Administer the next dose on time.2. Increase the client's oral fluid intake.3. Notify the health care provider.4. Encourage the client to rest.

3. Notify the health care provider.- The therapeutic range of lithium for initial management is 1 to 1.5 mEq/L (1 to 1.5 mmol/L). Toxic manifestations may occur at levels greater than 1.5 mEq/L (1.5 mmol/L), and the HCP should be notified. Observe for vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, and muscle twitching. The therapeutic range of lithium for maintenance is 0.8 to 1.2 mEq/L (0.8-1.2 mmol/L). Think like a nurse: The client's lithium level is elevated, which should be reported to the health care provider. Increasing oral fluids will not affect the serum blood level of the medication. Administering the next dose of the medication would be malpractice and should not be done. Resting will not decrease the serum level of the medication or prevent the development of symptoms of lithium toxicity.

The nurse prepares a client for a skin biopsy. Which client statement will the nurse report to the health care provider?1. "I've been taking aspirin for my sore knees."2. "Using lotion has helped my dry skin."3. "I went to the tanning salon yesterday."4. "I had a big breakfast this morning."

1. "I've been taking aspirin for my sore knees."-Aspirin compounds can increase bleeding time and should not be taken prior to a surgical procedure. Think like a nurse: Aspirin has anti-platelet properties. It blocks thromboxane A2 (produced by activated platelets and has prothrombotic) properties to prevent platelet aggregation. Long-term use of aspirin can cause bleeding, even during minor procedures such as a biopsy. The nurse should notify the health care provider of the client's aspirin use. It is also important to note that aspirin may be contained in some over-the-counter medications such as Pepto-Bismol. Medication reconciliation is an essential procedure that should be done when a client goes for a procedure.

The nurse administers an immunization to an adult client. Which observations made after the injection cause the nurse to immediately intervene? (Select all that apply.)1. The client is clearing the throat and coughing.2. The client has nasal drainage and sneezing.3. The client is anxious and exhibits rapid breathing.4. The client is feverish and sweating profusely.5. The client reports dizziness upon standing.6. The client has a diffuse rash across the trunk.

Answers: 1, 3, 5Explanation:1. The client is clearing the throat and coughing.- An anaphylactic reaction may begin with the client clearing the throat and coughing due to swelling in the airway. The nurse should assess the client for other signs of anaphylaxis and be prepared to intervene.3. The client is anxious and exhibits rapid breathing.- Tachypnea and feelings of impending doom occur with anaphylaxis. This client needs immediate assessment and care.5. The client reports dizziness upon standing.- Dizziness upon standing may be indicative of hypotension, which occurs with anaphylaxis and shock. The nurse should immediately assess this client's vital signs. Think like a nurse: A vaccination is used to immunize against a specific antigen. Some people may have an unknown allergy to the vaccine and develop symptoms of anaphylaxis, which include airway swelling, rapid heart rate, feeling of impending doom, and low blood pressure as a sign of developing shock.

The nurse prepares to teach a client recovering from a spinal fusion on how to move from a supine to standing position at the left side of the bed with a walker. Which direction by the nurse is appropriate?1. Raise the head of the bed to sit straight up, bend the knees, and swing the legs to the side and then to the floor.2. Rock the body from side to side, going further each time until enough momentum is built up to be lying on the right side, and then raise the trunk towards the toes.3. Reach over to the left side rail with the right hand, pull the body onto the left side, bend the upper leg so the foot is on the bed, and push down to elevate the trunk.4. With the left elbow as a pivot, grasp the mattress edge with the left hand and push on the mattress with the right hand above the left elbow, and then slide the legs over the side of the mattress.

4. With the left elbow as a pivot, grasp the mattress edge with the left hand and push on the mattress with the right hand above the left elbow, and then slide the legs over the side of the mattress. — Using the arms maintains spinal alignment and prevents injury.Think like a nurse: The nurse forms a mental view of what needs to be done, paying particular attention to client safety and preventing injury. The nurse considers that spinal fusion is a complicated surgery and requires special post-operative care to maintain the incision and prevent rotation of the vertebra within the surgical site. The first action by the nurse is to assess the client's physical and psychological ability to implement the teaching. Once ability is determined, the client is coached to use the arms and the legs to move the body into position for standing. The nurse observes the client's ability to change position while protecting the surgical site.

The nurse provides care for a client who anticipates using a prosthesis after an above-the-knee amputation. Which action should the nurse take when caring for this client?1. Encourage the client to sit in a chair for extended periods of time.2. Maintain the compression dressing to the amputation site.3. Provide range-of-motion exercises twice a day. 4. Elevate the residual limb for 72 hours.

2. Maintain the compression dressing to the amputation site.- When caring for a client after an above-the-knee amputation, the nurse needs to maintain the compression dressing to the amputation site. This minimizes edema and prevents infection. Think like a nurse: Proper residual limb bandaging fosters shaping and molding for eventual prosthesis fitting. A compression dressing is typically ordered to reduce edema, support soft tissues, and promote limb shrinkage and maturation. The delayed prosthetic fitting may be the best choice for clients who had above knee or below the elbow amputations, older adults, debilitated individuals and those with infections. The compression bandage should be worn at all times except during physical therapy and bathing.

A client is prescribed an intravenous dose of naloxone hydrochloride 0.2 mg. Which action is essential for the nurse to perform after administering this medication?1. Decrease external stimuli.2. Encourage oral fluids.3. Place in lateral recumbent position.4. Monitor respiratory rate.

4. Monitor respiratory rate. — Naloxone hydrochloride is used to reverse narcotic-induced respiratory depression. The client 's blood pressure, respiratory rate, and heart rate should be assessed frequently.Think like a nurse: Naloxone hydrochloride is administered to clients experiencing respiratory compromise as a result of an opioid medication or illicit drug. The nurse assesses a client 's vital signs to determine effectiveness of this medication, particularly the client 's respirations. The duration of action of most opioid drugs will extend beyond the duration of naloxone effectiveness. After naloxone administration, the client experiences acute withdrawal symptoms. Within a few minutes, the client begins to calm as the naloxone wears off and the opioid can attach to the receptors and begin to work again. At this point, the client is in jeopardy of overdose effects recurring. The nurse monitors vital signs and likely administers a follow-up dose of naloxone.

The nurse provides care to a client who is scheduled to undergo lumbar puncture during a workup for suspected multiple sclerosis (MS). Which information does the nurse include when preparing the client for lumbar puncture?1. "You will receive general anesthesia for this procedure."2. "You cannot eat or drink for 8 hours immediately before having the procedure."3. "You will need to remain very still during the procedure."4. "You will wear a compression dressing at the puncture site for 24 hours after the procedure."

3. "You will need to remain very still during the procedure."- Movement during lumbar puncture can result in misplacement of the spinal needle and subsequent damage to nerves or blood vessels. The client should be advised to remain still and to breathe normally during the procedure. Think like a nurse: In preparation for the lumbar puncture, the nurse should follow institution protocol. Key activities include: obtaining the informed consent and placing it in the medical record, having the client empty the bladder, obtaining the appropriate lumbar puncture kit, performing a time out prior to the procedure, placing the client in an appropriate position and identifying landmarks, cleaning the site using sterile technique, and placing sterile drapes while observing aseptic technique. The nurse can assist the health care provider during the procedure and support the client in positioning, as well as provide emotional reassurance. The nurse will inform the client about staying on bed rest for 6 to 8 hours after lumbar puncture. The client is monitored for headache and signs of meningeal irritation.

Answers:1, 3, 6Explanation:1. "Immunizations are recommended to provide immunity before exposure."— Even though the person asking the question is not currently sexually active, receiving the vaccine before exposure is the goal of immunizations. 3. "This vaccine is recommended for males and females at 11 -12 years of age."— The HPV vaccine is recommended at 11 -12 years of age for males and females prior to sexual activity. 6. "The human papillomavirus can cause cervical or penile cancer."— It is correct that HPV can cause cancer in multiple locations, as well as genital warts. Think like a nurse: Teaching about the causes and risks associated with the human papillomavirus is appropriate during the adolescent years. It is during this time when sexual identity is being explored and clients of this age may experience their first sexual encounter. The clients need to understand the purpose of immunization for this virus is a precautionary measure against future disease processes. The vaccine is recommended regardless of the client's sexual experience. The vaccination is recommended for both genders and should be emphasized as such. The ideal age for receiving this vaccination is prior to having sexual encounters.

The nurse evaluates a 5-day old newborn during a home visit. The neonate is being breastfed. Which assessments indicate to the nurse that breastfeeding is successful? (Select all that apply.)1. Newborn appears relaxed after feeding.2. Mother 's breast feels firm after feeding.3. Newborn breastfeeds every 4 hours.4. Newborn has 8 wet diapers in 24 hours.5. An audible swallow is heard as the newborn sucks.

Answers: 1, 4, 5Explanation:1. Newborn appears relaxed after feeding.- The newborn should appear content after feeding. 4. Newborn has 8 wet diapers in 24 hours.- The newborn should have six to eight wet diapers every 24 hours after day 4. 5. An audible swallow is heard as the newborn sucks.- Audible swallowing should be present as the newborn sucks. Think like a nurse: While assessing the infant, the nurse should reflect on the developmental level of the infant and behaviors that indicate an adequate fluid volume and satiety. An infant who is restful and relaxed after breastfeeding is receiving enough nourishment. Adequate fluid balance is determined by the number of saturated diapers per day. Developmentally, the infant who is able to swallow without difficulty when being breastfed is most likely receiving adequate nutritional intake. Swallowing is also indicative of the presence of milk; if the infant sucks without swallowing, the infant should be moved to the other breast or breastfeeding session is stopped. Engorged breasts most likely indicate that frequency of breastfeeding should be increased to every 3 hours.

1. The client's temperature is 102°F (38.4°C), pulse is 120 beats per minute, and blood pressure 88/54 mm Hg.— An increased pulse rate with thready quality, decreased blood pressure, and elevated temperature indicate that the client may be experiencing hypovolemic shock related to decreased fluid volume. This is a priority concern.Think like a nurse: The nurse recognizes that a rapid heart rate and dropping blood pressure indicates low fluid volume. The client also has a fever, which is contributing to fluid losses, as well. This client needs immediate fluid replacement and diagnostic testing to determine the cause for the elevated temperature. The nurse should anticipate that the health care provider will likely order a battery of diagnostic tests, including a complete blood count (CBC), basic metabolic panel (BMP), blood cultures, and urinalysis.

The nurse conducts a neurologic assessment on a new client in the neurology clinic. Assessment of the biceps and patellar deep tendon reflexes does not readily elicit a response. Which action is most important for the nurse to take?1. Record the reflexes as either 0 or 1+ and proceed to assess the pulses of all four extremities with a Doppler ultrasound device.2. Test again using the opposite side of the reflex (percussion) hammer and strike more firmly.3. Retest the biceps while the client clenches the teeth, and retest the patellar while the client interlaces the fingers and pulls them against each other.4. Tap the client 's face just below and in front of the ear and leave a blood pressure cuff inflated on client 's arm for 3 minutes.

3. Retest the biceps while the client clenches the teeth, and retest the patellar while the client interlaces the fingers and pulls them against each other.— These actions are known as reinforcement techniques. Isometric contraction of other body muscles can increase the generalized reflex response/activity of the body. Distraction may also be a reason for this effectiveness, as tension can inhibit a reflex being elicited. Think like a nurse: When abnormal findings occur during the physical assessment, the nurse needs to mentally explore the meaning of, and possible causes for, the abnormal response. At times, a reflex is not able to be elicited and part of the problem is the client's focus on the assessment method. In some instances, the client will react with an over-reactive response. Should this occur, a strategy called a reinforcement technique can be used. This means that another part of the body is used to distract the client from focusing on the area being tested for a reflex.

A tornado has just leveled a large housing division near the hospital, and the disaster alarm has been announced at the hospital. The nurse working on the postpartum/pediatric unit considers which client is most appropriate for discharge within the next hour?1. A postpartum client who delivered 4 hours ago and has an intact perineum.2. A postpartum client diagnosed with an infection who has been receiving antibiotics for the past 24 hours.3. A toddler with newly diagnosed type 1 diabetes mellitus, diarrhea, and vomiting.4. A 3-day-old breastfeeding neonate with a total serum bilirubin of 14 mg/dL (239 µmol/L).

4. A 3-day-old breastfeeding neonate with a total serum bilirubin of 14 mg/dL (239 µmol/L).- This is the most stable client. Phototherapy is considered for the neonate with a total serum bilirubin greater than 15 mg/dL (257 µmol/L) at 72 hours of age. The upper limit for the breastfed neonate is 15 mg/dL (257 µmol/L). Therefore, the current serum bilirubin level does not indicate the need for treatment. Think like a nurse: In response to such a disaster as a tornado, the hospital activates its emergency operations plan (EOP). Planning for coordinated care of clients into and out of the hospital is an essential component of the EOP. This involves identifying the clients which can be discharged to make beds readily available for disaster victims. A client with newly diagnosed diabetes mellitus, nausea, and vomiting requires frequent monitoring. A client with a postpartum infection receiving antibiotics for 24 hours may or may not be responding to treatment, and subsequently requires further monitoring. A postpartum client who delivered 4 hours ago is at risk for postpartum hemorrhage. A total serum bilirubin level of 14 mg/dL (239 µmol/L) in a neonate who is 3 days old and being breastfed falls within normal limits.

The nurse manager reviews the medical records for clients receiving care on the unit. Which documentation entries require the completion of an incident report? (Select all that apply.)1. "Client fell at 09:00 while getting out of bed. Client denied pain. No injuries noted. "2. "Client reports 8/10 pain after receiving pain medication. Health care provider notified. "3. "Levofloxacin 500 mg PO prescribed. Levofloxacin 750 mg PO administered."4. "Vesicant medication infusing. Client 's IV site warm to touch, reddened, and swollen. "5. "Client left facility before signing a leaving against medical advice form. "

Answers:1, 3, 4, 5Explanation:1. "Client fell at 09:00 while getting out of bed. Client denied pain. No injuries noted. "— Falls, regardless of injury, require an incident report. 3. "Levofloxacin 500 mg PO prescribed. Levofloxacin 750 mg PO administered."— Medication errors require incident reporting. 4. "Vesicant medication infusing. Client 's IV site warm to touch, reddened, and swollen. "— Intravenous infiltration requires incident reporting. Also, vesicant medications can severely damage the client 's tissues. 5. "Client left facility before signing a leaving against medical advice form. "— All medical/legal occurrences require incident reporting. Think like a nurse: Reporting incidents, including medication errors, is now typically done electronically in most facilities. These reports may be used by the legal team to defend the health care agency against lawsuits. The report is considered confidential communication and cannot be subpoenaed by clients or used as evidence in lawsuits. In writing the report, the nurse must objectively describe the incident. No entry should be made in the client 's record about the existence of an incident report. The chart should, however, provide enough information about the incident so that appropriate treatment can be given. The agency may choose to do a root cause analysis for serious incidents.

The nurse provides care for a client who had a transurethral resection of the prostate (TURP). The client has a three-way urinary catheter connected by gravity with continuous bladder irrigation (CBI) of normal saline. Which observations require the nurse to intervene? (Select all that apply.)1. Temperature of 101.4°F (38.3°C).2. Urinary output of 100 mL in 4 hours.3. Fluid leakage around the catheter tubing.4. Blood pressure of 112/76 mm Hg.5. 230 mL of sanguineous fluid in the catheter bag.6. Client reports pressure in the pelvis.

Answers:1, 2, 3, 5Explanation:1. Temperature of 101.4°F (38.3°C).— An elevated temperature may indicate an infection, which is a complication of TURP.2. Urinary output of 100 mL in 4 hours.— The client should produce at least 30 mL of urine per hour, so should have a minimum of 120 mL in 4 hours. In addition, the client will have the bladder irrigation fluid.3. Fluid leakage around the catheter tubing.— Fluid leakage from the urethra around the catheter suggests a concern with the catheter. The nurse should assess for balloon inflation and proper positioning of the catheter.5. 230 mL of sanguinous fluid in the catheter bag.— Hemorrhage is the greatest danger following TURP. While pink-tinged urine with occasional clots is expected, the client should not have sanguinous drainage, as it suggests hemorrhage. Think like a nurse: The nurse considers which findings are normal after a transurethral resection of the prostate (TURP) is performed and which findings indicate a complication. For any client, a fever over 101°F or urine output less than 30 mL per hour is a reason to notify the health care provider. Determining whether the client is bleeding will be difficult when the collection bag is full of urine, irrigation solution, and blood. The nurse is concerned when unmistakable, concentrated red blood is noted, indicating a site of hemorrhage. Decreased urine output can indicate hemorrhage, catheter blockage, or other complications.

The nurse provides care for a client diagnosed with paranoia. Two days after admission, the client refuses to give any information other than name and age. Which action is most important for the nurse to take?1. Tell the client that the hospital is a safe place.2. Urge the client to reveal more information.3. Focus on developing a trusting relationship with the client.4. Introduce the client to other clients on the unit.

3. Focus on developing a trusting relationship with the client.— When caring for a client who is resistant and paranoid, the first priority is to develop a trusting relationship with the client. Think like a nurse: The client experiencing paranoia has an issue with trust. The most important action for the nurse to take is to establish a trusting relationship with the client. Without trust, the nurse-client relationship cannot move forward. One way for the nurse to earn the client's trust is to follow through on things promised to the client. When the client realizes that the nurse will follow through when needed, the client will be inclined to share more information with the nurse. This is essential to developing a beneficial and realistic plan of care.

The nurse provides care for the client diagnosed with esophageal cancer. Which goals does the nurse establish in the plan of care? (Select all that apply.)1. Client will experience remission of the cancer.2. Client will swallow liquids without aspiration.3. Client will state an acceptable level of pain.4. Client will maintain weight within normal range.5. Client will agree to hospice consult.

Answers:2, 3, 4Explanation:2. Client will swallow liquids without aspiration.- Risk for aspiration is an appropriate nursing diagnosis for this client, and this is an appropriate goal for that diagnosis.3. Client will state an acceptable level of pain.- Pain is an appropriate nursing diagnosis for this client, and this is an appropriate goal for that diagnosis.4. Client will maintain weight within normal range.- Risk for imbalanced nutrition is an appropriate nursing diagnosis for this client, and this is an appropriate goal for that diagnosis.Think like a nurse: Esophageal cancer impacts the client's ability to swallow. A nursing diagnosis that addresses the risk for aspiration is appropriate. Additionally, the client's nutritional status will be compromised due to the problem with swallowing. A nursing diagnosis that addresses weight management is essential. Pain management is an appropriate intervention because of the diagnosis and location of the pathology.

While performing hourly rounds for a client diagnosed with sepsis, the nurse finds that the client is very lethargic, but has a pulse. Which nursing action is the priority for the client?1. Start a normal saline IV through a large bore needle.2. Establish airway patency and call for a Rapid Response Team (RRT).3. Call for a "code" and start chest compressions.4. Obtain a lactic acid level and apply 100% oxygen.

2. Establish airway patency and call for a Rapid Response Team (RRT).- The situation warrants a call for the RRT, while making sure the client's airway is patent.Think like a nurse: Finding a client lethargic with a pulse could mean that the client is not receiving adequate oxygen. The nurse needs to stop and think about the priorities of emergency care by addressing airway, breathing, and circulation (ABCs) first. The best action is to ensure that the client has an adequate airway. Once ABCs are evaluated, the nurse should consider the client's diagnosis of sepsis. The nurse needs to remember that sepsis can cause septic shock, and it is possible that the client's condition is deteriorating. The nurse realizes that the care and needs of this client is beyond the nurse's scope of practice. Additional help is needed and calling for the Rapid Response Team is an appropriate action to take.

The nurse assists in the care provided by the LPN/LVN for client who had a mastectomy. The client has a wound drainage evacuator in place. Which observation concerns the nurse?1. The LPN/LVN secures the drainage evacuator to the client's gown without applying tension on the drainage tubing.2. The LPN/LVN fully compresses the drainage evacuator with one hand, while replacing the spout plug with the other hand.3. The LPN/LVN uses an alcohol wipe to clean the drainage evacuator's spout and plug prior to reestablishing the vacuum.4. The LPN/LVN releases manual pressure on the drainage evacuator after the plug is in place, and the unit rapidly inflates.

1. The LPN/LVN secures the drainage evacuator to the client's gown without applying tension on the drainage tubing.INCORRECT - This is an appropriate action. The unit should be fastened to the client's gown. Tension should not be applied to tubing because it can cause dislodgment. 2. The LPN/LVN fully compresses the drainage evacuator with one hand, while replacing the spout plug with the other hand.INCORRECT - This is an appropriate action. After emptying the drain, the goal is to reestablish a negative pressure vacuum that creates suction. 3. The LPN/LVN uses an alcohol wipe to clean the drainage evacuator's spout and plug prior to reestablishing the vacuum.INCORRECT - This is an appropriate action to decrease the risk for infection. 4. The LPN/LVN releases manual pressure on the drainage evacuator after the plug is in place, and the unit rapidly inflates.CORRECT - Rapid reinflation indicates an air leak is present. If this occurs, the nurse should compress the unit again and check the plug for a secure fit. Think like a nurse: The drainage evacuator device should remain deflated after the plug is in place and manual pressure released. Should the device inflate, either the plug was not secure or the device has a leak. The nurse should compress the device again and re-secure the plug. The nurse should periodically assess and document the amount and characteristics of the drainage.

A postpartum client receives an intramuscular injection of butorphanol tartrate 2 mg. Which action does the nurse make a priority after administering this medication?1. Assess bowel sounds.2. Monitor fluid and electrolyte balance.3. Monitor rate and depth of respirations.4. Assess urinary output.

3. Monitor rate and depth of respirations.— Butorphanol tartrate can cause respiratory depression by decreasing the rate and depth of respirations. This is an analgesic used for moderate to severe pain. Side effects include a change in blood pressure, bradycardia, and respiratory depression.Think like a nurse: Butorphanol tartrate is a synthetically derived opioid agonist-antagonist analgesic. Butorphanol tartrate, in addition to analgesia, can produce the following central nervous system effects: cough suppression, miosis, nausea/vomiting, respiratory depression, and sedation. When providing care to a client who is prescribed any opioid analgesic, the nurse must monitor for respiratory depression as this can quickly escalate to a medical emergency (i.e., respiratory arrest) if not promptly treated. In the event of a butorphanol tartrate overdose manifested by respiratory depression, naloxone should be considered. Repeat dosing with naloxone may be required because butorphanol tartrate's duration of action usually exceeds naloxone's duration of action.

The nurse performs an initial assessment of a client in the outpatient clinic with a diagnosis of myxedema. For which symptoms does the nurse carefully assess the client?1. Tachycardia, fatigue, and intolerance to heat.2. Polyphagia, nervousness, and dry hair.3. Lethargy, weight gain, and intolerance to cold.4. Tachycardia, hypertension, and tachypnea.

3. Lethargy, weight gain, and intolerance to cold.- These are signs and symptoms of hypothyroidism (myxedema). Other assessment findings may include dry hair, a mask-like facial expression, thickened skin, an enlarged tongue, and drooling.Think like a nurse: Myxedema is a manifestation of severe hypothyroidism. Manifestations of hypothyroidism are associated with a slowing of the metabolism and include lethargy, weight gain, and intolerance to cold temperatures.

The public health nurse visits an Asian American client who receives directly-observed therapy for tuberculosis. Which nursing actions demonstrate cultural competence when providing care to this client? (Select all that apply.)1. Understanding the differences between the client 's and the nurse 's cultures.2. Ensuring that the client understands why tuberculosis treatment requires Western medicine.3. Understanding that different cultures hold different beliefs about health and disease.4. Accepting the stereotypes based on the client 's culture.5. Respecting the client 's values and beliefs.

Answers:1, 2, 3, 5Explanation:1. Understanding the differences between the client 's and the nurse 's cultures.—A culturally competent nurse understands the differences between the nurse 's own culture and the culture of the client. 2. Ensuring that the client understands why tuberculosis treatment requires Western medicine.—The nurse who demonstrates cultural competence is able to recognize that the client may have different views about Western medicine and may not understand the importance of drug therapy in treating tuberculosis or may want to utilize therapies used in their own culture. 3. Understanding that different cultures hold different beliefs about health and disease.—A culturally competent nurse understands that different cultures hold different beliefs about health and disease, including the cause of disease. 5. Respecting the client 's values and beliefs.—A culturally competent nurse should respect the individual client 's culture and beliefs. Think like a nurse: Cultural competence includes recognizing that individuals and groups differ in terms of their beliefs, perceptions, and values. Moreover, cultural competence includes understanding that within a specific cultural group, not all members necessarily think alike. Presuming an Asian American client does not understand the relevance of Western medicine in the treatment of tuberculosis may constitute stereotyping. Rather than making assumptions based on ethnicity, the nurse 's role is to tactfully explore the client 's beliefs and preferences. The nurse then advocates for incorporating the client 's preferences into the plan of care whenever it is possible to safely do so. If the nurse seeks first to understand, then to teach and care, clients are often happy to explain their perspective.

The nurse teaches the spouse of a client about changing the dressing on a central venous catheter (CVC). The spouse asks, "What is that round foam disc for?" Which response by the nurse is accurate?1. "The disc ensures that the insertion site stays clean and dry."2. "The disc has anti-microbial properties to help prevent infection."3. "The disc serves as an anchor to hold the catheter in place."4. "The disc helps to keep the line from clotting."

2. "The disc has anti-microbial properties to help prevent infection."- The disc is impregnated with an anti-microbial product intended to help prevent infections at the insertion site. Think like a nurse: The nurse is aware that a central venous catheter is inserted using a sterile procedure, and all care of this site is done using the same approach. Because the access site provides a direct line into the client's vascular system, extra effort should be taken to reduce the risk of an infection. In this scenario, the client's spouse is asking about part of the existing dressing. The nurse will explain that the central line wound care kit includes a gauze sponge impregnated with an anti-microbial substance to help prevent infection of the site and subsequent infection in the client's body. This sponge is placed over the site and changed according to the manufacturer's recommendations.

The nurse monitors a client receiving the first of two units of packed RBCs. The client reports a headache and lower back pain approximately 2 hours into transfusion of the first unit. Which intervention does the nurse perform first?1. Assess the client's vital signs and respiratory status.2. Administer acetaminophen as prescribed and monitor response.3. Stop the infusion of blood.4. Notify the health care provider.

3. Stop the infusion of blood.— The symptoms indicate a possible hemolytic reaction. Immediately stop the transfusion, as continuing it may worsen the client's reaction and even result in death. Think like a nurse: A headache and back pain are indications of a hemolytic transfusion reaction. The nurse knows that the only way to resolve this problem is to stop the transfusion immediately. After the transfusion is stopped, the client's vital signs should be assessed. The health care provider should be notified and the blood product and tubing preserved in anticipation of returning it to the blood bank for analysis.

A client newly diagnosed with emphysema is being discharged to home. Which client statement indicates to the nurse an understanding of the discharge instructions? (Select all that apply.)1. "I need to get my annual influenza vaccine."2. "I need to decrease my smoking to half a pack a day."3. "I will sit while watching my grandson's soccer games."4. "I should limit my fluid intake to 4 cups of water a day."5. "I am signing up for tai chi at my local community center."6. "I should eat three large meals each day."

Answers: 1, 3, 5Explanation:1. "I need to get my annual influenza vaccine."CORRECT — It is important to limit the risk for infection. Clients with emphysema are at high risk of infection and develop influenza-related complications, such as pneumonia, more easily. 2. "I need to decrease my smoking to half a pack a day."INCORRECT— The client needs to quit smoking completely.3. "I will sit while watching my grandson's soccer games."CORRECT — It is important for this client to conserve energy when possible. 4. "I should limit my fluid intake to 4 cups of water a day."INCORRECT — Fluid intake should be increased to liquefy secretions. Four cups of liquid per day is not adequate. This client needs to drink more than the recommended daily intake of 8 cups. 5. "I am signing up for tai chi at my local community center."— It is important to practice relaxation and stress reduction techniques. Exercise also will help this client gain control of respiratory effort. 6. "I should eat three large meals each day."INCORRECT— The client should eat small, frequent meals. This helps prevent pressure on the diaphragm, which increases the work of breathing. Think like a nurse: Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method. Clients with emphysema should be informed on which warning signs to report to their provider (e.g., peak flow meter readings in the red zone).

The nurse instructs a client with a necrotizing spider bite how to perform dressing changes at home. Which statement indicates the client understands aseptic technique? 1. "I should buy sterile gloves to redress this wound."2. "I should wash my hands before redressing my wound."3. "I should keep the wound covered at all times."4. "I should use an over-the-counter antimicrobial ointment."

2. "I should wash my hands before redressing my wound."— Washing hands before changing the dressing indicates an understanding of aseptic technique as hand washing is a hallmark strategy. Think like a nurse: Aseptic technique is another term for clean technique. Preparation for changing this type of dressing is to perform hand hygiene to remove microorganisms from the surface of the hands. Sterile gloves are not used when performing a dressing change using aseptic technique. The wound does not need to be covered at all times. The client should use the prescribed medications on the wound.

The nurse provides care for a client at 28 weeks' gestation. The nurse counsels the client about how to prepare her 2-year-old child for the new baby. Which statement made by the client indicates that further teaching is necessary?1. "I am going to wait another month to tell my child about the new baby."2. "I have given my child a baby doll, bottles, and diapers."3. "I am talking to my child about being a big sibling."4. "We are already getting my child used to sleeping in a bed rather than the crib."

3. "I am talking to my child about being a big sibling."— This is not age-appropriate. A toddler is too young to understand and focus on the big sister/big brother concept. Explaining this concept would be more appropriate for preschoolers.Think like a nurse: It is important to prepare children for the arrival of a new family member during a pregnancy. This information should be presented to the child using age-appropriate explanation. The toddler is not developmentally prepared to understand the concept of sibling order or time. Therefore, it is best to prepare the toddler for the arrival of the new baby in other ways, such as waiting until closer to the time of delivery to explain the arrival of the new member to the family.

The nurse teaches a new parent about childhood immunizations for a 2-month-old client. Which immunizations does the nurse include in this teaching? (Select all that apply.)1. Rotavirus.2. Diphtheria, tetanus, pertussis.3. Varicella.4. Haemophilus influenzae type b.5. Inactivated poliovirus.6. Measles, mumps, rubella.

Answers:1, 2, 4, 5Explanation:1. Rotavirus.CORRECT - Rotavirus vaccine (RV) is due at 2 months. 2. Diphtheria, tetanus, pertussis.CORRECT - Diphtheria, tetanus, pertussis (DTaP) vaccine are due at 2 months. 3. Varicella.INCORRECT - The varicella vaccine is due at 12 to 15 months and 4 to 6 years. 4. Haemophilus influenzae type b.CORRECT -Haemophilus influenzae type b (Hib) is due at 2 months. 5. Inactivated poliovirus.CORRECT- The inactivated poliovirus (IPV) vaccine is due at 2 months. 6. Measles, mumps, rubella.INCORRECT - Measles, mumps, and rubella (MMR) vaccine is administered at 12 to 15 months and 4 to 6 years. Think like a nurse: The Centers for Disease Control and Prevention (CDC) publishes a table that identifies when specific vaccinations should be received. A 2-month-old child should receive immunization against rotavirus, diphtheria, tetanus, and pertussis, Haemophilus influenzae , and poliovirus. Immunization against varicella and measles, mumps, and rubella are provided when the child is between 12 to 15 months of age, and then repeated when the child is 4 to 6 years of age.

The nurse provides care to a client diagnosed with a hearing impairment. Which approach will the nurse use to facilitate communication with the client?1. Use a normal tone.2. Speak directly into the impaired ear.3. Talk louder.4. Talk faster.

1. Use a normal tone.— Using a normal voice tone is important, as is talking directly to the client while facing the client and speaking clearlyThink like a nurse: Clients with hearing impairments often will not tell the nurse, feeling that it is embarrassing or unimportant. If an individual's response to verbal communication is not appropriate, hearing assessment may be indicated. Hearing impairment, not deafness, usually occurs over a prolonged period and the client gradually adjusts to accommodate those around them. Clients who experience gradual hearing loss learn to read lips, so speaking in normal tones while directly facing the client is very useful.

The nurse notes that a health care provider prescribed D5W 100 mL with 80 mEq KCl to infuse in 30 minutes. Which action does the nurse take first?1. Assess the client's urinary output.2. Ensure the patency of the client's IV.3. Request a prescription for IV lidocaine.4. Contact the health care provider.

4. Contact the health care provider.- The rate of IV administration should be no faster than 10 mEq/hr (20 mEq to 30 mEq per hour in highly specialized settings and only through a central venous line). The nurse first contacts the health care provider to clarify this prescribed dose. Think like a nurse: The client is prescribed a large dose of potassium chloride that should be administered at a rate so as not to cause cardiac irritation. This amount of potassium should also be infused through a central line. Because the type of intravenous access is not known and the dose is extremely large, the health care provider should be contacted for clarification of the prescription. The client has a low potassium level and is most likely not experiencing a decline in renal function. Potassium is irritating to the veins. Because of the dose, a central line may be used. If so, lidocaine would not be needed.

A community experiences a prolonged heat wave. The emergency department has several clients admitted from a construction project. Which indications will alert the nurse to the diagnosis for heat stroke?1. Elevated temperature, diaphoresis, nystagmus.2. Hypotension, tachypnea, tachycardia.3. Hemiplegia, diplopia, dysarthria.4. Headache, hot dry skin, hypertension.

2. Hypotension, tachypnea, tachycardia.— A client will have a temperature of 105°F (40.6°C) or above with skin that is hot and dry. A client's behavior may be bizarre, with confusion or delirium, or the client may be comatose.Think like a nurse: Heat stroke occurs when the body is not able to dispel accumulated body heat from exposure to high temperatures or warm environments. Manifestations of heat stroke include a drop in blood pressure, rapid heart rate, and rapid respirations.

The nurse provides care to a client receiving topiramate. For which client statement will the nurse intervene?1. "I drink at least 10 glasses of water each day."2. "I change positions slowly."3. "I should contact my health care provider if I have blurred vision."4. "I use oral contraceptives."

4. "I use oral contraceptives."- Non-hormonal contraceptives should be used when taking topiramate. Think like a nurse: Topiramate, an enzyme-inducing anti-epileptic medication, can affect pharmacokinetics of oral contraceptives, leading to contraceptive failure. Generally, the efficacy of combined oral contraceptives is diminished in clients taking enzyme-inducing anti-epileptic drugs, such as, phenytoin, phenobarbital, and carbamazepine. The client and partner should be informed about using other methods of birth control, such as a condom, when taking these medications.

The nurse notes that four clients arrive for emergency care at the same time. In which order will the nurse assess the clients? (Please arrange in order. All options must be used.) - Client diagnosed with an open fracture and chest contusions from a motor vehicle crash.- Client diagnosed with COPD experiencing shortness of breath and an oxygen saturation of 88 percent - Client diagnosed with diaphoresis and feeling chest pressure.- Client diagnosed with dyspnea and swollen lips after being stung by a bee.

- Client diagnosed with dyspnea and swollen lips after being stung by a bee.- Client diagnosed with diaphoresis and feeling chest pressure.- Client diagnosed with an open fracture and chest contusions from a motor vehicle crash.- Client diagnosed with COPD experiencing shortness of breath and an oxygen saturation of 88 percent Think like a nurse: If approaching the triage of these clients with the ABCs (airway, breathing, and circulation), the client with a condition affecting the airway should be addressed first. The client with dyspnea after a bee sting is at risk for an occluded airway as a result of an anaphylactic reaction to the bee sting. The client with chest pressure should be addressed next, because of the potential for a myocardial infarction. The client with an open limb and chest contusion is at risk for bleeding and compromised oxygenation. The client diagnosed with a chronic pulmonary disease who has a low oxygen saturation level takes lowest priority, because of the chronicity of the health problem.

2. Thoughts about vision loss.— Because the loss of vision is permanent, it is important for the nurse to allow the client to verbalize thoughts and fears about the future and to assist the client to maximize remaining vision. This information is most important for the nurse to assess.Think like a nurse: Age-related macular degeneration (ARMD) is the leading cause of irreversible vision loss in the industrialized world, and its onset can be acute or insidious. Though peripheral visual acuity usually remains intact, clients with ARMD typically report painless, progressive blurring or central visual acuity distortion. The nurse should assess the client's level of understanding about ARMD and the potential risk for permanent vision loss. The nurse can help explain and clarify the client's understanding of the treatment plan for ARMD. The nurse should keep in mind that clients with ARMD have been shown to have an increased risk for depression and frequent falls. The nurse should screen affected clients for depression and institute fall-prevention strategies.

When administering preoperative medication to a client, the nurse notices small insects crawling out of the closet where the client placed the suitcase. The client refuses to allow the nurse to inspect the suitcase. Which action by the nurse is best?1. Notify security.2. Kill the insects.3. Inspect the client's suitcase.4. Double-bag the client's suitcase.

4. Double-bag the client's suitcase.- This is the priority action in order to limit the area of contamination. Think like a nurse: The nurse should think quickly, "What action can I take that respects the client's rights and also protects the area from the small insects?" Sealing the suitcase in two plastic bags, using a double-bagging technique, contains the insects within the plastic bags preventing infestation of the surrounding area. Moreover, it protects the client's rights by complying with the client's wishes to not search the suitcase. Double-bagging the suitcase will eventually kill the insects. The nurse should notify the infection control department of the infestation, so they can gather additional information about the insects, and if needed, report the incident to the local department of health.

A client who uses a triphasic birth control pill calls the clinic with reports of dull pain in the left lower extremity. The pain started after a routine 4-mile run and has continued. Which action does the nurse take first?1. Instruct the client to elevate the leg for six hours.2. Ask the client to apply a heat pack to the left leg.3. Recommend the client take an anti- inflammatory medication.4. Request that the client come to the clinic immediately.

4. Request that the client come to the clinic immediately. — Deep vein thrombosis (DVT) is an adverse effect of birth control pills. This client has symptoms of thrombosis and must be evaluated urgently. This action must be taken first to ensure proper diagnosis. Think like a nurse: Triphasic birth control pills have constant or changing estrogen concentrations and varying progestin concentrations throughout the cycle. The nurse should inform the client about the dangerous side effects of birth control pills using the mnemonic ACHES; A - abdominal pain (severe); C - chest pain; H - headaches (severe); E - eye disorders; and S - severe leg pain or lower leg swelling. Signs and symptoms of deep vein thrombosis (DVT) require prompt evaluation and treatment.

The nurse teaches a community education program about cancer prevention for both men and women. Which strategy is most important for the nurse to include in the teaching?1. Regular examination of reproductive organs.2. Smoking cessation.3. Routine colonoscopies.4. Protection from ultraviolet light.

2. Smoking cessation.— Lung cancer is the leading cause of cancer deaths in the United States for men and women. Stopping the use of tobacco is one of the most important cancer prevention behaviors.Think like a nurse: One of the most effective strategies available to nurses to support health promotion and disease prevention is to provide health teaching. Oftentimes this teaching is provided when the client is experiencing a health problem and prevention is no longer an option. However, ideally, teaching is received when the client is experiencing optimum health and offers strategies to maintain the current health level. One of the most effective recommendations to make to a client to maximize health is to avoid smoking and the use of other tobacco products. The use or exposure to tobacco products has been directly linked to many health conditions, which can be avoided if the client does not use the substance.

A nursing team discusses the new nurse manager's leadership style. The unlicensed assistive personnel (UAP) states, "The new nurse manager does not give us any direction or supervision." Which is an accurate response by the nurse?1. "The nurse manager has an autocratic leadership style. It is best to not challenge the nursing chain of command."2. "The nurse manager has a democratic leadership style. We will vote on all decisions in staff meetings."3. "The nurse manager has a situational leadership style. Direction will be provided during a crisis."4. "The nurse manager has a laissez-faire leadership style. Are there specific issues that you have questions about?"

4. "The nurse manager has a laissez-faire leadership style. Are there specific issues that you have questions about?"- This nurse manager is exhibiting a laissez-faire leadership style, which is one in which little direction is provided to the group. Many people feel confused and frustrated under this style of leadership. The nurse is responsible for supervising the UAP and should respond to any concerns that the UAP expresses. The nurse is acknowledging the situation and uses an open-ended question to elicit further concerns. Think like a nurse: The laissez-faire leadership style is characterized by behaviors such as permissiveness, provision of little or no direction, upward and downward communication between members, dispersed decision-making, and lack of criticism. The nurse should keep in mind that the leadership style has a great deal of influence on the climate and outcomes achieved by the nursing unit.

The nurse prepares an adolescent for a pelvic exam because the client is experiencing sharp bilateral pelvic pain. Which is the priority action by the nurse?1. Instruct the client to remove all clothing.2. Collect a urine and fecal specimen.3. Give a brief explanation of the procedure.4. Perform teaching about sexually transmitted infections.

3. Give a brief explanation of the procedure.- The nurse should prioritize preparing the client for the procedure by providing an explanation of what to expect. Think like a nurse: Since it is unlikely that the adolescent client has had a previous pelvic examination, the priority for the nurse would be to explain the procedure to the client. This will help reduce the client's anxiety and add support applicable to the client's developmental level. The nurse should also encourage the client to ask questions before and after the procedure. The nurse will advocate for the client's right to privacy, and only allow other persons in the examination room if the client gives permission.

The nurse is teaching a group of clients about vasectomies and tubal ligations. Which information does the nurse include in the teaching?1. A tubal ligation is medically less complicated than a vasectomy.2. Menstruation ceases after a tubal ligation.3. Birth control measures are required after a vasectomyuntil the client has a negative sperm count.4. A vasectomy is performed as a laparoscopic surgery.

3. Birth control measures are required after a vasectomyuntil the client has a negative sperm count.- It may take approximately 3 months for the client to achieve a negative sperm count in seminal fluid analysis after a vasectomy. Alternative methods of birth control should be used during this period.Think like a nurse: Sterilization is a personal decision, and both vasectomy and tubal ligation are generally considered irreversible pregnancy prevention options. Vasectomy is accomplished via a 30-minute procedure in the health care provider's office, complications are low, and it is 99% effective after about 3 months. Vasectomy reversal is not guaranteed and is costly and complex. Tubal ligation, which is performed at a surgery center, requires anesthesia (general, spinal, or local) and also takes around 30 minutes to complete. Compared to vasectomy, tubal ligation has a higher risk of complications and is about 99% effective. Reversal of tubal ligation requires surgery.

The nurse reviews a client's medication administration record. Which prescriptions are correctly questioned by the nurse? (Select all that apply.)Medication AdministrationJane Doe, 7/22/1964, MRN J000376584 Allergies: meperidine, hydrocodone and ibuprofen, pantoprazole, iodine, latex, nifedipine, levofloxacin, glipizide, sulfamethoxazole and trimethoprim1. The frequency of acetaminophen administration.2. The administration of pantoprazole.3. The dosage of lisinopril.4. The administration of azithromycin.5. The route of rivaroxaban.6. The administration of trimethoprim- sulfamethoxazole.

Answers:2, 6Explanation:2. The administration of pantoprazole.— The nurse should question administration of pantoprazole as the client has a documented allergy to this medication. 6. The administration of trimethoprim- sulfamethoxazole— The nurse should question administration of trimethoprim-sulfamethoxazole as the client has documented allergy to this medication. Think like a nurse: When evaluating a client's medication administration record, the nurse is responsible for identifying contraindicated medications, including medications that are inappropriate due to allergies, health alterations, or potential medication interactions. The nurse also evaluates medication appropriateness in terms of dosage, frequency of administration, and route of administration. Nurses are held to a high legal standard regarding medication administration. Along with identifying contraindicated medications and evaluating medication appropriateness, the nurse also must verify the Rights of Medication Administration.

The nurse provides care to a client diagnosed with asthma. The client's plan of care includes respiratory treatments administered via nebulizer. The nurse recognizes which condition as a potential complication of prolonged respiratory treatments, such as nebulizer use?1. Hypovolemia.2. Metabolic acidosis.3. Hypervolemia.4. Metabolic alkalosis.

3. Hypervolemia.- When the use of respiratory treatments is prolonged, hypervolemia can result from the inhalation and absorption of excessive amounts of water vapor through the lung tissue.Think like a nurse: The nurse is aware the use of a nebulizer to administer medications in the treatment of asthma is a common delivery approach. The nebulizer is a device that delivers the medication through a mist, which is inhaled to directly affect constricted lung tissue. The inhaled mist deposits extra fluid in the client's respiratory system that is absorbed into the general circulation. In this scenario, the device is used on an extended basis, which puts the client at risk for an increased amount of total body fluid. The nurse should assess the client for symptoms of fluid volume overload to include pitting edema, bounding pulses, rapid heart rate, dyspnea, and elevated blood pressure.

The nurse is assessing a client who is at 10 weeks' gestation. Which assessment finding does the nurse expect to see?1. Striae and linea nigra on the abdomen.2. Chloasma over the facial cheeks.3. The client reports leg cramping at night.4. Enlargement of the client's breasts.

4. Enlargement of the client's breasts.- Hypertrophy of mammary glandular tissue and increased vascularization, pigmentation, and size and prominence of nipples and areolae are caused by hormonal stimulation and begin early in the first trimester.Think like a nurse: Each stage of pregnancy is associated with predictable physiological and psychological changes. The nurse offers anticipatory guidance on these matters to reassure the client, to explain the anticipated changes, to differentiate expected changes from issues that need to be brought to the health care provider's attention, and to offer useful and evidence-based strategies for relief. For example, douching is avoided in pregnancy and is not used in response to increased vaginal discharge. Anemia can often be offset by increasing iron-rich foods, but the client should alert the health care provider about unreasonable fatigue and dizziness. Nocturnal leg cramps can be eased with positioning, dietary changes, and applying warm packs to the legs.

The triage nurse prioritizes clients for evaluation. Which client does the nurse determine needs to be seen first?1. A woman at 6 weeks' gestation and who reports left lower quadrant abdominal pain and vaginal spotting.2. A toddler whose parents report nausea and vomiting for 2 hours and a fever of 102.8°F (39.3°C).3. A client who is diagnosed with renal disease and who missed dialysis the day before and reports dependent edema.4. A school-age client with a forehead laceration from a fall and who is smiling and playful.

1. A woman at 6 weeks' gestation and who reports left lower quadrant abdominal pain and vaginal spotting.- The symptoms are indicative of an ectopic pregnancy, which may result in death if allowed to progress.Think like a nurse: The nurse should begin by determining the level of distress each client is experiencing. Most importantly, the nurse must determine which client is least stable and at greatest risk. The client who is early in a pregnancy experiencing acute left lower quadrant abdominal pain and vaginal spotting may be experiencing an ectopic pregnancy. This can be life-threatening and must be addressed first. In this type of pregnancy the embryo is implanted in a fallopian tube instead of the uterus. The growth of the embryo is restricted by the fallopian tube, which can rupture. This causes pain and possible bleeding within the lower abdominal region.

The nurse in the newborn nursery receives report on a group of clients. Which client does the nurse assess first?1. A 2-day-old client, quietly alert, heart rate of 185 beats per minute.2. A 1-day-old client, crying, and the anterior fontanel is bulging.3. A 12-hour-old client, respirations 45 and irregular.4. A 5-hour-old client, hands and feet are blue bilaterally.

1. A 2-day-old client, quietly alert, heart rate of 185 beats per minute.— This newborn has tachycardia. The normal resting rate is 120 to 160 beats per minute, and this finding requires further investigation.Think like a nurse: Supraventricular tachycardia (SVT) is the most common arrhythmia diagnosed in pediatric clients. The newborn exhibiting tachycardia, especially at rest, requires further examination and should be seen by the nurse first. The nurse first compares the current readings with the baseline. Any abnormalities in vital signs during the neonatal period, especially with heart rate and respiration, may be indicative of infection. When assessing the newborn client, both the heart rate and respiratory rate should be counted for a full 60 seconds. The nurse should keep in mind that bradycardia in pediatric clients is an ominous sign, usually a result of hypoxia, requiring prompt intervention.

The nurse is feeding a resident in the dining room of a long-term care facility. Suddenly, the resident starts to choke and becomes cyanotic. Which is the best action for the nurse to take?1. Stand behind the resident and deliver a quick blow to the middle of the back with the palm of the hand.2. Embrace the resident from behind and, with a fist, quickly thrust upward into the abdomen.3. Check the resident 's mouth and throat for food, and perform a finger sweep.4. Lay the resident on the floor and prepare to initiate cardiopulmonary resuscitation.

2. Embrace the resident from behind and, with a fist, quickly thrust upward into the abdomen.- This describes the Heimlich maneuver, which expels the remaining air in victim 's lungs, along with the foreign body. Think like a nurse: A client who is visibly choking with cyanosis needs immediate intervention from the nurse. After determining that the client is unable to speak and is unable to take a deep breath, the nurse performs the Heimlich maneuver. This is done by standing behind the client, placing a fist slightly above the client's navel. Then the other hand is placed over the fist and thrusts are delivered inward and upward to dislodge the item from the trachea. This is performed until the object is dispelled or the client become unconscious.

The nurse screens an 8-month-old client in a pediatric clinic. Which statement from the parent concerns the nurse?1. "Today's weight is almost doubled from birth."2. "When I walk in the room, my child smiles at me."3. "My child cries around my parents."4. "I haven't heard my child say 'mama' yet."

1. "Today's weight is almost doubled from birth."— Weight should double by 6, not 8, months of age.Think like a nurse: A diagnosis of failure to thrive (FTT) is made when a child's weight or rate of weight gain is significantly below that of other children who are of similar age and sex. If an infant or child experiences FTT, the nurse will note that head circumference, height, and weight do not match standard growth charts, and weight falls lower than the third percentile (as outlined in standard growth charts) or 20% below the child's ideal weight for height. Also, the nurse may observe that growth has slowed or stopped after a previously established growth curve. Physical skills, such as rolling over, sitting, standing, and walking, are delayed or slow to develop in an infant with FTT.

A female adolescent client learns about having had intercourse 3 weeks ago with a person who has syphilis. Which manifestation does the nurse expect to see if the client has contracted syphilis?1. A papule-like lesion in the vaginal area.2. An abnormal Pap smear.3. A non-reactive blood serology test.4. A cluster of painful blisters on the genital area.

1. A papule-like lesion in the vaginal area.— In primary syphilis a chancre develops within 2 to 6 weeks. It appears at the point of entry and starts as small papule that develops into a painless ulcer. Think like a nurse: The nurse understands it is not unusual for an adolescent to engage in sexual experimentation; however, there is a risk of contracting a sexually transmitted infection (STI). Since the client learned of exposure to such an illness, the nurse needs to consider the characteristic signs of the infection. For syphilis, the nurse should assess the genital region for the presence of a chancre sore. The signs for other STIs will depend upon the infecting organism. It is important for the nurse to interact with the client therapeutically and to present a non-judgmental attitude with the client. The scenario presents an excellent opportunity for the nurse to provide education.

ANSWERS:1, 2, 4, 5Explanation:1. "An infant 's stool will vary depending on how the infant is fed."- The formula-fed infant excretes pale yellow to light brown stools. They are firmer in consistency than those of the breastfed infant. The stools of infants fed with breastmilk are seedy, and the color and consistency of mustard with a sweet-sour smell. 2. "Bowel control is usually achieved before bladder control."- Bowel control is usually achieved before bladder control. 4. "Constipation in the older adult can be related to decreased gastrointestinal motility."- Older adults may experience slowed peristalsis related to the loss of muscle elasticity, reduced intestinal mucous secretion, or a low-fiber diet. 5. "Fecal impaction may be associated with oozing of liquid feces."- The cardinal sign of impaction is continuous oozing of liquid stool, with no normal stool. Oozing occurs as the liquid portion of feces higher in the intestines seeps around the mass. Think like a nurse: Comprehensive bowel assessment requires an understanding of normal gastrointestinal (GI) functions in various developmental stages. During the interview of clients with diarrhea or constipation, the nurse should inquire about its onset, duration, and character, as well as associated symptoms and alleviating factors. The nurse can inquire about the client 's usual bowel patterns, routines followed to promote bowel elimination, diet and fluid intake history, medication use, and medical-surgical conditions affecting the GI function.

The school nurse assesses four school-age clients. Which client's parents will be contacted to pick up the child from school?1. Child with a red rash on the cheeks that makes the face look like it has been slapped.2. Child with a fever reporting headache, malaise, anorexia, and an earache when chewing.3. Child with allergies whose conjunctiva are inflamed with swollen eyelids and watery drainage.4. Child with clusters of small, erythematous, intensely pruritic papules in the antecubital space.

2. Child with a fever reporting headache, malaise, anorexia, and an earache when chewing.- The child with a fever, headache malaise, anorexia, and ear pain with chewing indicates probable mumps. The child is most communicable immediately before and after the swelling begins. Think like a nurse: The child with the communicable disease needs to go home. Symptoms of mumps include fever, headache, malaise, anorexia, and ear pain. The period of time when the disease is most communicable is before and immediately after the swelling begins. The other children with infections are not contagious.

The nurse assesses a 1-month old infant. Which finding will the nurse investigate further?1. Anterior fontanel taut when the infant cries.2. Head lag present when the infant is pulled from a lying to a sitting position.3. Top of the infant's right knee is 1 inch higher than the left knee.4. Left arm and leg extend when the head is turned to the left.

3. Top of the infant's right knee is 1 inch higher than the left knee.— Unequal knee height suggests developmental dysplasia of the hip. Other symptoms include asymmetry of the gluteal and thigh folds.Think like a nurse: Especially when assessing an infant client, asymmetrical findings are a cause for concern. Vertebrae should be in straight alignment, the arms should demonstrate equal length and range of motion, and the legs should be equal in length. Gluteal and thigh folds should be symmetrical, as well. Asymmetry of gluteal and thigh folds is a sign of hip dysplasia, which may be unilateral or bilateral. For the client diagnosed with unilateral hip dysplasia, assessment findings may include a hip click in addition to unequal limb length and unequal knee height.

The nurse reviews the prenatal records of pregnant clients. Which maternal factor, associated with the potential for fetal macrosomia, is appropriate for the nurse to identify? (Select all that apply.)1. Gestational diabetes.2. Maternal tobacco use during pregnancy.3. Pregnancy-induced hypertension (PIH).4. Intrauterine infection.5. Maternal obesity.

ANSWERS: 1, 5Explanation:1. Gestational diabetes.— Gestational diabetes can result in macrosomia.5. Maternal obesity.— Maternal obesity is a risk factor for macrosomia.Think like a nurse: Fetal macrosomia describes a newborn who is significantly larger than average. Regardless of gestational age, babies diagnosed with fetal macrosomia have birth weights of more than 8 pounds, 13 ounces (4000 grams). During prenatal care, the nurse screens the client for risks of macrosomia, such as diabetes mellitus, obesity, excessive weight gain during pregnancy, and previous pregnancy. The mother is informed about possible complications, labor difficulties, postpartum hemorrhage, genital tract laceration, and uterine rupture. The teach-back method is used in all client education encounters.

The nurse instructs a client on self-instillation of gentamicin sulfate eye drops. Which client statement indicates to the nurse that further teaching is required?1. "I should apply light pressure with my finger at the inner corner of my eye for one minute after instilling the drops. "2. "I should gently clean away any crusts around my eye before I put in more drops. "3. "I should place the tip of the eye dropper against my lower eyelid to steady my hand, and then squeeze the bottle. "4. "I should call my health care provider if my eyelids start to itch or swell. "

3. "I should place the tip of the eye dropper against my lower eyelid to steady my hand, and then squeeze the bottle."— The client should be instructed to never touch the eye with the medication dropper. This will contaminate the medication.Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client 's understanding. Proper eye drop and eye ointment administration requires the medication (in this case gentamicin) to have good contact with the absorptive surface of the inner eyelid. To avoid contamination, the medication container should not contact any surface of the eye. Self-administering eye medication can be difficult, because it goes against natural instincts to avoid touching the eye and to rub the eye when something foreign enters it. The client requires teaching and then should be encouraged to provide a return demonstration of the procedure to evaluate the effectiveness of that teaching.

The nurse placed a client on therapeutic hypothermia 1 hour ago. Which action does the nurse take to determine whether the client is having an adverse reaction to therapeutic hypothermia?1. Install a working suction setup.2. Monitor the client for seizure activity.3. Measure the Braden Scale score.4. Assess bowel sounds every 2 hours.

2. Monitor the client for seizure activity.— The client is monitored for seizure activity, which is an adverse reaction to hypothermia.Think like a nurse: The nurse has a responsibility to understand the purpose, expectations, and unexpected responses to prescribed treatment. Therapeutic hypothermia is prescribed for serious conditions, such as after cardiac arrest. The nurse needs to be aware seizures are common in comatose clients receiving the prescribed therapy. The nurse might anticipate routine use of electroencephalogram (EEG) monitoring to assist in early detection of seizures in this client, providing an opportunity for intervention to potentially improve outcomes. The nurse should also remember that hypothermia, or a temperature less than 95.9°F (35.5°C), causes peripheral vasoconstriction, and a shift of the oxygen-hemoglobin dissociation curve to the left. A shift to the left indicates that less oxygen is released from hemoglobin to the tissues, causing tissue hypoxemia.

The nurse provides care to a client admitted with mild hyponatremia secondary to excessive water consumption. Which intervention does the nurse anticipate including in the client's plan of care?1. Administering 0.45% sodium chloride IV.2. Restricting fluid intake.3. Administering 3% sodium chloride IV.4. Encouraging frequent ambulation.

2. Restricting fluid intake.- For treatment of hyponatremia secondary to hypervolemia, restriction of fluid intake is an appropriate intervention.Think like a nurse: The nurse is aware there are a variety of reasons for a client to develop hyponatremia. However, in this scenario the client is diagnosed with the disorder being caused by excess free water consumption. The nurse needs to consider application of the principles of physiology. When the water is metabolized, it takes body sodium with it. (Remember: where sodium is, water will follow.) To reverse the process and re-balance the sodium level, a fluid restriction will be prescribed. The nurse is aware that when possible the cause of any imbalance is best addressed when identified. In this scenario, the nurse should anticipate fluid restrictions.

A female client reports that she discovered a lump in her breast about 4 months ago, and the lump seems to be getting larger. Which action is most important for the nurse to take?1. Notify the health care provider to schedule a mammogram.2. Ask the client if she is taking oral contraceptives.3. Ask the client the date of her last period.4. Instruct the client to discontinue any hormones.

1. Notify the health care provider to schedule a mammogram.— A mammogram is an x-ray of the breast, which screens for breast cancer. It is the first step to determine whether the lump is malignant or benign. This is the priority action. Think like a nurse: Sometimes the nurse needs to ask, "What nursing intervention will address the client's needs best?" Nurses are encouraged to use the nursing process when providing care. However, there are times when the nurse recognizes that any application of the nursing process will not change the client's condition. This client has a breast mass or lump, which needs further examination. The client should first be scheduled for a mammogram. Depending upon the results, the client may need a breast biopsy.

The nurse provides care for a client with a peptic ulcer. Which initial assessment finding indicates to the nurse that the client has a perforated ulcer?1. Nausea and vomiting.2. Bradycardia.3. Rigid, boardlike abdomen.4. Swelling in the legs.

3. Rigid, boardlike abdomen.- A rigid, boardlike abdomen is the typical sign of the surgical emergency that occurs when a gastric ulcer perforates. Sharp, sudden, intolerable pain begins and spreads over the abdomen.Think like a nurse. When assessing the client in this scenario, the nurse will apply knowledge of the physiology of the gastrointestinal tract. The stomach is the organ where food begins the digestive process. At times, an excess amount of hydrochloric acid in the stomach injures the tissue wall. If left untreated, the injury enlarges, erodes through the tissue, and can progress to a perforation. The body's immediate response to tissue injury is bleeding, swelling, and pain. Bleeding will be present within the stomach, but also throughout the abdominal cavity. Bleeding into this area will cause the abdominal tissues, organs, and muscles to cramp. The abdomen becomes hard and extremely painful.

The nurse assesses a client who gave birth to a baby 10 hours ago. Which findings are expected for this client? (Select all that apply.)1. Elevated white blood cells (WBC) level.2. Pulse oximetry reading of 96%.3. Elevated neutrophils.4. Temperature of 100.4°F (38°C).5. Pulse rate of 102 beats/min.

ANSWERS: 1, 2, 3, 4EXPLANATIONS: 1. Elevated white blood cells (WBC) level.- During the first 10 to 12 days after childbirth, values between 20,000/mm 3 (20×10 9/L) and 25,000/mm 3 (25×10 9/L) are common.2. Pulse oximetry reading of 96%.- CORRECT- Pulse oximetry level should be within normal limits at this time3. Elevated neutrophils.- CORRECT - Neutrophils are the most numerous white blood cells postpartum.4. Temperature of 100.4°F (38°C).- CORRECT - During the first 24 hours, temperature can increase to 100.4°F (38°C) as a result of dehydrating effects of labor.Think like a nurse. Postpartum assessment of the client typically includes vital signs, pain level, epidural site inspection for infection, and a systematic head-to-toe review of systems. The acronym BUBBLE-EE (breasts, uterus, bowel, bladder, lochia, episiotomy/perineum, extremities, and emotions) can be a useful mnemonic. The nurse anticipates assisting the client with bowel and bladder elimination; promoting a balance of activity, rest, and exercise; assisting with self-care measures; educating about sexuality and contraception; promoting maternal nutrition; and supporting the client's choice of infant feeding method.

The nurse provides care for a client diagnosed with myasthenia gravis. When completing a physical assessment, which clinical manifestations does the nurse expect to see? (Select all that apply.)1. Rigidity.2. Muscle weakness.3. Facial paralysis.4. Propulsive gait.5. Ptosis.6. Diplopia.

2. Muscle weakness.- Muscle weakness is a clinical manifestation associated with myasthenia gravis. The nurse expects this clinical manifestation upon assessment. 5. Ptosis.- Ptosis, or drooping eyelids, is a clinical manifestation associated with myasthenia gravis. The nurse expects this clinical manifestation upon assessment.6. Diplopia.- Diplopia, or double vision, is a clinical manifestation associated with myasthenia gravis. The nurse expects this clinical manifestation upon assessment. Think like a nurse. Myasthenia gravis causes muscle weakness and fatigue because of a change in response to the neurotransmitter that controls muscle movement and function. Manifestations of this disorder include muscle weakness, eye ptosis, and diplopia. The eyes are affected first because of the size of the muscles.

The nurse makes rounds on clients on the medical-surgical unit. It is important for the nurse to intervene for which observation?1. A client 10 hours post-tonsillectomy sits in a bedside recliner watching television.2. A client admitted 4 hours ago with a closed head injury lies flat in bed with legs elevated.3. A client 3 days post-below knee amputation (BKA) lies prone in bed.4. A client admitted yesterday with COPD sits with the head of the bed elevated 45 degrees.

2. A client admitted 4 hours ago with a closed head injury lies flat in bed with legs elevated.- Clients with closed head injuries are prone to increased intracranial pressure. A modified Trendelenburg is dangerous for the client. Elevate head of bed 30 to 45 degrees to promote venous drainage.Think like a nurse. Proper client positioning in consideration of illnesses or procedures is an essential and frequent nursing function. For the client with the potential for increased intracranial pressure, reducing pressure from venous return and arterial blood pressure is partially accomplished by positioning the client with the head and upper body raised into the semi-Fowler position, which promotes blood drainage. Standard Fowler may be considered, but high-Fowler position is avoided unless autonomic dysreflexia is suspected.

The nurse provides information about acute grief reaction to volunteers of a mobile disaster unit. Which statement made by a volunteer indicates to the nurse the need to provide further teaching?1. "We can expect people to react in different ways based on their cultural background."2. "If we come upon a lone survivor, we should stay with the person until help arrives."3. "We can expect that someone might accuse us of causing the death."4. "We should not allow a survivor to assist us in our duties."

4. "We should not allow a survivor to assist us in our duties." - If a survivor is able to assist, the activity can help relieve the acute discomfort caused by the grief reaction. Think like a nurse. Survivors of a traumatic event may want to help other victims as a way to alleviate the grief of the disaster. This should be supported as long as the survivor is well enough to participate.

The nurse assesses a client who had a thyroidectomy eight hours ago. The nurse notes that the client has a weak voice and hoarseness. Which is the best action from the nurse? 1. Tell the client this is likely due to edema. 2. Administer intravenous calcium gluconate.3. Notify the health care provider immediately.4. Monitor the client for esophageal bleeding.

1. Tell the client this is likely due to edema. - Initial hoarseness after a thryoidectomy often occurs as a result of edema or use of an endotracheal tube during surgery and will subside. Persistent hoarseness may be indicative of a laryngeal nerve injury. Think like a nurse. The nurse is aware the client having a thyroidectomy will have an incision across the front of the throat in order to have the gland removed. The position of the body during the surgery and the use of a breathing tube can cause the throat to be irritated. The nurse needs to reassure the client recovering from a thyroidectomy that throat soreness is expected and a temporary manifestation. The nurse understands the importance of closely monitoring the client for actual complications, which include bleeding, thyroid storm, and hypocalcemia. During surgery, the parathyroid glands can accidentally be damaged (resulting in hypocalcemia), and after surgery, a thyroid storm can occur if remnants of thyroid tissue are left behind.

The nurse prepares to administer the polio vaccine by intramuscular injection to a child. The parent says "I am afraid my child will get polio from the vaccine." Which response by the nurse is best?1. "The vaccine cannot cause polio because it contains killed virus particles."2. "The vaccine contains weakened toxins that produce an immune response, not polio."3. "Do not worry, your child will not get polio from the vaccine."4. "The vaccine contains live virus, but it is weakened so it will not give your child polio."

1. "The vaccine cannot cause polio because it contains killed virus particles."- The polio vaccine administered by the intramuscular route contains inactivated (or killed) polio virus. The organism causes an immune response, but is incapable of reproducing and causing infection.Think like a nurse. Health promotion and disease prevention activities include monitoring and providing required vaccinations at the appropriate times. The use of vaccinations may cause anxiety for some parents because of a lack of knowledge of how the vaccine works and what the vaccination is intended to do. The parent who is concerned that a vaccination will cause a disease needs information about the contents of the vaccine and the expected response once the vaccine is administered. The person receiving the vaccination may also be concerned and the nurse should provide teaching prior to administering the vaccination. The nurse should maintain knowledge about the mechanism of immunity associated with various vaccines.

The nurse in a community clinic evaluates a client diagnosed with type 1 diabetes mellitus. Which observation indicates to the nurse that the client is not rotating insulin injection sites?1. Wheal present at an injection site.2. Discomfort at an injection site.3. Glucose levels rise temporarily.4. Increased muscle mass at an injection site.

3. Glucose levels rise temporarily.- Failure to rotate sites results in poor absorption of the insulin, which increases the blood glucose level.Think like a nurse. Clients diagnosed with diabetes mellitus are often required to perform self-injection of prescribed insulin. The nurse teaches the client to use sites on the front of the body. The abdomen absorbs insulin the fastest, followed by the arms, thighs, and buttocks. The client is reminded to keep a record of which injection sites are used and to rotate appropriately so that absorption is not negatively affected. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. It is best to use the teach-back method to verify the client understands what was taught.

The nurse provides discharge teaching to a client recently diagnosed with asthma. Which prescribed medication should the nurse instruct the client to use during an acute asthma episode?1. Fluticasone.2. Guaifenesin.3. Theophylline.4. Albuterol.

4. Albuterol.- Albuterol is a fast-acting bronchodilator used for treatment of acute asthma episodes. Albuterol may be administered using a metered-dose inhaler or a nebulizer.Think like a nurse. Discharge teaching for a client with asthma includes a thorough explanation on how to use rescue (e.g., albuterol) and maintenance (e.g., ipratropium) medications. The nurse informs the client of potential side effects of albuterol, such as tachycardia, palpitation, or chest pain. The client is also taught how to use and to interpret findings from use of the peak flow meter. When the client is in the "red zone" based on the peak flow meter reading, the client should call 911 or report to the emergency department. The nurse should encourage the client to ask questions and should use the teach-back method in teaching.

The nurse in the psychiatric day program provides care for a client diagnosed with recurrent depression. In doing the initial assessment based on the therapist's recommendation for a cognitive approach to therapy, which aspect is important for the nurse to evaluate?1. The client's use of language.2. The client's insight into the depression.3. The client's socialization history and skills.4. The client's attitude toward medications.

1. The client's use of language.- The cognitive viewpoint of depression sees it as stemming from errors in thinking, which may be negative, illogical, and/or irrational. Language is used in thought as well as in speech. Speech and writing are used to express thoughts, and thereby are indicators of the client's automatic thoughts, their schemata or cognitive structure about themselves and the world, and their cognitive distortions. Think like a nurse. The premise of cognitive therapy centers on the assumption that an individual's mood and thought patterns are directly related. Negative, dysfunctional thinking has an impact on an individual's mood, self-concept, behaviors, and physical well-being. Goals of cognitive therapy include educating an individual about identifying negative thought patterns, evaluating the validity of the thought patterns, and replacing negative thoughts with healthier patterns of thinking.

The nurse provides care to an adult client with newly-diagnosed rheumatoid arthritis (RA). Which information does the nurse include in the client's discharge instructions?1. "Avoid taking naps during daylight hours. "2. "Move your joints as much as you can each day. "3. "To move an object, lift it instead of sliding it. "4. "Install doorknobs that are turned instead of pushed. "

2. "Move your joints as much as you can each day. "- With RA, pain often decreases with joint use. By contrast, with osteoarthritis (OA), joint use typically causes joint pain to worsen in intensity. Think like a nurse. Goals of rheumatoid arthritis (RA) treatment include reducing or eliminating pain, decreasing inflammation around the joints, stopping joint damage, and maintaining a desired quality of life. Surgery, medications, and complimentary therapies such as diets, vitamins, or acupuncture may be used, but the client should be aware of the limits of each therapy's effectiveness. For example, acupuncture does not affect the joint condition, but may reduce pain, and, therefore, be of use. The nurse encourages exercise promoting flexibility, range of motion, and general strengthening to best help this client.

The nurse determines that a client with malnutrition is at risk for pressure injuries. Which interventions will the nurse include in this client's plan of care to decrease this risk? (Select all that apply.) 1. Avoid the use of donut-type devices.2. Massage bony prominences.3. Elevate the head of the bed no more than 30 degrees.4. Position flat when side lying.5. Avoid prolonged periods of sitting in a chair.

ANSWERS: 1, 3, 5EXPLANATIONS:1. Avoid the use of donut-type devices.- Donut-type devices promote ischemia.3. Elevate the head of the bed no more than 30 degrees. - Elevating the head of the bed no more than 30 degrees will decrease the chance of pressure injury development from shearing forces.5. Avoid prolonged periods of sitting in a chair.- Prolonged sitting can lead to decreased blood flow and pressure injuries. Think like a nurse. To prevent pressure injuries, the National Pressure Ulcer Advisory Panel recommends that the nurse ensure that the client's heels are free from the bed. Additionally, the staff should use heel offloading devices or polyurethane foam dressings on individuals at high risk for heel pressure injuries. The nurse should inspect the skin upon admission as soon as possible (within 8 hours). Heel pressure injury can develop over a short period. When a client suffers from neuropathy (e.g., reduce leg sensation), the client may not feel pain on the injured heel. Persons at risk for pressure injury from malnutrition should be referred to a registered dietitian/nutritionist. Monitor a client's weight and adequacy of oral or enteral nutrition daily.

The nurse overhears two unlicensed assistive personnel (UAP) discuss a client's protected health information (PHI) in a public elevator. Which action does the nurse take next?1. Assess the elevator for visitors and nonstaff passengers.2. Contact the supervisor on the floor where the UAPs work.3. Instruct the UAPs to stop the conversation immediately.4. Notify the hospital risk manager and ethics committee.

3. Instruct the UAPs to stop the conversation immediately.- The nurse's priority action is to stop the conversation before additional, confidential information about the client is shared. PHI should not be discussed in public spaces where information can be heard by those who do not have a "need to know."Think like a nurse. All health care providers have the responsibility to ensure that all clients are treated with respect and receive the privacy that they deserve. The inappropriate discussion of a client's personal health information is a violation of the trust that the client has in the health care system and those who provide the care. The nurse knows that discussing a client's private information hinders this trusting relationship and it must be stopped. The only appropriate action in this scenario is to direct the care providers to immediately stop discussing the client's information.

The home health nurse is conducting a home safety assessment in the home of an older adult client who lives alone. Which observation made by the nurse requires follow up and teaching? (Select all that apply.)1. The cleaning supplies are left unlocked under the kitchen sink.2. The testing supplies for diabetes management are left on the kitchen counter.3. The client purchases non-childproof caps that are easy to open for medications.4. The bottom drawer on the client's nightstand is broken and will not stay closed.5. The client has a weekly laundry service that delivers clean laundry inside the front door.

4. The bottom drawer on the client's nightstand is broken and will not stay closed.-The client may trip over the nightstand drawer when getting out of bed, which creates a risk for falls. This observation would require follow up and teaching by the nurse.5. The client has a weekly laundry service that delivers clean laundry inside the front door. - The client may trip over laundry baskets or bags, which creates a risk for falls. This observation would require follow up and teaching by the nurse. Think like a nurse. A priority when planning care, including teaching needs, is client safety. An older adult client, who lives alone in the home, is at risk for falling. The nurse must carefully assess the environment, and plan care, to decrease this client's risk. A drawer that will not stay closed along with laundry bags in a walkway both increase this client's risk for falling. The nurse must address these issues as they impact the client's safety. The other situations do not represent a safety risk for the older adult client who lives alone in the home.

The nurse notes that after a laboratory technician draws a blood specimen from a client there are drops of blood on the floor and the wall next to the needle container. Which action does the nurse take first?1. Contact the laboratory supervisor to report the incident.2. Contact the nurse manager to report the incident.3. Call housekeeping to clean and disinfect the area.4. Counsel the laboratory technician about appropriate technique.

3. Call housekeeping to clean and disinfect the area.- The priority for the nurse is cleaning up the contaminated area in the client's room by contacting housekeeping to clean and disinfect the area.Think like a nurse. The nurse identifies two concerns in this situation: a biohazard spill that poses a risk of contamination and an inappropriate action on the part of the lab technician that led to a spill. The nurse first needs to address the immediate physical risk of contamination. A blood spill needs to be immediately cleaned by the person or department with the appropriate cleansing materials. Contacting the housekeeping or environmental department to clean the spill is the best approach for the nurse to take.

The nurse counsels the mother of a school-age client who is diagnosed with laryngitis secondary to pharyngitis. Which intervention is appropriate for the nurse to suggest to the mother?1. Instruct the child to come close and whisper when something is needed.2. Encourage the child to take frequent sips of warm or cold milk.3. Encourage the child to sing favorite songs while taking a shower.4. Give the child a paper and pencil to communicate.

4. Give the child a paper and pencil to communicate. - Resting the voice for at least 24 hours or until the inflammation subsides is the most effective measure for healing laryngitis. The school-age child should be able to use paper and pencil to communicate needs effectively.Think like a nurse. The nurse will apply knowledge about anatomy and physiology when formulating client/parent teaching. The nurse knows that the client's diagnosis involves the larynx and interferes with normal speaking. The nurse instructs the client with laryngitis to rest the voice to promote healing. The client should be offered an alternate method of communication until the vocal cords heal. The nurse's teaching is appropriate because of the age of the client.

The nurse provides care for a 7-year-old client during a wellness examination. Which factor in the child's history alerts the nurse that hyperlipidemia screening is necessary?1. Maternal history of obesity.2. Paternal history of diabetes mellitus.3. Sibling history of stroke.4. Grandparent history of hypertension.

3. Sibling history of stroke.- If the child has a sibling with a history of stroke, screening for hyperlipidemia is recommended in children ages 2 to 8 years. Think like a nurse. The nurse is aware that the development of a chronic disease can either be controlled or uncontrolled. A non-modifiable risk factor cannot be controlled and is dependent upon age, race, gender, and family history. The younger a person is when diagnosed with a chronic health problem, the stronger the predisposition for other family members to develop the disease process. If a client at the age of 7 years has a sibling with a chronic health problem, it would be wise to assess the client's risk for the same health problem at an early age.

The client diagnosed with sickle cell anemia is admitted to the hospital for a vaso-occlusive crisis. The nurse reviews admission prescriptions. Which prescriptions does the nurse question? (Select all that apply.)1. Restriction of oral fluid intake.2. Water aerobic therapy for joint pain.3. High calorie, high protein diet.4. Acetaminophen 10 mg/kg every 6 hours as needed for pain.5. Oxygen via nasal cannula at 2 L/min.

ANSWERS:1, 2, 4EXPLANATIONS:1. Restriction of oral fluid intake.- In vaso-occlusive crisis, IV and oral fluids are the primary treatment to reduce blood viscosity. The nurse needs to question this prescription.2. Water aerobic therapy for joint pain.- In vaso-occlusive crisis, activity is limited to decrease oxygen needs, which prevents further sickling. The nurse needs to question this prescription. 4. Acetaminophen 10 mg/kg every 6 hours as needed for pain.- Vaso-occlusive crisis is characterized by severe pain. A combination of opioid and nonopioid therapy are used for management of mild to moderate pain, whereas opioid analgesics are used for severe pain. The nurse needs to question this prescription. Think like a nurse. Treatment of this disorder includes fluids to reduce blood viscosity and improve circulation. The altered shape of the red blood cells affects oxygen-carrying capacity. As such, activity should be limited or restricted. The client will experience severe pain and should be prescribed opioid analgesics.

A client diagnosed with multiple myeloma experiences persistent lower back pain. In which position will the nurse place this client?1. In bed with the head elevated 45 degrees and hips and knees moderately flexed.2. In bed with the head elevated 60 degrees and arms resting on the overbed table.3. In bed with the head of the bed elevated 15 degrees and legs extended.4. In a straight-backed chair with feet resting on the floor.

1. In bed with the head elevated 45 degrees and hips and knees moderately flexed. - Flexing the knees relieves pressure on the sciatic nerve and disk. Think like a nurse. To maximize comfort and reduce pain, the client with low back pain is encouraged to sleep on the side with a pillow between the knees. The client can also sleep on the back with a pillow under the knees and a small pillow under the small of the back. The client is advised not to sleep on the stomach. During waking hours, the client is advised to sit as little as possible, and only for short periods (10 to 15 minutes).

The nurse prepares a client for a computed tomography (CT) scan with contrast enhancement. Which question is most important for the nurse to ask?1. "Do you have a history of respiratory disease?"2. "Do you have any allergies to food or medication?"3. "Have you ever smoked?"4. "What x-ray tests have you had before?"

2. "Do you have any allergies to food or medication?"- The contrast enhancement is performed with iodine contrast media. The nurse should ask about allergies to seafood, iodine, and other contrast dyes.Think like a nurse. The nurse needs to be aware the contrast medium used for diagnosed tests contains iodine. Individuals with an allergy to iodine, seafood, or other contrast dyes may need another diagnostic test approach or receive medication to prevent an allergic response. It is important for the nurse to understand the process and procedures for diagnostic tests in order to prevent adverse effects or complications for the client.

The nurse provides care for a client scheduled for an adrenalectomy to treat pheochromocytoma. For which symptom will the nurse monitor the client first?1. Hypertension.2. Urine glucose.3. Intake and output.4. Urine acetone.

1. Hypertension.- Hypertension is the classic sign of pheochromocytoma. The client's blood pressure should be closely monitored. Think like a nurse. Hypertension has often been characterized as "the silent killer" and there can be a physiologic reason for the development of this health problem. The nurse is aware one reason for secondary hypertension to develop is the presence of a pheochromocytoma, which is a tumor within the adrenal gland. This tumor alters adrenal gland hormone secretion, which causes hypertension. While clients with pheochromocytoma may present with thirst, increased urinary output, and increased blood glucose, these symptoms are unlikely to result in immediate harm to the client. The severe hypertension found in pheochromocytoma may result in stroke or myocardial infarction.

The nurse provides care for clients on the medical and surgical unit. Which observation requires intervention by the nurse?1. The health care provider prepares to insert the needle for a lumbar puncture at the level of the posterior iliac crest.2. As the nurse leaves the client 's room, the nurse removes gloves and then the gown, folding the gown inside out.3. The unlicensed assistive personnel (UAP) feeds a client while the client 's neck and head are flexed slightly forward.4. The LPN/LVN repositions a client in Buck traction by first removing the traction weights.

4. The LPN/LVN repositions a client in Buck traction by first removing the traction weights.- Skeletal traction weights should never be removed without a health care provider prescription to do so, including when repositioning the client. Such an action would be painful for the client and would interrupt the line of pull. Think like a nurse: Traction (to pull) is based on simple mechanical principles. To apply traction effectively, there must be something to pull against, which is an effort to pull in the opposite direction. Buck traction is an example of running traction, in which the pulling force is in one direction and the patient 's body acts as countertraction. Traction should be continuous and not interrupted, even during client movement such as turning. Removing the weight could induce muscle spasms.

A client is admitted to the hospital with an acute myocardial infarction. The client's spouse states, "There has been an issue with heavy drinking for years." Based on this data, the nurse observes the client for which symptoms?1. Insomnia, hyperactivity, decreased appetite.2. Lack of energy, avoidance, sense of failure.3. Watery eyes, cramps, mild tremors.4. Hyperalertness, easily startled, anorexia.

4. Hyperalertness, easily startled, anorexia.- Hyperalertness, easily startled, and anorexia are symptoms of early withdrawal from alcohol. Other symptoms include increased pulse, anxiety, tremors, insomnia, and hallucinations.Think like a nurse. When signs of acute alcohol withdrawal are first observed, a psychiatric consult should be initiated. Client safety and injury prevention are major nursing priorities when caring for a client with acute alcohol withdrawal. The client's room should be kept quiet with the television off (visitors should be reminded of this). The client is permitted to have visitors unless the client's behavior becomes aggressive. However, relaxing music can be played in the background, as long as the music does not cause agitation. When providing client care, the nurse should provide simple explanations, and questions should be kept to a minimum. The nurse should closely monitor for signs of aggression (e.g., facial expressions, suggestive body language).

The nurse teaches a group of nursing students about elder abuse. Which older adult client does the nurse list as most likely to be a victim of abuse?1. A male diagnosed with moderate hypertension.2. A male with newly diagnosed cataracts.3. A female with advanced Parkinson disease.4. A female diagnosed with early stage Lyme disease.

3. A female with advanced Parkinson disease.- The typical abuse victim is a woman of advanced age with reduced social interaction and at least one physical or mental impairment.Abuse of the older adult client can be physical, sexual, domestic, psychological, or financial in nature. In some cases, elder abuse takes the form of neglect. The nurse assesses at-risk and vulnerable people carefully for signs of an abusive situation. Nurses have a duty to report suspected abuse situations to specified state agencies. The nurse must have a reasonable suspicion, not proof, that abuse is occurring. If this condition is met, the reporting nurse has immunity from legal repercussions. Reports are confidential to protect the reporting nurse. On the other hand, failure to report such instances can result in legal consequences.

The nurse prepares to complete an initial assessment for a client who has an indwelling urinary catheter. Which observation indicates to the nurse a need for intervention?1. The client's urinary drainage bag contains amber-colored urine.2. The client's urinary drainage tubing does not contain a dependent loop.3. The client's urinary drainage system is positioned below the level of the bladder.4. The client's urinary drainage bag is secured to the client's sheet.

4. The client's urinary drainage bag is secured to the client's sheet.- The client's urinary drainage bag should be properly secured to the client's thigh (not the bed linen) to prevent catheter movement, which increases the risk for catheter-associated urinary tract infections. Think like a nurse: An indwelling urinary catheter may be placed for a variety of reasons. Prior to inserting this device, the nurse should review the physiology of the urinary system and the purpose for the catheter. Because the device is inserted into the body, there is a high risk for urinary tract infection, so the nurse is careful to perform the procedure using sterile technique. Once inserted, the catheter should be secured to the client's leg to prevent accidental dislodging and injury. And to ensure that urine flows unobstructed, the collection device needs to be placed lower than the level of the bladder. Clients with an indwelling urinary catheter are always placed on input and output measurements.

The nurse is preparing the client for a C3 to C4 laminectomy. Which client statement indicates to the nurse the client requires further instruction? (Select all that apply.)1. "My pain will be completely gone when I wake up."2. "I should not twist my back right after surgery."3. "I will probably be incontinent after the surgery."4. "I do not smoke so there will not be complications."5. "It does not matter if I take herbal supplements."

ANSWERS: 1, 3, 4, 5EXPLANATIONS:1. "My pain will be completely gone when I wake up."— Postoperative pain is common. This client requires further instruction regarding this common phenomenon. 3. "I will probably be incontinent after the surgery."— Bowel or bladder incontinence would be an unexpected complication that might indicate spinal cord injury. This statement indicates the need for further instruction. 4. "I do not smoke so there will not be complications."— The client may still have complications, although the risks for many complications are reduced. This statement indicates the need for further instruction. 5. "It does not matter if I take herbal supplements."— The use of herbal supplements should be shared with the health care team as some herbs interfere with other treatments and medications. This statement indicates the need for further instruction. Think like a nurse: Although the client may be experiencing severe nerve pain generating from the C3-C4 site, the surgery, in time, will eliminate or decrease that pain. However, post-operative pain will still occur. The spine will need to be kept in proper anatomical alignment after a laminectomy until healing is complete.

A client is admitted to the psychiatric unit with a diagnosis of major depression. The client describes to the nurse suicidal thoughts that have occurred for the past 3 days. Which client statement causes the nurse to institute a one-to-one observation of the client?1. "This is not the first time I felt this way."2. "I will not sign a no-suicide contract."3. "This is my fifth hospitalization for depression."4. "My mother attempted suicide at age 40."

2. "I will not sign a no-suicide contract."- Place the client on one-to-one observation and stay with client to help control self-destructive impulses. The client is never out of sight of a supervisory health care staff member. One-to-one observation is required for clients currently verbalizing a clear intent to harm self, unwilling to sign a no-suicide contract, with poor impulse control, and who have already attempted suicide in the past by a lethal method (hanging, gun).Think like a nurse: Refusing to sign a no-suicide contract is a red-flag to the nurse. The client is at risk for suicide and should be constantly observed. The client may be at risk for suicide because of a family history of the behavior.

A preschool-age client is recovering from a tonsillectomy and adenoidectomy. The client is discharged home with the parents. Which instruction will the nurse give to the parents? (Select all that apply.)1. Monitor the child for continuous swallowing.2. Encourage the child to deep breathe and cough every 2 hours.3. Administer pain medication, such as acetaminophen, as needed.4. Administer codeine elixir routinely for pain.5. Monitor the child for restlessness and difficulty breathing.

ANSWERS:1, 3, 5EXPLANATIONS:1. Monitor the child for continuous swallowing.— Frequent swallowing is a sign of bleeding.3. Administer pain medication, such as acetaminophen, as needed.— The throat is sore after surgery and pain medication is needed regularly for the first few days.5. Monitor the child for restlessness and difficulty breathing.— Restlessness or difficulty breathing is a sign of bleeding or airway obstruction.Think like a nurse: Post-tonsillectomy, the nursing interventions are focused on assessing for airway clearance, providing pain relief, and monitoring for excessive bleeding. Discharge teaching may include reinforcing adherence with antibiotics, when to notify the health care provider (e.g., signs of difficulty breathing), and improving fluid and food intake. Water, apple juice, and grape juice, are well tolerated post-operatively. Soft foods such as applesauce, pudding, ice cream, sherbet, and yogurt are easy to swallow and will provide the client with nutrients. The nurse should instruct the client to avoid crunchy, hard foods and hot or spicy foods. The client may take pain medicine an hour before meals to reduce pain while eating.

The nurse visits the home of a client receiving carbidopa-levodopa. Which statement by the caretaker indicates to the nurse that the medication is effective?1. "The client 's weight increased by 2 pounds."2. "The client is getting over an upper respiratory infection."3. "There is an increase in the fine motor tremors."4. "The client seems to be more ambulatory."

4. "The client seems to be more ambulatory."— There is no cure for these symptoms that occur with Parkinson disease, but carbidopa-levodopa does reduce the rigidity and tremors. The medication helps facilitate mobility for the client.Think like a nurse: The nurse needs to use knowledge about the manifestations of the client's diagnosis and recall the purpose and mechanism of action related to the prescribed medication. The nurse will be assessing for the manifestations that indicate improvement. Carbidopa-levodopa is used to treat Parkinson disease, which affects dopamine levels in the brain, causing neuromotor deficits. Since the medication facilitates the replacement of dopamine, which is required for motor functioning, evidence that the medication is being effective would be an improvement in physical activity and mobility.

The nurse provides care for a client before surgery. Thirty minutes after administering the preoperative medication, the nurse observes the unlicensed assistive personnel (UAP) ambulate the client to the bathroom. Which action should the nurse take first?1. Have the UAP assist the client back to bed.2. Ask the UAP if the client had difficulty walking.3. Determine why the UAP ambulated the client.4. Ensure that the UAP receives the appropriate training.

1. Have the UAP assist the client back to bed.- The client may be sleepy after receiving preoperative medications and is at risk for falling. The client should not ambulate after receiving preoperative medications. The priority nursing action is to assist the client back to bed. Think like a nurse: The nurse is responsible for supervising and evaluating care provided by the UAP. Usually, preoperative medication includes a sedative. Once this medication is administered, the client is to remain in bed for safety. The UAP needs to return the client to bed immediately. Afterwards, the nurse can counsel the UAP on the importance of maintaining client safety after receiving preoperative medication since the nurse is ultimately accountable for the provision of client care.

The nurse manager on the oncology unit makes rounds during the day shift. Which observation by the manager requires an immediate intervention?1. Wearing gloves, the nurse firmly seals all four edges of the sterile gauze dressing at an IV catheter insertion site with tape.2. Using a marking pen, the nurse labels an IV fluid bag with the date and time the IV was initiated and the nurse's initials.3. The nurse secures aluminum foil around a hanging IV solution of nitroprusside.4. The nurse wears a cap, mask, gown, and gloves when initiating a peripherally inserted central catheter (PICC) line.

2. Using a marking pen, the nurse labels an IV fluid bag with the date and time the IV was initiated and the nurse's initials.— A marking pen should not be used to label an IV bag, especially directly on the plastic IV bag. Ink can penetrate the plastic and diffuse into the solution, posing a risk to the client. Labeling should be done on a label or tape using a regular pen and then placed on the IV bag. Think like a nurse: The nurse needs to understand the reason for institutional policies, procedures, and protocols; understanding promotes compliance. As a professional, nurses also need to keep abreast of best practices, which can change with research. Ink should not be placed directly onto the intravenous infusion bag since the chemicals within the ink can be absorbed by the plastic and inadvertently contaminate the solution. A time tape should be placed along the mL markings of the solution bag where the nurse can document the expected infusion amount and time.

The nurse performs a physical assessment of a newborn who is 4 hours of age. Which finding is appropriate for the nurse to report to the health care provider (HCP)?1. Head circumference of 40 cm.2. Chest circumference of 32 cm.3. Acrocyanosis noted to both feet. 4. An apical pulse rate noted at 160 beats/min.

1. Head circumference of 40 cm.— The average head circumference is 33-35 cm. An increased circumference may indicate hydrocephalus or increased intracranial pressure. Think like a nurse: The nurse who is working in a speciality area needs to be aware of the parameters, which indicates that assessment findings are normal. When abnormal assessment finding are noted, the nurse can reassess for accuracy. The expected head circumference of a newborn is between 32 and 36 cm. When the client's head circumference is 40 cm, the nurse should suspect hydrocephalus may be occurring. This abnormal finding needs to be addressed immediately and the nurse should report the information to the health care provider.

The nurse conducts a quality assurance review of a laboring client's health record. Which entry does the nurse reviewer bring to the attention of the nurse manager?1. 1035: Five minutes after epidural initiated, client's blood pressure is 80/48 mm Hg. Client positioned left side down.2. 1050: Fetal heart rate is 90 to 100 beats/min after epidural block. O2 by face mask administered to client at 10 L/min. 3. 0820: 500 mL IV fluid bolus of Lactated Ringer's solution completed. 1030: Anesthesiologist present to begin administration of epidural block.4. 1102: Fetal heart rate sustained at 100 beats/min for more than 10 minutes. Lactated Ringer's solution infusion rate increased to wide open per protocol.

3. 0820: 500 mL IV fluid bolus of Lactated Ringer's solution completed. 1030: Anesthesiologist present to begin administration of epidural block.— Epidural blockade produces vasodilation and typically causes a decrease in blood pressure. Administration of an IV fluid bolus prior to an epidural block is intended to offset potential hypotension by increasing the fluid volume in the intravascular space. To optimize the effects of the fluid bolus, the IV fluid should be administered over 20-30 minutes and the epidural procedure begun shortly thereafter.Think like a nurse: When administering medication, the nurse considers the intended purpose of the medication. The purpose of the fluid bolus is not hydration, but to rapidly increase circulatory volume and cardiac output. When administering a bolus to a client who is about to have an epidural placed, a bolus is a prophylactic measure that avoids the adverse effect of hypotension. Prevention is essential to the mother and baby's well-being. Fluid administered 2 hours before the epidural placement has already distributed through circulation to be excreted through the kidneys. When there is a delay in epidural placement, the nurse considers administering an additional bolus.

A client needs continuing care after an abdominal hysterectomy. Which roommate is appropriate for the nurse to place this client?1. Client recovering from a craniotomy for a brain abscess.2. Client with cellulitis of the left leg.3. Client with a methicillin-resistant wound infection.4. Client recovering from gastric bypass surgery.

4. Client recovering from gastric bypass surgery. — The client recovering from gastric bypass surgery is the most comparable with the client recovering from abdominal surgery. Both clients require post-surgical care and are considered "clean. " These clients can safely share a room.Think like a nurse: A client recovering from surgery is at risk for infection because of the effects of anesthesia, the stress of the procedure on the body, and the fact that surgery is an invasive procedure. Before making the room assignment for the post-operative client, the nurse considers the available options. Any client with an infection is immediately ruled out as a potential roommate because of the risk for transmitting the infection to the client recovering from surgery. The only viable option is the client who is also recovering from surgery since the risk for infection for both of the post-operative clients is equal.

The nurse notes that a client who delivered a newborn 18 hours ago reports swelling and pain in the right calf. Which action is appropriate for the nurse to implement? 1. Assess the client for a positive Homan sign.2. Place the client on bed rest with the right leg elevated on a pillow.3. Elevate both legs on a pillow and apply ice.4. Palpate both legs to determine actual nature of pain.

2. Place the client on bed rest with the right leg elevated on a pillow.- Initial treatment when a deep vein thrombosis has occurred includes bed rest, with the affected leg elevated to decrease interstitial swelling and to promote venous return from the leg.Think like a nurse: The development of a deep vein thrombosis (DVT) can occur during pregnancy due to the increase in circulating blood volume, influence of hormones, and the change in activity level. Following delivery, the risk for DVT is related to the amount of time spent in the lithotomy position and inactivity. Should DVT occur, the nurse should recall the pathophysiologic process of the health problem and immediately implement measures to prevent complications. The client's extremity will be warm and edematous. The pulses in the foot of the affected extremity may be weak. The first action is to support the affected limb by placing it on a pillow and instructing the client to remain on bed rest until the health care provider can further evaluate the limb and prescribe treatment.

The nurse provides care for a client who is one day postpartum. The client voids large amounts of urine frequently. Which action does the nurse implement?1. Assure the client that this is expected after delivery.2. Ask the client if the urine is cloudy.3. Check the urine specific gravity of the urine.4. Notify the health care provider.

1. Assure the client that this is expected after delivery.- Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Postpartum diuresis is caused by several factors, including a decrease in serum estrogen levels, the elimination of increased venous pressure in the lower extremities, and by the loss of any remaining pregnancy-induced increases in blood volume. All of these factors work together to aid the body in ridding itself of excess fluid. A urine output of 3000 mL or more each day during the first 2 to 3 days is expected. Think like a nurse: The body undergoes major physiological changes during pregnancy. Upon delivery, the body realizes that the changes needed to support the developing fetus are no longer needed, and begin sto adjust. One of the body changes in pregnancy is an increase in circulating blood volume. The extra blood is needed to support both the mother and developing fetus. Once the fetus is delivered, the extra blood is no longer needed and the body can start to remove the extra fluid from the general circulation. Evidence of the body making appropriate adjustments to the mother's fluid volume is an increase in the amount of urination. This is an expected occurrence that should be explained to the client.

Which post-operative recommendation by the nurse is best when assisting a client prepare for cataract surgery?1. "Have someone do the vacuuming."2. "Eat foods high in antioxidants."3. "Have loperamide 2 mg available."4. "Ask someone to sit with you for 2 days."

1. "Have someone do the vacuuming."— The client should not vacuum following cataract surgery because the jerky movements and bending at the waist can increase intraocular pressure. This is the best recommendation by the nurse to prevent postoperative complications.Think like a nurse: The client post-cataract surgery should be taught not to do any activities that may increase intraocular pressure, such as pushing or pulling on a vacuum sweeper. The client should also be encouraged to eat a high-fiber, high-fluid diet to avoid constipation. Additional teaching includes instructing the client and caregiver about prescribed eye drops to prevent infection, reduce inflammation, and control eye pressure. The client should be informed to call the provider if the client experiences vision loss, persistent pain, increased eye redness, or if the client reports light flashes or multiple new spots (floaters) in front of the eye.

An older adult client's laboratory results reveal an elevated serum blood urea nitrogen (BUN) level. Which assessment data is most helpful when further evaluating the client's condition?1. Blood pressure.2. Oral temperature.3. Heart tones.4. Lung sounds.

1. Blood pressure.- In the older adult client, dehydration is a common cause of elevated serum BUN. Blood pressure assessment is most helpful when evaluating the client's fluid volume status. Elevated serum BUN may also occur due to renal dysfunction, in which case the client would require evaluation with additional laboratory and diagnostic tests. Think like a nurse: The nurse needs to review the physiologic changes that can occur with aging. This client has an elevated laboratory value that could be due to a normal age-related process or an undiagnosed health problem. An elevated blood urea nitrogen level could mean renal disease; however, it may also be due to low body fluid volume. To help rule out the reason for this laboratory value elevation, the nurse should first assess the client's blood pressure. If the blood pressure is low, increasing fluids should cause the laboratory value to become closer to normal. If fluids do not correct the value, then additional diagnostic testing would be required to identify the reason for the elevation.

The nurse prepares a solution of parenteral nutrition (PN) to infuse through a client's central line. Which piece of equipment is most important for the nurse to obtain before starting the infusion? 1. Glucose monitor.2. Electronic infusion pump.3. Pulse oximeter.4. Urine glucose strips.

2. Electronic infusion pump.- Because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind.Think like a nurse: Nutritional support is a major function of nursing care. For some clients though, this support needs to be provided using an alternative approach. Parenteral nutrition is the administration of a highly concentrated glucose solution mixed with additives to provide the nutrients required for body functioning. Because the client receiving this type of nutrition is most likely physically challenged, the nurse needs to ensure this solution is delivered safely and within expected parameters. An infusion pump is to be used when providing this nutritional support. After the infusion is started, the nurse will need to obtain a glucose meter to check the blood glucose every 6 hours.

An ice storm paralyzes a community during the night. The two nurses on a 24-bed medical/surgical unit learn that it will be 12-15 hours before they can expect the next shift to arrive. Which action do the nurses take first?1. Each nurse takes a shower while the other nurse cares for all of the clients.2. Instruct the unlicensed assistive personnel (UAP) to begin morning care at 0400.3. Make a list of all of the clients' breathing treatments and intravenous medications for the next 12-15 hours.4. Plan to administer all of the clients' as needed pain medication before they ask for it.

3. Make a list of all of the clients' breathing treatments and intravenous medications for the next 12-15 hours.- The priority is to determine treatments and medications that are vital to the well-being of the clients. Think like a nurse: After an ice storm paralyzes a community, two night shift nurses working on a 24-bed medical/surgical unit must continue caring for clients on the unit because the day shift nurses cannot access the hospital. To combat the staffing dilemma, the nurses should think, "What essential care must we give to protect the clients from harm?" The nurses should determine which essential medications and treatment interventions, with consideration of the ABCs (airway, breathing, circulation), that they must provide to ensure the clients' well-being. Nonessential interventions should be eliminated.

The client is admitted with extreme fatigue, shortness of breath, anxiety, and chest pressure. Which intervention does the nurse implement? (Select all that apply.)1. Place the client on bed rest.2. Administer supplemental oxygen.3. Administer ketorolac for pain.4. Assess serum troponin level.5. Monitor intake and output.

ANSWERS:1, 2, 4, 5EXPLANATIONS:1. Place the client on bed rest.— The client is experiencing the symptoms of a myocardial infarction. Bed rest decreases stress on the heart by decreasing muscle metabolism and therefore oxygen demand. 2. Administer supplemental oxygen.— In a myocardial infarction, administering oxygen is a priority action as this client is experiencing poor oxygenation to the heart muscle. 4. Assess serum troponin level.— The troponin level is sensitive to cardiac damage and can confirm that the client is having a myocardial infarction. 5. Monitor intake and output.— The nurse should monitor intake and output to assess for fluid overload. The client is at high risk to experience heart failure due to death of myocardial tissue. Think like a nurse: These symptoms suggest that the client is experiencing a myocardial infarction. The first action is to place the client on bedrest to reduce myocardial oxygen demand and apply supplemental oxygen to ensure adequate oxygenation of myocardial tissue. Monitoring intake and output is essential for early detection of fluid overload, which can occur when myocardial tissue is damaged. A troponin level is used to evaluate for myocardial tissue damage.

The nurse attaches an external electronic fetal monitor to the abdomen of a pregnant client in labor. Which action does the nurse take next?1. Determine the frequency of contractions.2. Identify the types of accelerations.3. Determine the intensity of contractions.4. Assess the baseline fetal heart rate.

4. Assess the baseline fetal heart rate.- The baseline fetal cardiac rate is the most important initial assessment so that abnormal variations of the baseline rate can be identified, if they occur.Think like a nurse: When caring for a client in labor, the nurse needs to remember that there are two clients who require care. The mother's needs should be addressed; however, the viability and impact of labor on the fetus needs to be monitored closely. One way to ensure that labor is not causing stress to the fetus is through electronic fetal monitoring. The device monitors the fetal heart rate, which can be assessed for changes related to the length and strength of contractions. The first action for the nurse to take is to acquire a tracing of the fetal heart rate, which is used as a baseline reference for all future tracings.

The nurse receives hand-off communication from the previous shift about assigned clients with mental health disorders. Which client will the nurse see first? 1. Client with mania and bipolar disease threatening to sue the primary nurse for negligence.2. Client with depression stating that things are better and that he will be leaving soon.3. Client with delusions stating a plan to kill the spouse after being discharged. 4. Client with schizophrenia denying hearing voices.

2. Client with depression stating that things are better and that he will be leaving soon.- The client with depression who states that things are better and will be leaving soon may be an indirect suicide threat with a plan. The nurse must clarify the client's statement, as this client can be in immediate danger. Think like a nurse: A client with depression is at risk for suicide and may feel "better" once a plan to commit suicide is made. This client should be assessed immediately for suicide ideation and placed on suicide precautions.

The nurse provides care to infant and toddler clients in a day care facility that has experienced an outbreak of hepatitis A. To control disease transmission and prevent a future outbreak of hepatitis A, the nurse prioritizes the implementation of which intervention? 1. Restricting contact with children who have symptoms of hepatitis A.2. Educating staff and clients about proper hand hygiene protocols.3. Advising staff and clients to request administration of immune globulin (IG) from their health care providers.4. Recommending mandatory hepatitis A screening of all potential staff members.

2. Educating staff and clients about proper hand hygiene protocols.- Following proper hand hygiene protocols is the most effective measure to prevent or control an outbreak of hepatitis A. Restricting contact with individuals who have symptoms of hepatitis A is not an effective strategy for controlling disease transmission, as the disease may be transmitted before symptoms appear. Immune globulin (IG) is effective against hepatitis if administered within 2 weeks of exposure. Because of the cost of blood tests used to screen for hepatitis A, routine screening is not recommended. Think like a nurse: Hepatitis A is a fecal-oral disease, and as such, it flourishes in areas with poor sanitation. Teaching hand hygiene and providing ways in which to make hand hygiene part of the daily routine are important interventions in stopping the spread of hepatitis A. In a day care setting, workers need to perform hand hygiene after diaper changes or assisting with toileting in addition to helping children clean their hands.

The nurse reviews the laboratory results of an older adult client diagnosed with a bacterial infection. Which result does the nurse expect to find?1. Severe thrombocytopenia.2. Elevated hematocrit.3. Decreased hemoglobin.4. Minimal leukocytosis.

4. Minimal leukocytosis.- Leukocytosis refers to an increase in the number of white blood cells (WBCs). Although a bacterial infection typically triggers an increase in the WBC count, up to 40% of older adults with serious infections may not develop leukocytosis. As a result, absence of leukocytosis in an older adult does not necessarily rule out an infectious process.Think like a nurse: When analyzing the laboratory results of an older adult client, the nurse should stop and recall age-related changes that can occur in the immune system. An older adult client will not necessarily have an increase in white blood cell count with an infection. This is due to the normal aging process of the immune system, which reduces the body's ability to develop white blood cells in the bone marrow. This adversely affects the older adult client's ability to fight an infection. The older adult client may also not develop a fever or demonstrate other signs of an infection that would be seen in a client younger in age.

The nurse reviews the health care needs for a group of clients. Which client does the nurse identify as being at the highest risk for developing a Dupuytren contracture?1. An older adult female client from Russia diagnosed with osteoarthritis.2. A middle-age adult male client from Norway diagnosed with diabetes.3. An adult female client from Haiti who has a fractured femur.4. A school-age male client from Poland diagnosed with Duchenne muscular dystrophy.

2. A middle-age adult male client from Norway diagnosed with diabetes.— A Dupuytren contracture is a slow progressive contracture of the palmar fascia causing flexion of the fourth and fifth fingers. This results from an inherited autosomal dominant trait. It occurs most often in men over 50 years of age (middle-age) of Scandinavian or Celtic descent, and is associated with diabetes, gout, arthritis, and alcoholism. The client's age and diagnosis are risk factors. Think like a nurse: Dupuytren contracture is a contracture of the fourth and fifth fingers of the hand. This condition is associated with diabetes mellitus, gout, arthritis, and alcoholism, and is believed to have a genetic link. Other risk factors include male gender, middle-age, and being of Scandinavian descent. Female gender, Haitian descent, and muscular dystrophy are not risk factors for the development of this contracture.

The nurse admits an older adult client who has a full thickness burn over 15% of the total body surface area (TBSA). Which action does the nurse take first?1. Administer prophylactic intravenous antibiotics.2. Administer a tetanus toxoid injection intramuscularly.3. Administer Lactated Ringer's solution intravenously.4. Administer intravenous morphine every 5 to 10 minutes.

3. Administer Lactated Ringer's solution intravenously.-Burns result in large insensible fluid loss through damaged skin. The greatest risk to the client following a full thickness burn of 15% of the TBSA is hypovolemia shock. The nurse should first administer crystalloid IV solution to maintain vascular volume.Think like a nurse: Before implementing any interventions or prescriptions, the nurse should stop and recall, "What happens to the body when the skin is burned?" The skin has several functions; one being the containment of body fluids and maintenance of electrolyte status. Since the client experienced a major burn, an area of the skin is gone, body fluid and electrolytes are lost, and the client is at risk for low fluid volume and electrolyte imbalance. The priority should be to begin fluid resuscitation, using fluids that will maintain vascular volume and electrolyte levels. Once fluid replacement is started, the nurse can then address the client's needs for pain management, which is considered a psychosocial need according to Maslow.

A client with type 1 diabetes mellitus (DM) who delivered a healthy newborn asks how insulin needs will change with breastfeeding. Which response by the nurse is appropriate? 1. "You will need to change to an oral hypoglycemia agent that will control glucose levels more effectively than insulin."2. "You will need to bottle feed your newborn since insulin received through breastfeeding may cause hypoglycemia in the child."3. "Your need for insulin will increase while you are breastfeeding."4. "You will have a decrease in your insulin dosage due to hormonal changes after delivery."

4. "You will have a decrease in your insulin dosage due to hormonal changes after delivery."- Insulin needs should decline rapidly after the delivery of the placenta and abrupt cessation of placental hormones. Blood glucose levels should be monitored at least four times daily so that the insulin dose can be adjusted to meet individual needs. Women with type 1 DM usually return to their pre-pregnancy insulin dosages.Think like a nurse: When caring for a postpartum client with type 1 diabetes mellitus, the nurse needs to recall the pathophysiology of the disease process and the impact it has on gestation. During pregnancy, the nurse is aware that insulin needs will increase to support both the client and developing fetus. Once the newborn is delivered, the need for the additional insulin will decrease. The client's blood glucose levels should be closely monitored immediately after delivery so that the insulin doses can begin to be adjusted.

A new nurse makes staff assignments for the first time. After completing assignments, the nurse is called to a meeting. When returning to the unit, the new nurse finds extensive assignment changes were made. Which response by the new nurse is best?1. "I noticed the assignments were changed. Did something happen while I was gone?"2. "Why did you change the assignments? I was asked to make them today."3. "Changing the assignments makes me appear incompetent. Next time, please ask first."4. "I would appreciate it if you would not make changes in the assignments I make."

1. "I noticed the assignments were changed. Did something happen while I was gone?" - Seeking information in a non-accusatory way allows staff members to discuss the situation so that the nurse can learn from the changes made. Think like a nurse: The nurse should use assertive communication techniques to find out why the assignments were changed, but should avoid asking "why?" directly. Client conditions may have changed, which necessitated making adjustments. The nurse should not assess the reason for the assignment changes in an accusatory, emotional, or hostile way since this will not support intra-professional communication.

The nurse was assigned to the mental health care area from another area in the facility. A client accuses the nurse of being a terrorist with poisonous pills when the nurse is preparing medications. Which response by the nurse is best?1. "I am not a terrorist."2. "Is it your feeling that I am trying to poison you?"3. "This is your medication, which you have to take now."4. "I am a nurse from another unit in this hospital."

4. "I am a nurse from another unit in this hospital."- The nurse's explanation serves as orientation to reality. It also addresses the client's concern without reinforcing the delusion. Think like a nurse: The client does not recognize the nurse and thinks the nurse plans to do the client harm. The best way to address the client's delusion is to explain who the nurse is.

The parents bring their toddler into the emergency department (ED). The nurse observes that the client is having difficulty breathing and appears to be wheezing on inspiration. Which question is most important for the nurse to ask the parents?1. "Is your child's immunization schedule current?"2. "Do you or the child's siblings have a history of asthma?"3. "What toy does your child like playing with the most?"4. "Was your child eating anything immediately before developing breathing problems?"

4. "Was your child eating anything immediately before developing breathing problems?"— Toddlers are in danger of aspirating large pieces of meat and hot dogs, as well as nuts, dried beans, chewing gum, grapes, or marshmallows.Think like a nurse: The nurse recognizes that the client is exhibiting signs of airway obstruction. Based upon the age and size of the client and the symptoms, the client could have aspirated a small piece of food. If the child was eating immediately prior to symptom onset, ask the parents if the child started coughing or choking. Observe the client's throat and assess for indicators of hypoxia, such as central cyanosis, a low oxygen saturation level, and an altered level of consciousness. If the presence of a foreign body is confirmed or highly suspected, a bronchoscopy for foreign body retrieval will be needed.

A client returns to the unit after placement of a split-thickness autograft to a burn on the right arm. Which intervention does the nurse give the highest immediate priority?1. Managing pain at the recipient site.2. Immobilizing the graft.3. Minimizing light exposure.4. Observing for signs of rejection.

2. Immobilizing the graft.— Graft adherence to the site is essential for vascularization and "taking" or survival of the graft. Immobilization of the graft and the limb is a priority. A thin fibrin network develops quickly after graft placement, but it takes 7 to 10 days for the graft to really adhere and longer than that to mature.Think like a nurse: The priority of care for this client is immobilizing the limb with the graft. Adherence of the graft takes between 7 to 10 days and unnecessary movement can adversely effect this process. Rejection does not occur immediately, but will become a priority after the dressing is removed in 3 to 5 days.

The clinic nurse instructs a client about an ambulatory electrocardiogram (ECG). Which client statements indicate to the nurse a need for additional education? (Select all that apply.)1. "I will have to use a safety razor while the monitor is in place."2. "I will keep a log of all of my activities during monitoring."3. "I will wrap the device with plastic wrap before taking a shower."4. "I will contact the health care provider if I experience lightheadedness."5. "I will decrease my fiber during the monitoring."

ANSWERS:3, 4, 5EXPLANATION:3. "I will wrap the device with plastic wrap before taking a shower."- The monitor cannot get wet so the client needs to avoid taking a bath or shower during monitoring. The nurse needs to provide additional education based on this statement. 4. "I will contact the health care provider if I experience lightheadedness."- If the client experiences dizziness, the client needs to document it in the event log along with pushing the event-marker button on the monitor. The client does not need to call the health care provider. This statement indicates that additional education is needed. 5. "I will decrease my fiber during the monitoring."- There is no reason to change diet while being monitored. This statement indicates that additional education is needed. Think like a nurse: Often called a Holter monitor, an ambulatory ECG is a portable device that is used to record a client's heart rhythm for 1 or 2 days. Just like a typical heart monitor, it has leads that attach externally on the torso. The client records symptoms by pushing a button on the device. This device is excellent for capturing episodic dysrhythmias or cardiac conduction abnormalities that only occur under certain circumstances. The client needs explicit instructions about using the device in order for it to be effective and worthwhile.

A client is recovering from a myelogram that used an oil-based contrast medium. Which action is most important for the nurse to take?1. Apply ice packs to the puncture site.2. Ambulate the client.3. Monitor for seizures.4. Encourage oral fluids.

4. Encourage oral fluids.— The nurse should encourage oral fluids because the client needs to replace fluids lost with the removal of the oil-based contrast medium. The nurse should also offer oral analgesics if the client experiences headache.Think like a nurse: For a myelogram, different types of contrast dyes, either oil-based or water-soluble, may be used. If an oil-based dye is used, the dye must be withdrawn after the myelogram (before the needle is removed). If a water-soluble dye is used, withdrawing the dye is not necessary because the dye can be absorbed by the body and excreted through the kidneys. If an oil-based contrast agent was used, the client must lie flat in bed for up to 12 hours, positioned with the head raised at least 30 degrees, after the procedure. The client is encouraged to drink clear fluids to avoid dehydration and to help flush out the contrast dye. If a lumbar puncture was done, extra fluids also help to speed the replacement of cerebrospinal fluid.

The nurse assesses a group of clients for risk of developing psoriasis. The nurse identifies which client as being low risk for developing psoriasis? 1. A young adult African American.2. A client with a family history of the condition.3. A client reporting prolonged emotional stress.4. An older adult experiencing menopause.

1. A young adult African American.— The incidence of psoriasis is lower among darker-skinned races.Think like a nurse: The nurse should mentally review the pathophysiologic process of psoriasis along with the etiology and risk factors prior to identifying the client most at risk for the development of the disorder. The reasons for the development of psoriasis vary from being a genetic disorder to being an autoimmune reaction. The one factor that is linked to the development of the disorder is skin color. Psoriasis is more likely to occur in lighter-skinned clients of European descent than in dark-skinned clients. Regardless of the reason, psoriasis has periods of latency and exacerbation that have been linked to stress and hormone imbalances.

The nurse reviews dietary guidelines with a client diagnosed with gastroesophageal reflux disease (GERD). Which statement by the client helps the nurse determine that teaching was effective?1. "If my stomach feels bloated, I will drink peppermint tea."2. "I will switch from orange juice to tomato juice at breakfast."3. "I will eat three meals per day and not snack between meals."4. "I will raise the head of my bed 12 inches prior to sleeping each night."

4. "I will raise the head of my bed 12 inches prior to sleeping each night."— The recumbent position significantly impairs esophageal clearance. The client's head should be elevated 6 to 12 inches to prevent nighttime reflux. Think like a nurse: Gastroesophageal reflux disease (GERD) may cause pulmonary microaspiration during sleep. The client is advised to sleep with the head of bed elevated. The client is also taught to eat frequent small meals to prevent gastric distension. Advise the client not to lie down for 2 to 3 hours after eating, not to wear clothing tight around the waist, or to bend over, especially after eating. The nurse should be alert to the risk of asthma exacerbation secondary to GERD. The nurse should anticipate giving the client histamine-2 blockers or proton-pump inhibitors.

The nurse provides care for infants in the pediatric clinic. When teaching parents about developmental milestones, in which order does the nurse present the information? (Arrange developmental milestones in the proper order. All options must be used.)1. Begins drooling2. Responds to own name3. Picks up bite sized pieces of cereal4. Doll's-eye reflex disappears5. Takes deliberate steps when standing

ANSWERS:4, 1, 2, 5, 3EXPLANATION: 4. Doll's-eye reflex disappears- Disappears at 2-3 months1. Begins drooling- Begins at 4 months2. Responds to own name- Happens at 6-8 months5. Takes deliberate steps when standing- Starts at 9-10 months3. Picks up bite sized pieces of cereal- Can do this at 11 monthsEXPLANATION: First, the infant loses the doll's eye reflex at 2 to 3 months of age and can follow a moving object briefly. At about 4 months of age, the infant begins drooling as the gums swell and teeth erupt. The infant responds to name by 6 to 8 months of age. The infant will take deliberate steps when held up or after pulling self up to a standing position at 9 to 10 months of age. Lastly, an infant will pick up bite-size pieces of cereal at 11 months and deliberately put them in the mouth.

The nurse provides care for clients on an acute pulmonary unit. The nurse prepares a written report for the next shift. Which information is most critical to communicate to the next shift?1. Abnormal laboratory work, arterial blood gas reports, nutritional intake, and vital signs for the shift.2. Abnormal assessment findings, activity tolerance, and variances in vital signs during the shift.3. Name of each client 's health care provider, the date each client was admitted, dietary intake for each client, and each client's general condition.4. Urinary output, fluid intake, visits by the attending health care provider, vital signs, and any respiratory problems encountered.

2. Abnormal assessment findings, activity tolerance, and variances in vital signs during the shift.— This information is documented, but because it may reflect variances in the client's status, it should be included in the hand-off report. The nurse on the next shift may not be able to review all client records immediately. Think like a nurse: Hand-off communication should include information that is the most critical for the oncoming nurse to know in order to provide safe effective care. Abnormal assessment findings, activity tolerance, and changes in vital signs would be the most pertinent for the clients on this care area. Items that can be found in the medical record are not necessarily reported, unless there is a change such as an abnormal laboratory value, change in urine output, or exacerbation of the health problem.

A client is scheduled to have a transabdominal pelvic ultrasound for evaluation of a uterine mass. The nurse includes which statement when preparing the client for the procedure?1. "Do not eat anything for at least 8 hours before the test."2. "You may feel a stinging sensation as the machine moves over your skin."3. "Drink four glasses of water 1 hour before the test and do not urinate."4. "Be prepared for the test to take 1 to 2 hours."

3. "Drink four glasses of water 1 hour before the test and do not urinate."- A full bladder is necessary for this test for several reasons, including the fact that it serves as a window for the ultrasound beam transmission. It also provides a less obstructed view by pushing the uterus away from the pubic symphysis, as well as by pushing the intestine out of the pelvis.Think like a nurse: The nurse will have access to diagnostic study requirements specific to the facility of employment and will not need to recall every pre-procedure and post-procedure detail. However, whenever a client procedure is scheduled, consider the purpose and nature of the procedure. The uterus sits low and deep in the pelvis. Given the structure of the pelvis, lifting the uterus out of the pelvic cavity offers a better view of a potential pelvic mass. Filling the bladder with water prior to the test expands the uterus, causing it to move up and out of the pelvic cavity, which improves visualization.

The nurse plans discharge care for the client diagnosed with recurrent cancer and lymphedema. Which client statements alert the nurse to a need for home health services? (Select all that apply.)1. "I use this magnifying glass when I need to read small print. "2. "Sometimes I don 't get to the bathroom in time."3. "My hands always shake when I try to pick things up. "4. "My dentures don 't fit so I don 't wear them, but I eat just fine. "5. "I can 't feel a thing in my feet. It 's been that way for a while. "6. "I 'm not able to get in the bathtub anymore. "

ANSWERS:2, 3, 4, 5EXPLANATION:2. "Sometimes I don 't get to the bathroom in time."— A home health referral could benefit this client by assessing for durable medical equipment that might assist the client in using the bathroom. If incontinence is a problem, the client may need assistance with personal care. 3. "My hands always shake when I try to pick things up. "— This client may need assistance preparing meals, and managing medication administration. Home health care can provide accurately assess and provide appropriate referrals. 4. "My dentures don 't fit so I don 't wear them, but I eat just fine. "— Although the client says, "I eat just fine, " a dietary referral will ensure the client has the home resources and ability to eat a balanced diet. The fact that the dentures don 't fit may indicate the client has lost significant weight. 5. "I can 't feel a thing in my feet. It 's been that way for a while. "— A home health referral will determine if this client has safety needs in the home because of numbness in the feet. Slippery or uneven surfaces could be dangerous for this client. Think like a nurse: Referral for home health services requires assessment and documentation of the client 's needs. The nurse should collaborate with the case manager or social worker in determining which services may be required. Use standardized tools (e.g., Katz Index of Independence in Activities of Daily Living) to assess and document activities of daily living limitations that may be required.

The home care nurse visits a client with dementia. The client's adult child tells the nurse, that after talking with the health care provider, the client is taking ginkgo. Which statement, if made by the client's child to the nurse, requires an intervention?1. "My mother takes ibuprofen every day for arthritis."2. "There is a large clock and calendar in my mother's room."3. "I encourage my mother to take a walk with me every day."4. "Mother takes digoxin at the same time every day"

1. "My mother takes ibuprofen every day for arthritis."- Ginkgo is an antiplatelet agent and central nervous system stimulant sometimes taken for dementia syndromes. The risk of bleeding increases when given with NSAIDs. Think like a nurse: The nurse evaluates the client for safety issues and medication interactions. The nurse evaluates the client's dementia and use of ginkgo biloba, ibuprofen, and digoxin. All the statements indicate correct actions by the client and adult child, except the use of ibuprofen with gingko. Gingko increases the risk for bleeding. Some research suggests the beneficial effects of ginkgo may outweigh the risks. However, when taken with a nonsteroidal anti-inflammatory drug (NSAID), the bleeding risk is much more significant and presents an immediate physiological threat to the client.

The nurse learns that a new admission was responsible for the death of a neighbor during a robbery. The nurse says to the head nurse, "I don't think that I can care for that client." Which is the best response by the head nurse?1. "I will talk with the supervisor about your situation."2. "I can see about transferring you to another unit."3. "Please share with me your concerns."4. "You are a professional and will care for the client."

3. "Please share with me your concerns."— This is therapeutic, as it allows the nurse to express concerns and resolve the situation.Think like a nurse: The nurse is a professional who should be able to care for any individual, regardless of the circumstances; however, the nurse is also a human with thoughts, feelings, and experiences. The head nurse asks the nurse for his or her concerns, carefully listening for true conflicts in providing care. If the nurse was friendly with this neighbor, that likely is a true conflict, and the nurse should not be assigned to the client.

The nurse in the emergency department assesses a client diagnosed with burns. Which observation most concerns the nurse?1. Redness and swelling with fluid-filled vesicles noted on right arm.2. Charred, waxy, white appearance of skin on the left leg.3. Reddened blotchy painful areas noted on the trunk.4. Blistering and blanching of the skin noted on the back.

2. Charred, waxy, white appearance of skin on the left leg.— This describes a full-thickness burn. All the skin is destroyed and the muscle and bone may be involved. The substance that remains is called eschar and is dry to the touch. Full-thickness burns do not heal spontaneously and require grafting. All functions of the skin are lost. Think like a nurse: Clients who sustain burn injuries often exhibit varying degrees of burns, each of which is associated with unique nursing and medical considerations. A full-thickness burn, sometimes referred to as a third-degree burn, affects multiple skin layers and underlying structures, including muscle and nerves. Third-degree burns allow for loss of fluid and hematological components, are more prone to infection, present a more difficult recovery process, and are generally more complex compared to other classifications of burns.

The nurse becomes concerned when which client makes the statement, "I've had leg spasms that kept me awake all night, and now I can't feel my hands and feet!"? (Select all that apply.)1. A client with small cell lung cancer.2. A client with stage IV breast cancer with metastasis to the bone.3. A client with acute kidney injury and who has a urinary output of 4500 mL/24 hours.4. A client with acute pancreatitis due to medication toxicity.5. A client following surgery for removal of the thyroid gland.

ANSWERS:3, 4, 5EXPLANATION:3. A client with acute kidney injury and who has a urinary output of 4500 mL/24 hours.- During the polyuric phase of acute kidney injury, calcium is excreted at a higher than normal rate, leading to hypocalcemia. 4. A client with acute pancreatitis due to medication toxicity.- Acute pancreatitis leads to hypocalcemia, as calcium is bound with fatty acids. 5. A client following surgery for removal of the thyroid gland.- The risk of damage to the parathyroid gland in thyroidectomy clients places them at risk for hypocalcemia. Think like a nurse: Leg spasms and paresthesias are symptoms of a low calcium level. The client with the polyuric phase of acute kidney injury is at risk for hypocalcemia because calcium is excreted in the urine output. Hypocalcemia occurs in acute pancreatitis because calcium binds to the fatty acids. With a thyroidectomy, the parathyroid glands can be damaged, which places the client at risk for hypocalcemia.

The nurse manager observes a staff nurse perform tracheostomy suctioning and tracheostomy care. Which staff nurse action requires an intervention by the nurse manager? 1. Wearing clean gloves when removing the tracheostomy kit from its outer package. 2. Hyperoxygenating the client prior to suctioning the tracheostomy tube. 3. Wearing clean gloves while inserting the new inner cannula. 4. Leaving the old tracheostomy ties in place until the new ties are secured.

3. Wearing clean gloves while inserting the new inner cannula.— Sterile gloves are worn while inserting the new, sterile inner cannula to prevent introduction of organisms into the client's airway.Think like a nurse: Before performing tracheostomy care, the nurse needs to remember that tracheostomy care is a sterile procedure and mentally review the process. The nurse will apply knowledge of anatomy and physiology when accessing the tracheostomy, and the body system that is involved, which is the respiratory system. A tracheostomy is an artificial opening created in the trachea to establish either a temporary or permanent airway. Any procedure that involves the tracheostomy tube must be performed using sterile technique in order to prevent infection from developing in the respiratory system. The nurse will apply sterile gloves when changing the inner cannula of a tracheostomy.

The nurse instructs a primigravida woman during the third trimester about the signs and symptoms of impending labor. Which statement by the client indicates to the nurse that the teaching was effective? 1."I will call the health care provider when I see pink-tinged secretions from my vagina."2. "I will call the health care provider when my contractions occur every 5 minutes for an hour."3. "I will call the health care provider when I pass my mucus plug."4. "I will call the health care provider when I feel increased pelvic pressure."

2. "I will call the health care provider when my contractions occur every 5 minutes for an hour."— Contractions that last continuously for an hour generally indicate labor. In true labor, contractions are regular with decreasing intervals between contractions. Contractions will increase in intensity and duration. This statement by the client indicates client understanding.Think like a nurse: Braxton Hicks contractions (e.g. abdomen and groin), which the client may have been experiencing throughout pregnancy, may become stronger and more frequent as impending labor begins. In true labor, contractions are felt in the lower back. The nurse should inform the client about the differences between true and false labor.

The parish nurse knows that it is most important to encourage which parishioner to obtain screening for prostate cancer?1. A Caucasian young adult computer programmer diagnosed with cryptorchidism.2. An Asian-American adult restaurant owner diagnosed with ulcerative colitis.3. An African-American middle-aged adult factory worker in automobile tire manufacturing.4. A Caucasian older adult retired house painter who has been smoking for 40 years.

3. An African-American middle-aged adult factory worker in automobile tire manufacturing.— This client has three major risk factors for prostate cancer: age, race, and employment. Prostate cancer is found most commonly in men age 50 and over. African Americans are affected more than other ethnic groups. Occupation and environment are other definite risk factors, particularly exposure to carcinogens found in urban areas (which have a higher incidence of prostate cancer) and in occupations such as fertilizer, rubber, and textile industries.Think like a nurse: Risk factors for the development of prostate cancer include age, African-American race, and environmental exposure to carcinogens. Based on this information, the African-American client who is middle-aged and works in the automobile industry has the highest risk for the disease.

The nurse leads a family therapy session for the family of an adolescent diagnosed with depression. During the first session, one of the parents dominates the discussion. Which response by the nurse is most appropriate?1."Please let some of the other family members speak."2. "You appear to be frustrated about dealing with your teen."3. "You and I will speak privately after the session is over."4. "How do the rest of you feel about what your family member is saying?"

4. "How do the rest of you feel about what your family member is saying?"— This allows every member of the family to offer feedback about the effect the parent's monopoly of the session has on each person. This engages the family members and encourages them to practice setting boundaries in the relationship.Think like a nurse: Though this is a family counseling session, the focus must remain on the adolescent with depression. Recognizing one individual's tendency to monopolize the discussion helps the nurse understand the family dynamics. However, allowing the individual to continue to dominate the discussion is not therapeutic. Family members with dominant personalities sometimes do not realize their effect on others and may not be aware that their input could be perceived as overbearing or aggressive. Gathering insight from the other family members can assist the nurse with helping the family develop more productive communication strategies.

4. Notify the health care provider.— The nurse should notify the health care provider. The risks and benefits of the procedure must be explained by the person performing the procedure. Think like a nurse: When preparing a client for surgery, the nurse must complete a checklist to ensure all required steps have been taken prior to the procedure. A review of the consent form is completed by the nurse during this process. The consent form for the surgical procedure must be signed by the client when the client is not influenced by potentially mind-altering medication. Because the consent form was not signed before the preoperative medications were provided, the health care provider needs to be contacted to determine the next steps.

The nurse provides discharge teaching to a young adult client diagnosed with HIV and AIDS. Which client statement indicates the nurse's discharge teaching is effective?1. "I should not share a razor with anyone else."2. "I should have a private bathroom that no one else uses."3. "I should not eat my meals at the same table as my family members."4. "I should wash my laundry separately from my family members' clothing."

1. "I should not share a razor with anyone else."— HIV is transmitted through exposure to contaminated blood and body fluids. Sharing a razor may promote disease transmission if the blade is contaminated with blood that contains HIV. Think like a nurse: The nurse provides discharge teaching for a client diagnosed with human immunodeficiency virus (HIV) that has progressed to acquired immunodeficiency syndrome (AIDS). The nurse should think, "What important points should the client know to avoid spreading HIV to others?" HIV spreads through contact with infectious blood or body fluids, not through casual contact. Such personal care items as a razor or toothbrush should not be shared, because they may contain infectious blood or body fluids. Silverware and plates do not require designation for client use only. Only visibly soiled clothing requires separate washing from other household clothing.

The nurse provides care for a client who sustained a fractured right femur. The client has a cast applied. Which type of exercise does the nurse assist the client to perform?1. Passive exercises for the upper extremities.2. Active range of motion exercise of the left leg.3. Passive exercise of the right leg.4. Quadriceps setting of the right leg.

4. Quadriceps setting of the right leg.— Isometric exercise contracts the muscle without movement of the affected joint. This exercise will help maintain strength of the leg.Think like a nurse: The nurse is aware that isometric exercises while wearing a cast are important in preventing complications such as poor circulation and swelling. The exercises should be performed at least three times a day. The simplest exercise is to have the client wiggle the toes. Isometric, non-weight-bearing exercises, where the muscles are made taut and then relaxed in a repetitive manner, help in maintaining the strength of the leg muscles and in preventing weakness and atrophy. The nurse might consider offering the client pain medication prior to performing the exercises, or recommending the client perform the exercises after receiving medication for injury-related pain.

The nurse administers a client's prescribed medications. During administration of ampicillin/sulbactam IV piggyback, the client reports throat itchiness and difficulty breathing. Which actions will the nurse implement? (Select all that apply.)1. Auscultate the client's lungs.2. Stop the IV piggyback infusion.3. Give the client sips of water.4. Lower the head of the client's bed.5. Prepare for administration of epinephrine.

ANSWERS:1, 2, 5EXPLANATION:1. Auscultate the client's lungs.- Auscultation of the client's lungs may reveal wheezes or diminished breath sounds, both of which may occur as a result of bronchoconstriction due to an allergic reaction. 2. Stop the IV piggyback infusion.- Stopping the IV antibiotic infusion is a critical intervention, as the antibiotic medication may be triggering an allergic reaction. 5. Prepare for administration of epinephrine.- Treatment of an allergic reaction may include epinephrine administration. Think like a nurse: Ampicillin is an antibiotic within the penicillin family. Penicillin allergy is one of the most common medication allergies. An itchy throat and difficulty breathing are symptoms of a drug allergy. The first action is to stop the infusion and then auscultate the client's lung sounds. The nurse should also prepare to administer epinephrine, which is used to treat acute allergic reactions.

The nurse provides care to an older adult client with partial and full thickness burns over 75% of the body. Which assessment indicates to the nurse the client is developing shock?1. Epigastric pain and seizures.2. Widening pulse pressure and bradycardia.3. Cool, clammy skin and tachypnea.4. Kussmaul respirations and lethargy.

3. Cool, clammy skin and tachypnea.— The body responds to early hypovolemic shock by adrenergic stimulation. Vasoconstriction compensates for the loss of fluid and causes cool, clammy skin and a rapid rate of breathing. Think like a nurse: The older adult clients are predisposed to shock due to co-existing co-morbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations, and above all due to the effects of aging itself. One of the major age-associated changes in the cardiovascular response to physical or emotional stress is a decrease in cardiac output due to decreased heart muscle contractility and heart rate response to increased stress. The nurse should monitor the older adult client with shock more closely when providing fluid boluses due to increased risk for heart failure. The nurse should be attentive in looking for atypical signs of shock such as alteration in mental status.

The nurse assesses a client with a colostomy. Which stomal appearance indicates a prolapse has occurred? 1. Protruding.2. Narrowed and flattened. 3. Sunken and inverted. 4. Dark, bluish colored.

1. Protruding.- A prolapsed stoma is protruding and indicates that the bowel is protruding through the stoma.Think like a nurse: When preparing to care for a client with a colostomy, the nurse should mentally ask, "What characteristics are expected when assessing the stoma?" A normal stoma is nearly flush with the abdominal skin and is pink to beefy red in color. The skin around the site should be intact. The nurse identifies evidence of a problem if a portion of the colon can be seen protruding through the stoma. This is called a prolapse and must be immediately reported to the health care provider for evaluation and intervention.

A client in a domestic violence shelter asks the nurse to explain why the client continues to be beaten. Which response is the best for the nurse to make?1. "Can you remember what you said or did just before being hit? "2. "Let 's focus on getting your face and ribs healed first. "3. "We can help you when you 're ready. You do not deserve to be abused. "4. "Only the person who is beating you can tell us what causes the violence. "

3. "We can help you when you 're ready. You do not deserve to be abused. "- Saying that help is available when the client is ready is a reflective statement that is therapeutic. This statement also provides information because it offers support and a path to help, coupled with reinforcement that the client does not deserve to be abused. Think like a nurse: The nurse can help the client understand that the client is not responsible for the perpetrator 's violent behavior (e.g. saying to the client: "You are not responsible for your partner 's violence. ") As a general rule, when communicating with victims of violence, it is best for the nurse not to say anything the nurse is unsure can be followed through. The nurse should inquire if the violence involves children and follow protocol on how to protect them. In some institutions, a standardized screening form is used and an intervention algorithm is implemented.

The nurse prepares to administer the Haemophilus influenzae type b (Hib) vaccine to a 4-month-old infant. The nurse teaches the infant's parent about the vaccine. Which information does the nurse include in the teaching?1. "Monitor your child for signs of allergic reaction for a few hours after the vaccine."2. "Your child will receive 1 or 2 doses of the vaccine, depending on the vaccine used."3. "Immediately notify the health care provider of a low-grade fever."4. "This vaccine cannot be given at the same time as other vaccines."

1. "Monitor your child for signs of allergic reaction for a few hours after the vaccine."-Signs of allergic reaction to the Hib vaccine include hives, facial and airway edema, difficulty breathing, tachycardia, dizziness, and weakness. These typically begin a few minutes to a few hours after the child receives the vaccine.Think like a nurse: Health promotion and disease prevention activities include providing vaccinations at the appropriate age. Even though a vaccination is intended to prevent the onset of disease, the actual vaccination is not without risk. Some individuals will react immediately to the introduction of foreign material into the body, whereas others may not have a reaction until several hours have passed. Since it is not realistic to expect a client to remain in the presence of the health care provider until all risk of a reaction has passed, the nurse should instruct the parent or person receiving the vaccination of what to expect as signs of a reaction, and what actions to take should any of the signs occur.

The nurse provides care to a client who is admitted to the emergency department (ED) with a serum glucose level of 32 mg/dL (1.8 mmol/L). The client is drowsy and has cold, clammy skin. The nurse anticipates implementation of which priority intervention?1. Recheck the client's serum glucose level.2. Administer glucagon IM.3. Provide the client with orange juice.4.Obtain an EKG on the client.

2. Administer glucagon IM.- For the hypoglycemic client who demonstrates decreased level of consciousness, the priority intervention is administration of glucagon. If an IV access device is in place, dextrose 50% (D50) may be administered intravenously instead of glucagon IM. Administration of oral fluid is contraindicated due to the client's decreased level of consciousness. Rechecking the client's serum glucose level and obtaining an EKG are appropriate actions. However, administration of glucagon is the priority for this client. Think like a nurse: The nurse must recognize assessment findings that indicate hypoglycemia and be prepared to implemented preferred treatment. Hypoglycemia affects level of consciousness and all body functions. The client literally has no fuel in the form of glucose to perform any actions. Because the client is lethargic, oral intake is avoided due to the risk for aspiration. Glucagon, which stimulates the release of glucose by the liver, is administered by IM injection. As the client's condition improves, the nurse conducts additional assessments, which will determine implementation of additional treatment measures.

The nurse provides care to a client who is prescribed chlordiazepoxide. Which client observation is of most concern to the nurse?1. Shuffling gait and rigidity.2. Drowsiness and blurred vision.3. Photosensitivity and jerky movements.4. Hypertension and slurred speech.

2. Drowsiness and blurred vision.- Chlordiazepoxide is an antianxiety drug. Drowsiness and blurred vision are adverse reactions and should be reported to the health care provider. Additional side effects include constipation, slurred speech, dermatitis, anorexia, polyuria, pancytopenia, and thrombocytopenia. Administer after meals or with milk to decrease the GI irritation.Think like a nurse: Drowsiness and blurred vision are adverse effects of chlordiazepoxide, an anti-anxiety medication, and should be reported to the health care provider. Parkinsonism effects, jerky movements, and photosensitivity are frequently seen in those taking anti-psychotic medication. Hypertension and slurred speech may indicate a reaction to monoamine oxidase (MOA) inhibitor medication.

The nurse provides care for a client diagnosed with pneumonia who is pale and reports shortness of breath. Which laboratory test does the nurse expect the health care provider to prescribe to determine oxygenation status?1. RBC count.2. Sputum culture.3. ABG analysis.4. Urine culture and sensitivity.

3. ABG analysis.— ABGs evaluate gas exchange in the lungs, providing information about client's oxygenation status.Think like a nurse: The nurse is aware the client experiencing shortness of breath because of an acute lung infection may need an adjustment to supplemental oxygen or a change in prescribed medications. However, the nurse will expect the health care provider to gather diagnostic data before any changes are made. One test that will provide the most current and accurate information about respiratory functioning is the arterial blood gas. The nurse knows this test requires a sample of arterial blood. The blood is analyzed for the amount of oxygen and carbon dioxide in the blood. Based upon the results of this test, further treatment can be planned that will be the most effective for the client's symptoms.

The nurse in the prenatal clinic assesses a client at 38 weeks' gestation. The client reports an inability to get comfortable. Which statement by the nurse is appropriate?1. Encourage the client to exercise vigorously to stimulate labor.2. Tell the client to lie with back on a hard surface and feet elevated.3. Suggest the client drink 12 ounces of water per hour while awake.4. Inform the client that low-heeled shoes might help back discomfort.

4. Inform the client that low-heeled shoes might help back discomfort.— Because the client is at 38 weeks' gestation, there are changes in the curvature of the sacrum. Low-heeled shoes (or orthopedic shoes) may relieve back discomfort.Think like a nurse: Musculoskeletal pain is common during pregnancy. This is due to hormonal changes, muscle separation, postural changes, stress, and weight gain. Simple activities the client can do to relieve and prevent back pain include using legs to squat rather than bend over when picking up something from the ground, wearing low-heeled shoes, and wearing support hose. When sitting, the client is advised to use foot support and a pillow behind the back. The nurse should also explore and rule out other causes of back pain, such as uterine contractions, urinary tract infection, and musculoskeletal disorders

The nurse provides care for an antepartum client. Which factors, identified by the nurse on assessment, increase the risk of thrombosis? (Select all that apply.)1. Vaginal birth.2. Obesity.3. Maternal age greater than 27 years.4. Varicose veins.5. Forceps use during delivery.

ANSWERS:2, 4, 5EXPLANATION:2. Obesity.-Obesity is a risk factor for thrombosis. 4. Varicose veins.- Having varicose veins is a risk factor for thrombosis. 5. Forceps use during delivery.-Forceps use during delivery is a risk factor for thrombosis. Think like a nurse: The nurse is aware that pregnancy, labor, and delivery increase the risk of deep vein thrombosis (DVT), especially when the procedure is lengthy (which allows blood to pool) or when a vein sustains injury causing inflammation. Obesity increases pressure in leg veins and on the pelvic organs, resulting in increased blood stasis. Varicose veins allow blood pooling and clotting. Deliveries assisted by forceps are often prolonged, resulting in increased pressure on pelvic vessels, resulting in lower extremity venous pooling. Forceps can also cause vessel damage. Anyone who has given birth is at increased risk of DVT and pulmonary embolism for about 6 weeks due to hypercoagulation, vascular damage, and venous stasis from pressure in the pelvis.

The nurse counsels a client diagnosed with glaucoma. Which client statement demonstrates to the nurse that teaching is successful?1. "Because of glaucoma, the correction in my eyeglasses needs to be changed. "2. "I will schedule appointments with my physician early in the morning. "3. "I 'm glad that surgery can reverse the damage caused by the glaucoma. "4. "I will be happy when I don 't have to use the eye drops anymore. "

2. "I will schedule appointments with my physician early in the morning."— Intraocular pressure (IOP) tends to be higher in the early morning hours. An early morning assessment is likely to be more accurate. Think like a nurse: The nurse needs to understand that glaucoma causes an increase in intraocular pressure. A client with this health problem will need frequent ophthalmologic examinations to measure eye pressure. Depending upon the pressure, medications will be prescribed to reduce the pressure in efforts to maintain the integrity and function of the optic nerve and preserve vision. Since intraocular pressure peaks in the morning, the client should schedule ophthalmologic appointments early in the day so that appropriate treatment can be planned.

A client is in the emergency department to rule out a cerebral vascular accident (CVA). The client suddenly develops a severe headache and loses consciousness. Which finding is a priority for the nurse to report to the health care provider?1. A history of atrial fibrillation.2. The client takes warfarin every day.3. The blood glucose level is 200 mg/dL (11.1 mmol/L).4. Lung sounds are diminished bilaterally at bases.

1. A history of atrial fibrillation.- Atrial fibrillation results in a decrease in cardiac output because of ineffective atrial contractions or a rapid ventricular response. Thrombi form in the atria because of blood stasis. An embolus may develop and move to the brain, causing a CVA. Atrial fibrillation accounts for as many as 17% of all CVAs. Think like a nurse: While assessing a client with symptoms of a cerebrovascular accident (CVA) or stroke who loses consciousness, the nurse pauses and asks, "What information in the health history could be contributing to the current health problem?" The nurse recalls the risk for CVAs, which include blood clots or hemorrhage. When comparing the client's health history with potential causes of stroke, the nurse identifies that atrial fibrillation increases this client's risk stroke due to blood stasis in the right atrium. This is the information the nurse immediately shares with the health care provider.

The nurse provides care to a client who just underwent left modified radical mastectomy. When assisting the client with positioning, the nurse implements which action?1. Extend the client's left arm flat along the affected side.2. Elevate the client's left arm on a pillow.3. Rest the client's left arm across her chest.4. Place the client's left arm below the level of her torso.

2. Elevate the client's left arm on a pillow.- Following modified radical mastectomy, the client should be placed in semi-Fowler position. To promote lymphatic drainage without compromising circulation, the arm on the affected side should be elevated on a pillow. Elbow flexion or dependent positioning of the arm may impede lymphatic drainage and compromise circulation.Think like a nurse: The nurse needs to mentally ask, "What is a likely manifestation for a client following a mastectomy?" Reviewing the surgical procedure for a modified radical mastectomy, the nurse recalls it is likely that many, if not all, of the lymph nodes and glands surrounding the breast tissue were removed. The nurse can now conclude the removal of lymph tissue increases the client's risk of developing lymphedema in the extremity that is on the same side of the surgery. Lymphedema can increase pain and complicate healing. To reduce the risk of lymphedema, the nurse should make sure that the limb on the same side of the surgery is elevated on a pillow.

The nurse performs dietary teaching for a client with acute inflammatory bowel disease. The nurse determines that further teaching is required if the client makes which statement?1. "I make my sandwiches with white bread."2. "My favorite dessert is tapioca pudding."3. "My family likes to eat roasted chicken."4. "I drink a glass of red wine with dinner."

4. "I drink a glass of red wine with dinner."- Wine may exacerbate the inflammatory condition.Think like a nurse: When evaluating client education, the nurse asks the client to teach back. This client describes multiple foods that are acceptable for an individual diagnosed with inflammatory bowel disease (IBD). However, additional teaching is needed to explain that wine may exacerbate the client's symptoms. The client should be advised that intake of even one alcoholic beverage may trigger an exacerbation of IBD. The nurse considers the client's preferred diet and offers similar, acceptable alternatives where indicated.

The nurse in the emergency department provides care for a client experiencing a heroin overdose. The nurse administers naloxone to the client. The nurse anticipates which response?1. Heart rate 74 beats/min and pallor.2. Blood pressure 82/46 mm Hg.3. Prolonged lethargic state.4. Moderate volume emesis.

4. Moderate volume emesis.— Naloxone will cause signs and symptoms of opioid withdrawal: nausea, vomiting, restlessness, abdominal cramping.Think like a nurse: Clients who experience narcotic overdose will demonstrate shallow, slow respirations; flaccidity; and lethargy or unconsciousness. When naloxone is administered to a client for reversal of opioid overdose, the client may experience chest pain, seizures, vomiting, and diaphoresis as opioids are displaced from opiate receptors in the central nervous system. Administration of a reversal agent does not necessarily reverse all symptoms of the overdose. However, naloxone should reverse respiratory depression. The duration of action for naloxone is shorter than the duration of action of most opioids. As such, the client must be monitored for rebound opioid toxicity, especially respiratory depression. If necessary, administration of naloxone should be repeated as prescribed.

During the admission assessment, an older adult client exhibits poor skin turgor, dry lips, and an open sacral wound with reddened edges and malodorous drainage. The nurse observes the client has poor hygiene and a withdrawn affect. Which actions will the nurse implement? (Select all that apply.)1. Bring the client's caregiver into the room.2. Alert the nursing supervisor to possible elder abuse.3. Obtain a thorough skin assessment.4. Perform an elder mistreatment assessment.5. Conduct a mini mental status exam.

ANSWERS:2, 3, 4EXPLANATION:2. Alert the nursing supervisor to possible elder abuse.— Health care workers are mandated to report suspected mistreatment to the authorities. Follow the facility's procedure for reporting suspected abuse. 3. Obtain a thorough skin assessment.— A thorough assessment may reveal other indications of abuse. Document all findings clearly in the health care record. 4. Perform an elder mistreatment assessment.— Protocols for elder mistreatment screening should be followed. This will include documentation and photographs. Think like a nurse: The client's symptoms, hygiene, and affect could indicate elder abuse or neglect. The first action is to complete a thorough skin and elder mistreatment assessment. Based upon the findings, the nurse should notify the supervisor to report suspected elder abuse. The client should be assessed alone. Having family or a caregiver present could hinder free and honest communication from the client.

The nurse provides care for a client diagnosed with tuberculosis. Which transmission-based precautions will the nurse implement?1. Standard.2. Airborne.3. Droplet.4. Contact.

2. Airborne.— Tuberculosis is transmitted by airborne droplets. The nurse implements airborne precautions.Think like a nurse: Clients with pulmonary or laryngeal tuberculosis (TB) are placed on airborne precautions, in addition to standard precautions. The nurse and all staff members should wear an N95 mask (fit-tested size). Ideally, the client should have a private room with a negative pressure. Discontinue precautions only when the likelihood of infectious TB disease is deemed negligible and either there is another diagnosis that explains the clinical syndrome or the results of three sputum smears for acid-fast bacillus (AFB) are negative. Each of the three sputum specimens should be collected 8 to 24 hours apart, and at least one should be an early morning specimen.

The nurse assesses the uterus of a postpartum client who is breast feeding. The nurse notes that the fundus is boggy and deviated to the right side of the client's abdomen. Which action does the nurse take next?1. Have the client void and reassess the result.2. Ask if the client has experienced pelvic pain while breastfeeding.3. Assess when the client last breastfed.4. Put the baby to breast and reassess uterine muscle tone.

1. Have the client void and reassess the result.- The uterine fundus descends at a predictable rate as the muscle cells contract to control bleeding at the placental insertion site. After the placenta is expelled, the uterine fundus can be felt midline, at, or below the level of the umbilicus as a firm mass. A lateral deviation is related to a distended bladder.Think like a nurse: Prior to implementing a specific action, the nurse should mentally ask, "What does each of the assessment findings mean?" The nurse should recognize a boggy uterus because it will feel soft when palpated. A boggy uterus increases the client's risk of bleeding after delivery, because the blood vessels at the previous site of the placenta are not closed off. A displaced uterus can occur if the bladder is distended, and the nurse should first assess for the last time the client voided. After voiding, the nurse should reassess the status of the uterus. It may return to midline, but it may continue to be boggy, which can be addressed by external massage.

The nurse assesses the client diagnosed with seizures, migraines, and type 1 diabetes mellitus (DM). Which client statement requires follow up by the nurse? (Select all that apply.)1. "I see fireflies around my head."2. "I can't seem to wake up today."3. "My hands won't stop shaking."4. "I usually give myself the insulin."5. "I usually sleep after a seizure."

ANSWERS:1, 2, 3EXPLANATION:1. "I see fireflies around my head."— This client statement requires follow up by the nurse. Flashing lights may indicate aura before the seizure or a migraine. 2. "I can't seem to wake up today."— This client statement requires follow up by the nurse. Hypersomnia or fatigue may indicate hyperglycemia, an adverse effect of poorly managed type 1 DM. 3. "My hands won't stop shaking."— This client statement requires follow up by the nurse. Tremors may be associated with hypoglycemia, an adverse effect associated with type 1 DM. Think like a nurse: The client with seizures, migraines, and diabetes mellitus has significant nursing management needs, and symptoms of complications may overlap and cause confusion. Additionally, this client may be on multiple medications that also have interaction potential. The client's glucose must be tightly controlled. The brain is very sensitive to glucose levels and changes in stimulation of the central nervous system is avoided in the client with migraines or seizures.

The nurse provides care to a client diagnosed with a pelvic fracture after a motor vehicle accident. The nurse notes that the client is agitated and attempting to get out of bed. The client has removed the IV and reports shortness of breath. The client's blood pressure is 90/58 mm Hg, respirations 28 breaths/minute, pulse 133 beats/minute, and O2 sat 78% on 3.5 L/minute of oxygen. Which action will the nurse perform? (Select all that apply.)1. Administer normal saline 500 mL bolus.2. Assess breath sounds.3. Obtain arterial blood gases (ABG).4. Begin cardiopulmonary resuscitation (CPR).5. Continue to administer oxygen at 3.5 L/m via nasal cannula.6. Establish vascular access.

ANSWERS:2, 3, 6EXPLANATION:2. Assess breath sounds.— The client is responding to low oxygen levels; therefore, the nurse needs to assess to determine cause. 3. Obtain arterial blood gases (ABG).— The client is responding to low oxygen levels; therefore, the nurse draws an ABG to further assess the client. 6. Establish vascular access.— The nurse needs to reestablish IV access to administer medications. Think like a nurse: The client's symptoms indicate acute hypoxia, which may be caused by either a pulmonary or fat embolism. The nurse needs to intervene to ensure adequate oxygenation. Breath sounds should be assessed and arterial blood gases sent to help determine the cause for the symptoms. An intravenous access site is necessary for medication administration.

The nurse supervises a novice nurse providing care to a client with new symptoms of a cerebrovascular accident (CVA). Which actions by the novice nurse cause the seasoned nurse to intervene? (Select all that apply.)1. Administers to the client aspirin 325 mg by mouth.2. Prepares the client for a CT scan.3. Assigns the client a 0 score on the National Institute of Health stroke scale screen.4. Measures the client's blood pressure.5. Compiles a list of the client's home medications.6. Reassures the client that all symptoms will resolve.

ANSWERS:1, 3, 6EXPLANATION:1. Administers to the client aspirin 325 mg by mouth.— The client should have a CT scan first to determine whether the symptoms of the CVA are caused by ischemic changes or a cerebral hemorrhage. If the symptoms are caused by a hemorrhage, aspirin is contraindicated. Fibrinolytic therapy, and not aspirin therapy, should be considered if the stroke is not hemorrhagic in origin. 3. Assigns the client a 0 score on the National Institute of Health stroke scale screen.— If the client is demonstrating symptoms of a CVA, the National Institute of Health stroke scale screen cannot be 0. 6. Reassures the client that all symptoms will resolve.— The nurse cannot guarantee that all of the symptoms of the CVA will completely resolve. Think like a nurse: Before answering this question, recall the information within Benner's theory "From Novice to Expert." The novice nurse may have graduated from nursing school and passed the state board examination, but may still have learning needs. The client demonstrating symptoms of a stroke needs care to prevent additional cerebral ischemia or bleeding. This means that nothing should be provided to the client that may encourage bleeding. The nurse may not be experienced enough on the use of the stroke scale rating tool. And, the nurse is providing the client with false hope, which may hinder the recovery process. It is wise for the expert nurse to intervene to ensure for the client's safety, appropriate assessment, and realistic psychosocial support during this health crisis.

The nurse provides care for an adolescent admitted for burns to 50% of the body. What action is the highest priority for the nurse?1. Counsel the client regarding body image changes.2. Maintain airborne precautions.3. Maintain sterile technique during procedures.4. Encourage the client's friends to visit regularly.

3. Maintain sterile technique during procedures.— The client is at high risk for infection. The nurse should use careful sterile technique when performing wound care. This ensures the client physical safety and is the highest priority.Think like a nurse: The nurse needs to draw on integrated knowledge related to anatomy and physiology in making clinical judgments about this client's needs. Knowing the skin is the body's first line of defense against microorganisms will assist the nurse in making the best and safest care decisions. Since the client has lost 50% of the total body skin surface, the risk for infection is high. The nurse should ensure that all procedures and skin care are provided using sterile technique to reduce the client's risk for infection, which is the nurse's highest priority.

The nurse provides care for a client at 7 months gestation diagnosed with preeclampsia. An IV of magnesium sulfate is initiated at 2 grams/hour. Which is the most important action for the nurse perform?1. Darken the client's room.2. Perform a vaginal exam.3. Measure the deep tendon reflexes.4. Assist the client to a comfortable position.

3. Measure the deep tendon reflexes.— Magnesium sulfate is given to prevent eclampsia. Hypermagnesemia causes CNS depression, relaxes smooth muscle, and prevents seizures. Assess respirations and tendon reflexes for early signs of toxicity. Vital signs are monitored at least every 15 minutes.Think like a nurse: The client diagnosed with preeclampsia may be prescribed an infusion of magnesium sulfate. The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects. Therapeutic effects of the magnesium infusion are the result of blocked neuromuscular transmission and vasodilation production, and are evidenced by a normal or controlled blood pressure and absence of seizures. Side effects might include flushing, sweating, diplopia, blurred vision, and mild weakness. Adverse effects include respiratory paralysis, circulatory collapse, hypothermia, and hypocalcemia. Adverse reactions are often prevented by careful monitoring of deep tendon reflexes.

The nurse teaches a new mother who is breastfeeding about the stool that the newborn will eliminate. Which information will the nurse include?1. Several soft formed, brown stools daily are normal.2. Expect 3 to 6 small, soft, orange-yellow stools each day.3. One well-formed yellow stool daily.4. Frequent, loose, green stools will occur each day.

2. Expect 3 to 6 small, soft, orange-yellow stools each day.- The stool of a breastfed infant is orange-yellow, soft, and small with an even consistency. The mother should expect up to 6 stools a day. The number of stools decreases with age. The color changes with the introduction of solid foods. Think like a nurse: Before teaching the client about the type of stool the newborn will eliminate, the nurse should mentally recall the physiological processes associated with breastfeeding and the infant. The infant is not ingesting solid food and is being sustained on breast milk. Because breastmilk is more easily digested by the infant, the appearance and consistency of the bowel movements are affected. The nurse should include this information when teaching, and remind the client that the number of stools will decrease with time, and that the consistency and color will change as solid foods are introduced.

The nurse provides care to a school-age client who is prescribed amoxicillin suspension 250 mg PO for treatment of an upper respiratory infection (URI). Prior to administering the medication, the nurse provides which information to the client?1. "Amoxicillin is an antibiotic that will help you get well."2. "This medicine tastes just like fresh strawberries."3. "You can't drink anything for an hour after taking this medicine."4. "If you don't want to drink this medicine, I can give you a shot instead."

1. "Amoxicillin is an antibiotic that will help you get well."— For the school-age client, discussion of facts is appropriate. School-age clients can process information about their treatments and benefit from participating in their plan of care.Think like a nurse: School-age clients are given facts about their care. Telling things that are false, tricking, and trying to make the client fearful of other medication options is not professional, and will cause the child to become argumentative or distrustful. The nurse is honest and describes the client's care in age-appropriate words, empowering the child to help manage his or her own well-being.

The nurse instructs the client who is diagnosed with mastitis of the left breast about breastfeeding the client's infant. Which statement by the client best indicates understanding of the instructions?1. "I will feed the baby only from the right breast until this infection clears."2. "It will be necessary for me to wean my baby from breastfeeding very quickly."3. "Everyone in my family should use good handwashing techniques at all times."4. "I should wear a tight compression bra to decrease the tenderness."

3. "Everyone in my family should use good handwashing techniques at all times."— Anyone who is in contact with the infant should use good handwashing techniques to prevent the spread of infection. It is not necessary to discontinue breastfeeding on the affected breast and is not desired, as discontinuing breastfeeding will increase breast engorgement and exacerbate pain.Think like a nurse: The nurse should assess the client for risk factors for mastitis, such as poor hygiene, ductal abnormalities, nipple cracks and fissures, lowered maternal defenses due to fatigue, tight clothing, poor support of pendulous breast, failure to empty the breast properly while breastfeeding, or missing a breastfeeding. The nurse should use the teach-back method in all client education activities.

The nurse prepares to perform a breast examination on a 20-year-old female client. Which question is most important for the nurse to ask before beginning the examination?1. "When was your last menstrual period?"2. "Do you have a family history of breast cancer?"3. "How much caffeine do you consume a day?"4. "Have you ever had a mammography?"

1. "When was your last menstrual period?"- Breast examination is ideally done about 1 week after the onset of menses, when hormonal influences on the breasts are at a low level.Think like a nurse: A breast examination is considered a part of the physical assessment. However, before beginning this portion of the examination the nurse should mentally ask, "What is the most common event that can impact this examination?" Using knowledge of anatomy and physiology, the nurse should recognize the importance of determining when the client last had a menstrual cycle. If the breasts are assessed immediately before or during menses, the client may exhibit swelling and tenderness and experience unnecessary discomfort during the examination.

The nurse teaches parents of children prescribed atomoxetine. Which information does the nurse include in the teaching? (Select all that apply.)1. "There is a low risk of dependence with this medication."2. "Your child may take atomoxetine with or without food."3. "Record your child's weight weekly."4. "Offer your child fresh fruits and vegetables daily to prevent constipation."5. "Atomoxetine should not be taken by children under 95 pounds."6. "Risk of suicidal thoughts may occur in children taking atomoxetine."

ANSWERS:1, 2, 3, 4, 6EXPLANATION:1. "There is a low risk of dependence with this medication."-Atomoxetin is prescribed for attention deficit hyperactivity disorder (ADHD). When compared with other medications available to treat ADHD, atomoxetine has a low risk for dependence.2. "Your child may take atomoxetine with or without food."- This is correct information.3. "Record your child's weight weekly."- Even though atomoxetine is not a stimulant, anorexia may occur, so parents should monitor their child's weight.4. "Offer your child fresh fruits and vegetables daily to prevent constipation."- Atomoxetine may cause constipation. Increasing the intake of fresh fruits and vegetables (high in fiber) will help to alleviate this side effect.6. "Risk of suicidal thoughts may occur in children taking atomoxetine."- Suicidal ideation is an adverse effect of atomoxetine that may occur. Parents should monitor their child's mood.Think like a nurse: Medication teaching supports adherence and ensures the maximum effect of the prescription. Atomoxetine, a medication used to treat attention deficit/hyperactivity disorder, has a low risk for dependence. This medication can be taken with or without food and weight should be monitored because of anorexic effects. Constipation and suicide ideation can occur when taking this medication and actions should be taken to prevent the development of both.

The cardiac monitor of a client who is awake and alert and has a peripheral pulse shows ventricular tachycardia with a rate of 160 beats/min. Which actions are appropriate for the nurse to implement? (Select all that apply.)1. Defibrillate using 200 joules.2. Monitor blood pressure.3. Alert the rapid response team.4. Prepare to administer adenosine by slow IV push.5. Obtain a 12-lead electrocardiogram as prescribed.

ANSWERS:2, 3, 5EXPLANATION:2. Monitor blood pressure.— The nurse should monitor the client's blood pressure to determine whether the client is tolerating the rhythm. 3. Alert the rapid response team.— The nurse should alert the rapid response team to assist with the client's care. Evidence shows that rapid response teams help improve client outcomes when changes in condition occur. 5. Obtain a 12-lead electrocardiogram as prescribed.— The nurse should obtain a 12-lead ECG, as prescribed, to evaluate the client's cardiac conduction. Think like a nurse: Treatment of ventricular tachycardia with a pulse requires treatment of reversible causes. The nurse prepares for possible synchronized cardioversion. The client might require sedation prior to the procedure. The client's hemodynamic status should be monitored closely while promoting airway patency. The nurse is expected to draw a serum metabolic profile to verify if electrolyte imbalances caused the ventricular tachycardia. If the client becomes pulseless, the cardiac arrest team should be summoned (e.g., "call a code").

The nurse provides care for a 12-month-old client during a wellness visit. The client is due to receive the first dose of the measles, mumps, and rubella (MMR) vaccine. The nurse notes that the client has a low-grade fever and signs of a minor respiratory illness. Which action by the nurse is appropriate? 1. Administer the vaccine on schedule.2. Postpone the vaccination until the child becomes afebrile.3. Postpone the vaccination until the respiratory illness is gone.4. Administer an antipyretic and then administer the vaccine.

1. Administer the vaccine on schedule.—The child should receive the vaccine as scheduled. Vaccination should not be postponed because of low-grade fever or minor respiratory illness.Think like a nurse: After birth, the newborn is protected for a short period of time by the mother's immunity, which is provided while in utero. For future immunity, the newborn needs to receive vaccinations in order to prevent the development or contraction of certain illnesses. A schedule of immunizations has been created, which identifies the appropriate times when vaccination should be provided. Reasons to withhold the vaccine would be evidence of immunosuppression or allergy to the vaccine. Since these reasons are not present in this scenario, the nurse should proceed and provide the vaccination as recommended.

The nurse prepares to discharge a newborn home with the parents. Which statement by one of the parents indicates to the nurse a need for further teaching about newborn care?1. "I will notify my health care provider about absence of breathing for 10 seconds. "2. "I will notify my health care provider about more than one episode of projectile vomiting. "3. "I will notify my health care provider if my baby 's temperature is greater than 101 °F (38.3 °C). "4. "I will rock and cuddle my infant frequently to promote a sense of trust. "

1. "I will notify my health care provider about absence of breathing for 10 seconds."- It is normal for a neonate to have periods of apnea. Apnea lasting longer than 20 seconds should be reported to the health care provider. Think like a nurse: Infant apnea is diagnosed for any unexplained episode of the cessation of breathing that lasts 20 seconds or longer or when a shorter respiratory pause is associated with other symptoms (e.g. bradycardia, cyanosis, pallor, and the occurrence of marked hypotonia). While apnea is fairly common in preterm infants, it is rare among full-term healthy infants. When apnea occurs for full-term infants, it is usually an indication of an underlying pathology. The nurse should offer reassurance to parents by explaining the difference between true apnea and periodic breathing (pauses in respiration that last less than 10 seconds). Periodic breathing is not dangerous and no intervention is required.

The nurse provides care for the client in the post-anesthesia care unit (PACU). Which assessment finding requires the nurse to contact the health care provider (HCP)? (Select all that apply.)1. The client experiences coarse, crowing respirations.2. The client's respiratory rate is 10 breaths/min.3. The client is disoriented and has oliguria.4. The client is restless and shouting.5. The client's core temperature is 94.8 ºF (34.89 ºC).6. The client's blood pressure is 110/69 mm Hg.

ANSWERS:1, 2, 3, 4, 51. The client experiences coarse, crowing respirations.— Coarse, crowing respirations require the nurse to contact the HCP. Stridor indicates laryngospasm, which is an emergent airway complication. 2. The client's respiratory rate is 10 breaths/min.— A respiratory rate of 10 breaths/min requires the nurse to contact the HCP. Hypoventilation related to anesthesia and opioids indicates an oxygenation complication. 3. The client is disoriented and has oliguria.— Disorientation with oliguria requires the nurse to contact the HCP. Oliguria is a sign of hypoperfusion and indicates a circulation complication. Disorientation deepens the nurse's concern about this client. 4. The client is restless and shouting.— Restlessness and shouting require the nurse to contact the HCP. The emergence of restlessness may be neurological or a sign of an impending and emergent oxygenation or perfusion issue. 5. The client's core temperature is 94.8 ºF (34.89 ºC).— A core temperature below normal requires the nurse to contact the HCP. Hypothermia can increase risks and increases oxygen consumption. Think like a nurse: The immediate post-operative period is critical for monitoring the client for serious complications. The priority assessment and management is focused on airway, breathing, and circulation (ABC). The initial assessment should cover all the major body systems and the operative wound. The nurse needs to be aware of signs of inadequate oxygenation (e.g. changes in mental status and behavior). The nurse should escalate the scenario to the next level to get the client evaluated by the surgeon or anesthesiologist.

A client diagnosed with borderline personality disorder becomes angry when the nurse refuses to permit the client's partner to spend the night with the client in the hospital. Which response by the nurse is best?1. "If I made the rule, I could help you, but I can't."2. "It's not fair to put me in this difficult position."3. "Visiting hours are over at 8 pm, and all visitors must leave."4. "Your partner can stay until I leave at midnight, but lock your door."

3. "Visiting hours are over at 8 pm, and all visitors must leave."— Stating visiting hours and expectations that visitors must leave provides information and sets limits and expectations for the client to behave according to unit policy.Think like a nurse: In dealing with clients who have borderline personality disorder, the nurse should understand why the clients act and react the way they do, then respond in ways that validate their feelings and help them regain and maintain emotional control. For example, the nurse may say, "I understand how you feel." The nurse should not focus on the situation, but the emotion behind it. The nurse can set limits and should invoke institutional policy consistently.

The nurse leads group therapy for clients diagnosed with substance abuse. A client diagnosed with alcoholism, and who occasionally uses marijuana and cocaine, attends the meeting. During the meeting the client states, "I am having trouble sitting still. Am I bothering anybody? Maybe I should not come to these meetings." Which action by the nurse is most appropriate?1. Encourage the client to share problems with the group.2. Remove the client from the group and further assess needs.3. Recognize this as manipulative behavior and encourage the client to remain in the group.4. Tell the other group members to ignore the client and continue with the group meeting.

1. Encourage the client to share problems with the group.— The client is probably experiencing some mild level of anxiety. The nurse should reinforce and encourage the client to share feelings and attend the meeting. Think like a nurse: Group therapy for drug addictions is difficult for the client who might feel out of place, not know how to participate, and be generally uncomfortable in this new setting. An invitation to join in the discussion helps to guide the client into the environment and understand what is expected. The nurse works toward easing the client's anxiety and feeling secure in sharing information and thoughts.

The nurse notes that a client diagnosed with acquired immune deficiency syndrome (AIDS) has hyperpigmented skin lesions. Which complication associated with the current diagnosis does the nurse suspect this client is experiencing?1. Kaposi sarcoma.2. Varicella-zoster virus infection.3. Candida albicans.4. Herpes simplex type 1 infection.

1. Kaposi sarcoma.— Hyperpigmented skin lesions are associated with Kaposi sarcoma.Think like a nurse: The nurse is aware that acquired immune deficiency syndrome (AIDS) is caused by a virus that attacks and causes malfunctioning of the immune system. A client with this disorder is at risk for developing opportunistic infections because the body is unable to fend off microorganisms and disease processes. One disease process commonly seen in clients with AIDS is Karposi sarcoma. This illness is characterized by skin lesions that are darker than the client's skin tone. Definitive diagnosis of this illness occurs after a lesion is biopsied. Treatment will depend upon the findings.

An older adult client who appears alert, oriented, and well-groomed shares with the nurse, "Lately, I am seeing things that are not there. It is always people. I am awake and sitting down and I know they are not there, but I see them." Which response by the nurse is appropriate?1. "Has anyone in your family ever been diagnosed with schizophrenia?"2. "What medications have you been taking recently?"3. "Don't worry. You may actually have been asleep and dreaming."4. "The Alzheimer organization offers some tests you may want to take."

2. "What medications have you been taking recently?"- This response is an open-ended question. Some medications can cause confusion and hallucinations. Older adult clients are more prone to experiencing these manifestations as the renal function declines with age, decreasing the rate at which medications are eliminated from the body.Think like a nurse: The nurse should mentally ask, "What factor can be assessed first that will provide important information without a jump to conclusions or disregard of client's concerns?" Older adult clients are at risk for medication toxicity due to a variety of age-related physiologic changes, including decreased renal clearance. Adverse drug reactions among older adult clients may manifest as altered mental status, delirium, orthostatic hypotension, incontinence, and gastrointestinal manifestations such as anorexia and nausea. Depending on the prescribed medication, monitoring the client's serum medication level may be indicated.

The nurse performs a routine health screening at the middle school. Which statement made by the student most concerns the nurse?1. "I do not want to go home today. My dad is going to be really mad when I tell him I failed my math test."2. "I never get to go out with my friends. I have to watch my baby brother after school every day."3. "My friends and I play this cool game called 'the choking game.' Nobody really gets hurt so it is okay to play."4. "My best friend will not talk to me. She is upset because I would not let her copy my homework."

3. "My friends and I play this cool game called 'the choking game.' Nobody really gets hurt so it is okay to play."— The student is in imminent danger of physical harm. The "choking game," also called the "fainting game," is an activity in which the child puts their self or another child in a choke hold and squeezes until the child being choked loses consciousness. The nurse must immediately intervene.Think like a nurse: The choking game is a red flag. This "game" is played by having the airway and trachea occluded to the point where the person loses consciousness. This is a dangerous action, should not be considered a "game," and requires immediate intervention by the nurse. The person being choked is at risk for hypoxia and brain damage. The school nurse should explain this to the student and strongly suggest to avoid participating in this "game" in the future. Nurses, especially in school settings, need to be aware of "fads" and "trends" that place clients at risk.

The nurse is admitting a client diagnosed with chronic adrenal insufficiency. Which roommate assignment will cause the nurse to intervene?1. An older adult client diagnosed with a cerebrovascular accident.2. A middle-aged adult client diagnosed with pneumonia.3. A young adult diagnosed with type 1 diabetes mellitus.4. An adult client diagnosed with a fractured femur.

2. A middle-aged adult client diagnosed with pneumonia.— A client with adrenal insufficiency is at high risk for infection, and any infection can cause circulatory collapse due to lack of corticosteroid production. The client with pneumonia poses a high risk of infection. This roommate assignment should be immediately changed.Think like a nurse: Before making the room assignment, the nurse should consider the pathophysiological process causing the disease process. In adrenal insufficiency, there is an inadequate amount of glucocorticoids in the system. This deficiency increases the risk for the client to develop an infection. Any client with an infection should be immediately removed as a potential roommate for the client. Any client without an active infection would be an appropriate roommate for the client with adrenal insufficiency.

The nurse reading an electrocardiogram (EKG) rhythm strip determines that there are 8 QRS complexes in 30 large squares for a 6-second strip. Which heart rate does the nurse calculate?1. 60 bpm.2. 70 bpm.3. 80 bpm.4. 120 bpm.

3. 80 bpm.- Thirty large squares on the EKG paper represent 6 seconds. The nurse will multiply the number of QRS complexes found in 30 large squares by 10 (8 × 10 = 80 beats per minute).Think like a nurse: Nurses who work regularly with clients who are on telemetry will be provided education about monitoring and interpreting telemetry readings. There are different ways to calculate the heart rate from a rhythm strip. The paper is made up of a series of repeating boxes. The larger boxes are made up of 25 smaller boxes. To estimate the rhythm, a 6-second or 10-second strip is required. The number of boxes between the peaks of two QRS complexes are counted and then multiplied by the appropriate number, based upon the length of the rhythm strip. The number from this calculation is the client's heart rate.

The nurse provides instructions to a client prescribed hydralazine as treatment after a hypertensive crisis. Which client statements indicate to the nurse that the teaching is effective? (Select all that apply.)1. "I need to tell my health care provider if I lose my appetite."2. "I need to have my blood drawn twice a week."3. "I will take the prescribed medication with my breakfast."4. "I will call my health care provider before taking ibuprofen."5. "I will sit on the edge of my bed for 2 minutes before I stand up in the morning."

ANSWERS:1, 3, 4, 5EXPLANATION:1. "I need to tell my health care provider if I lose my appetite."- Anorexia is a possible adverse effect of hydralazine. The health care provider should be notified if this occurs.3. "I will take the prescribed medication with my breakfast."- Hydralazine should be taken with food to increase bioavailability of the medication. 4. "I will call my health care provider before taking ibuprofen."- The client needs to avoid over-the-counter medications unless directed by the health care provider. 5. "I will sit on the edge of my bed for 2 minutes before I stand up in the morning."- Orthostatic hypotension is a possible adverse effect of this medication. Sitting on the edge of the bed before standing up in the morning helps prevent this effect. Think like a nurse: During client teaching, the nurse uses the teach-back method to evaluate the client's understanding. The nurse ensures the client understands the indications for hydralazine administration, as well as health management related to the hypertensive crisis. Dizziness, which is a potential adverse effect of hydralazine, may increase the client's risk for falls. Adverse effects such as fainting, tachycardia, edema, or chest pain require immediate care. Dietary recommendations include a low-sodium diet. Reinforce the importance of adhering to the prescribed medication regimen. Educate the client about health risks associated with poorly managed hypertension, including stroke and heart attack.

The nurse assesses the precordium of an adult male. Which location will the nurse place the stethoscope to auscultate the mitral valve?

The mitral valve is located in the fifth intercostal space at the left of the midclavicular line. This is also the location of the apex of the heart. The nurse will assess for S1 at this location.

The nurse provides care to an infant client who is diagnosed with heart failure. Which assessment by the nurse best detects fluid retention in the client?1. Obtaining daily weights.2. Testing the urine for blood.3. Measuring abdominal girth.4. Counting the number of wet diapers.

1. Obtaining daily weights.- The earliest sign of fluid retention is weight gain. Think like a nurse: Infants with heart failure often exhibit subtle signs such as difficulty feeding and tiring easily. The nurse should pay close attention to parents' statements such as, "The baby drinks a small amount of milk and stops, but then wants to eat again very soon after," "The baby seems to perspire a lot during feedings," or "The baby seems to be more comfortable sitting up than lying down." Although the earliest sign of fluid retention is weight gain, the nurse should keep in mind that, in general, weight gain is a late sign of heart failure.

The nurse provides teaching to the parents of a newborn. Which parent statement requires an intervention by the nurse? (Select all that apply.)1. "Since our baby seems to prefer formula to breast milk, I will stop breastfeeding."2. "We will feed our baby formula until my breast milk comes in."3. "If our baby continues to suck after the feeding, we can use a pacifier to soothe our baby."4. "We will not give our baby a pacifier, due to an increased risk of sudden infant death syndrome (SIDS)."5. "I will call the health care provider's office if my baby does not have at least six wet diapers per day."6. "I will not worry if our baby's bowel movements are sticky and black at first."

ANSWERS:1, 2, 4EXPLANATION:1. "Since our baby seems to prefer formula to breast milk, I will stop breastfeeding."— The nurse should recommend that the parents not offer formula if breastfeeding. The newborn may become confused and refuse breast milk.2. "We will feed our baby formula until my breast milk comes in."— Parents planning to breastfeed should not offer formula. The newborn will obtain nutrient-rich colostrum before the breast milk comes in.4. "We will not give our baby a pacifier, due to an increased risk of sudden infant death syndrome (SIDS)."— Pacifier use is associated with a reduced risk of SIDS, not an increased risk.Think like a nurse: Newborn feeding is a priority for teaching. The mother should decide the feeding approach to use and follow it consistently. This means if the mother is breastfeeding, formula should not be introduced. Pacifiers are encouraged since they help soothe the newborn, and evidence suggests they help reduce the incidence of sudden infant death syndrome. Evidence of adequate nutrition and hydration in a newborn includes at least six wet diapers each day. Bowel movements that are sticky and black indicate passing of meconium, an expected type of bowel movement in a newborn.

The nurse provides care for a client 24 hours after an ischemic stroke. The nurse notes a BP of 222/128 mm Hg, a radial pulse of 92 beats/min, a respiratory rate of 22 breaths/min, a temperature of 98.9°F (37.2°C), and an oxygen saturation of 96%. Which actions are appropriate for the nurse to implement in this situation? (Select all that apply.)1. Provide supplemental oxygen of 2 L/min by nasal cannula.2. Contact the health care provider.3. Administer intravenous labetalol as prescribed.4. Place the client in high-Fowler position.5. Increase intravenous flow rate to 100 mL/hr.

ANSWERS:1, 2, 3EXPLANATION:1. Provide supplemental oxygen of 2 L/min by nasal cannula.- Supplemental oxygen may increase the oxygen reaching damaged brain tissue. Providing supplemental oxygen is done for clients diagnosed with a cerebral vascular accident (CVA) regardless of oxygen saturation or respiratory symptoms. 2. Contact the health care provider.- The health care provider should be notified of the client's current blood pressure, which is indicative of a hypertensive emergency. 3. Administer intravenous labetalol as prescribed.- Labetalol is among the list of IV medications used to treat hypertensive crises. It is given PRN. Think like a nurse: Hypertension after a stroke is common, as typical blood pressure regulatory mechanisms are impaired. For the client who experiences a stroke, avoidance of extremes in blood pressure (both hypotension and hypertension) is important. However, a slightly elevated blood pressure may be beneficial to restoring cerebral perfusion. Maintenance parameters for the client's blood pressure will be prescribed by the health care provider (HCP). Significant hypotension or a sudden decrease in blood pressure can cause decreased perfusion of vital organs. As such, for the client who requires interventions to decrease blood pressure, the nurse should proceed with caution. Gradual reduction of blood pressure is achieved by administering small doses of IV anti-hypertensive medication as prescribed. Supportive care may include oxygen administration. Notify the HCP of changes in the client's status.

A client receives furosemide for heart failure. Which response indicates to the nurse that the medication is effective? (Select all that apply.)1. Three pound weight loss in 24 hours.2. Increased thirst and dry mouth.3. Increased ease in breathing.4. Dizziness and light-headedness.5. Painful and swollen finger joints.6. Muscle weakness and cramping.

ANSWERS:1, 3EXPLANATION:1. Three pound weight loss in 24 hours.— Weight loss indicates diuresis, which is a desired effect for furosemide, a diuretic. 3. Increased ease in breathing.— Crackles and shortness of breath indicate pulmonary congestion, whereas easier breathing shows improvement. This data indicates a desired effect of furosemide, a diuretic. Think like a nurse: In evaluating effectiveness of medications used to treat heart failure, the nurse should look for manifestations indicating an improvement of cardiac output, renal function, tissue perfusion, and activities of daily living. The client is informed to report to the provider sudden or steady gain in daily weight, such as 2 to 3 lbs (0.91 to 1.4 kg) in 24 hours or 5 lbs (2.3 kg) or more in 1 week. If taking digoxin, the client should be taught how to take their pulse rate for a full minute and be aware not to take digoxin if rate is less than 60 beats/minute. The client taking furosemide should be informed to notify the provider if the client experiences leg cramps, a sign of hypokalemia.

The nurse assesses a school-age child after the surgical removal of a brain tumor. Which sign indicates to the nurse that brainstem involvement occurred during the surgery?1. Orthostatic hypotension.2. Hearing loss.3. Elevated temperature.4. Swallowing difficulty.

3. Elevated temperature.- The temperature may be elevated because of hypothalamus or brainstem involvement during surgery.Think like a nurse: Before identifying a deviation in assessed data, the nurse should stop and recall the physiology of the brain and the type of surgery from which the client is recovering. Depending upon the location of the brain tumor, the client may demonstrate a change in motor or sensory function or an alteration in vital signs. Considering the brain structures, the nurse knows the data that should be further investigated is the elevated body temperature, which could be indicative of brain stem involvement. The nurse is aware that pressure on the brain stem is a complication of brain surgery. Therefore, it is important for the nurse to report the elevated temperature to the health care provider so that the client can be further evaluated.

A client diagnosed with type 1 diabetes mellitus has a capillary blood glucose of 60 mg/dL (3.3 mmol/L) and reports hunger, sweating, tachycardia, and tremulousness. Which food choices does the nurse select that provide the client with 15 grams of an oral carbohydrate? (Select all that apply.)1. 8 oz of regular soda.2. Half cup of plain pasta.3. Half cup of canned fruit.4. 2 teaspoons of sugar.5. 1 cup of whole milk.6. 125 mL of apple juice.

ANSWERS:2, 3, 6EXPLANATION:2. Half cup of plain pasta.— One-half cup of plain pasta contains 15 grams of carbohydrates. 3. Half cup of canned fruit.— One-half cup of canned fruit contains 15 grams of carbohydrates. 6. 125 mL of apple juice.— Apple juice in the amount of 125 milliliters contains 15 grams of carbohydrates. Think like a nurse: For the client who experiences hypoglycemia, food and drink should be offered only if the client is alert and speaking clearly. If the client demonstrates a decreased level of consciousness, introduction of food or oral fluids may result in aspiration. Sublingual administration of carbohydrates, including glucose gel or granulated sugar, is an available option for these clients. If the client is unconscious, glucose may be prescribed for administration via intravenous, intramuscular, or subcutaneous routes. For the alert client experiencing symptomatic hypoglycemia, the nurse administers only the necessary amount of carbohydrate, as excess carbohydrate administration causes rebound hyperglycemia. The quick carbohydrate dose is followed by a meal, sandwich, or protein-rich snack.

The client diagnosed with dehydration is treated with IV normal saline (NS). Which client responses noted by the nurse demonstrate a therapeutic effect of the NS? (Select all that apply.)1. Crackles noted in the lungs.2. Blood pressure increases.3. The pulse rate decreases.4. Urine output increases.5. Hematocrit (HCT) level increases.

ANSWERS:2, 3, 4EXPLANATION:2. Blood pressure increases.— Hypotension may indicate decreased fluid volume. An increase in blood pressure to normotensive is a therapeutic and expected response to the fluid infusion. 3. The pulse rate decreases.— An increased pulse may indicate decreased fluid volume as the heart pumps faster to maintain homeostasis. A decrease of heart rate to the normal range indicates therapeutic effectiveness of the intervention. 4. Urine output increases.— Urine output decreases with hypovolemia. A client with adequate hydration replacement should experience increased urination. Think like a nurse: The nurse must differentiate between a medication 's therapeutic effects, side effects, and adverse effects, in addition to monitoring for medication interactions. For the client who is prescribed IV fluid therapy for treatment of dehydration, the desired therapeutic outcomes include a reversal of dehydration-related signs and symptoms. Classic manifestations of dehydration include hypotension, tachycardia, and oliguria. In the dehydrated client, hematocrit may be elevated due to hemoconcentration. Adequate fluid volume is associated with a normal blood pressure and heart rate, as well as sufficient urine production. Auscultation of crackles in the lungs indicates potential fluid volume overload and must be corrected.

A client experiences a flail chest from a motor vehicle crash. Which finding does the nurse expect when assessing this client?1. Chest on the affected side expands outward during inspiration and is pulled inward during expiration.2. Chest on the affected side is pulled inward during inspiration and bulges outward during expiration.3. A sucking sound is heard on inspiration and expiration.4. Absent or restricted movement noted on the affected side.

2. Chest on the affected side is pulled inward during inspiration and bulges outward during expiration.— A flail chest is caused by fractures of multiple adjacent ribs, causing the chest wall to become unstable and respond paradoxically. The chest then pulls in during inspiration and bulges outward during expiration.Think like a nurse: Flail chest requires immediate intervention to ensure adequate oxygenation, as the segment of the chest wall that is flail is unable to contribute to lung expansion. If the flail segment involves a great proportion of the chest and sternum, mechanical ventilation may be necessary to ensure adequate ventilation and oxygenation. The nurse should obtain a baseline ABG and assess the client for other sources of respiratory compromise.

The nurse provides care to a prenatal client who is 2 months pregnant. The client reports experiencing nausea each morning. Which recommendation does the nurse provide to the client?1. Consume only soft foods and fruit until evening.2. Eat pretzels before getting out of bed in the morning.3. Avoiding drinking carbonated beverages.4. Limit food intake to three full meals each day.

2. Eat pretzels before getting out of bed in the morning.- Strategies to prevent or decrease pregnancy-related nausea include eating dry carbohydrate foods (such as pretzels) 30 minutes to 1 hour prior to getting out of bed in the morning. Think like a nurse: Pregnancy-induced nausea is a miserable experience and may require trial and error to determine what helps the mother most. Eating a dry carbohydrate, like crackers or pretzels, prior to getting out of bed is a tried and true method. Frequent, small, nutrient dense meals are encouraged. Suckers, lemon or ginger drops, and sucking on other hard candies may be useful. The goal during this period is to prevent dehydration, ensure proper nutrition, and to maintain current maternal weight or minimize weight loss.

A client in labor is unable to get to the hospital because of inclement weather and calls the nurse who lives next door for help. Once the fetal head is delivered, which action is appropriate for the nurse to take?1. Instruct the client to bear down and push.2. Turn the neonate 's head in a clockwise direction.3. Check the neonate 's neck for the umbilical cord.4. Ask the client to pant through her mouth.

3. Check the neonate 's neck for the umbilical cord.— The neonate's neck should be assessed for presence of the umbilical cord. The newborn could become anoxic if the cord is around the neck. Think like a nurse: The nurse needs to be concerned with the welfare of both the mother and the fetus, and should immediately apply the concepts of airway, breathing, and circulation (ABCs). Since the baby's head has been delivered, the nurse needs to make sure the neonate will have adequate placental circulation until the first breath is taken. If the umbilical cord is wrapped around the neonate's neck, there is a risk for oxygen deficiency and respiratory distress. To check for the cord, the nurse should slide a finger around the circumference of the baby's neck. If the cord is present, the nurse needs to slip two fingers under the cord to ensure adequate oxygenation. Once the nurse ensures the neonate is able to receive oxygen, the rest of the body can be delivered.

The home care nurse provides care for the client diagnosed with stage 3 heart failure (HF). Which measure is included in the plan of care? (Select all that apply.)1. Instruct the client to check weight daily.2. Educate the client on a low-sodium diet.3. Review the prescription for daily digoxin therapy.4. Institute a cardiac rehabilitation program.5. Assess for adverse effects of an angiotensin converting enzyme (ACE) inhibitor.6. Teach the client when to stop taking medications.

ANSWERS:1, 2, 3, 4, 5EXPLANATION:1. Instruct the client to check weight daily.— This is appropriate to include in the plan of care. Daily weights can predict fluid retention and HF exacerbations. 2. Educate the client on a low-sodium diet.— This is appropriate to include in the plan of care. A low-sodium diet reduces fluid retention and decreases the risk of HF exacerbation. 3. Review the prescription for daily digoxin therapy.— This is appropriate to include in the plan of care. Digoxin decreases cardiac workload but should be monitored carefully. 4. Institute a cardiac rehabilitation program.— This is appropriate to include in the plan of care. Exercise may improve cardiac function and decreases the risk of HF exacerbation. 5. Assess for adverse effects of an angiotensin converting enzyme (ACE) inhibitor.— This is appropriate to include in the plan of care. ACE inhibitors are first-line medication therapy for HF, but they require careful assessment for adverse effects such as hyperkalemia (especially when administered with digoxin) and angioedema. Think like a nurse: Heart failure affects all body systems. Nursing care should focus on actions to reduce fluid retention, fatigue, and respiratory distress. Daily weights assess fluid balance. A low-sodium diet is appropriate to reduce accumulation of excess fluid. Digoxin is a cardiac glycoside that is used to decrease cardiac workload. Cardiac rehabilitation is appropriate once the client stabilizes. This program improves cardiac function and reduces the risk of exacerbations. ACE inhibitors are prescribed for heart failure. However, the client should be monitored for the development of adverse effects.

The nurse administers intravenous dopamine to a client. Which parameter will the nurse monitor to evaluate the response to this medication?1. Heart rhythm.2. Central venous pressure.3. Vital signs.4. Daily weights.

3. Vital signs.— Dopamine is indicated for correction of hemodynamic instability as a result of shock. Monitoring vital signs provides the most appropriate information regarding the effects of the medication. Think like a nurse: Dopamine affects the myocardium by increasing heart rate and cardiac contractility. At low doses (less than 2 mcg/kg/min), dopamine increases renal blood flow. At typical doses (3 to 10 mcg/kg/min), dopamine improves heart function and increases blood pressure. At high doses (greater than 10 mcg/kg/min), vasoconstriction increases blood pressure. At doses higher than 20 mcg/kg/min, peripheral circulation becomes compromised by vasoconstriction as the body attempts to maintain cardiac output. The nurse monitors the client carefully for therapeutic and adverse effects. Additionally, the nurse titrates the medication dose according to facility protocol and the health care provider prescriptions to balance an adequate blood pressure with other client needs.

A client with a history of alcoholism and cirrhosis of the liver is admitted to the medical unit for ascites management. Which prescribed substance will the nurse administer first?1. Albumin.2. Spironolactone.3. Indomethacin.4. Platelets.

1. Albumin. - Albumin is a hyperosmotic protein solution. It is given to pull fluid back into the blood vessels. Once the fluid has been moved into the bloodstream, diuretics can then promote excess fluid excretion.Think like a nurse: The nurse needs to understand the manifestations of the client's diagnosis of cirrhosis. The nurse also needs to know the actions of prescribed medications, how it will affect the client's symptoms, and what the expected outcome will be. Albumin is a form of protein used to pull fluid back into the general circulation and decrease the symptom of ascites. This is the prescription that the nurse should implement first. After the infusion, the diuretic can be given to help remove excess fluid from the blood stream.

The nurse provides care for a child client with suspected sickle cell disease. Which laboratory result does the nurse expect to be increased in sickle cell disease? 1. Hemoglobin level. 2. Hematocrit level. 3. White blood cell count. 4. Reticulocyte count.

4. Reticulocyte count.- These counts are elevated in children diagnosed with sickle cell disease because the lifespan of their sickled red blood cells is shortened. Think like a nurse: The nurse should mentally review the pathophysiology of sickle cell disease. This disease causes red blood cells to assume a sickle shape, which alters oxygen-carrying capacity and enhances the ability of the cells to become trapped in capillaries, causing pain. The sickling of the red blood cells enhances the lysis of circulating red blood cells. In response to red blood cell destruction, the body accelerates the process of creating new replacement cells, which are released into the bloodstream before maturity. Because of the disease process, the laboratory result most likely to validate the disease would be a high reticulocyte count.

A client comes to the outpatient clinic for evaluation of a possible basal cell carcinoma of the nose. Which client statement most concerns the nurse? 1. "I am a meat cutter at the local packing plant." 2. "My hobby is raising thoroughbred Great Danes." 3. "My parents immigrated from Sicily when I was born." 4. "I spend nearly every weekend sailing with my family."

4. "I spend nearly every weekend sailing with my family."— Exposure to the sun increases the risk of skin cancer. The nurse should urge the client to use sunscreen with SPF (solar protection factor) to block harmful rays and reapply sunscreen every 2 hours or after swimming. The client should also use lip balm with sunscreen protection and avoid sun exposure during peak sun hours. Think like a nurse: The nurse should understand that exposure to the sun's ultraviolet rays is the number one risk factor for skin cancer. This client spends a considerable amount of time outdoors sailing, which increases the risk for skin cancer. Water also magnifies the intensity of the sun, which could hasten the development of a cancerous lesion. The nurse should plan to teach all clients about the causes, preventions, and treatment for skin cancers. When performing skin assessment/screening, the nurse should be aware of genetic predispositions such as fair skin coloration, light colored eyes, and red or blond hair.

The nurse performs an assessment on a 42-year-old client. Which observation does the nurse expect to find? 1. The client's cognitive skills are beginning to decline. 2. The client is seeking to explore relationships. 3. The client's bone mass has increased. 4. The client compares life's accomplishments against goals.

4. The client compares life's accomplishments against goals. — At 42 years old, the client is moving into Generativity vs. Stagnation. This stage is one in which self-questioning occurs, as the client reappraises the past and discards unrealistic goals. The client may choose to move in a new direction or re-focus on previously set goals. Think like a nurse: It is important for the nurse to understand the physical and psychosocial milestones across the lifespan. This information will enable the nurse to relate to the client and identify client needs. The nurse can apply the information appropriately, even if there is a big gap in age between the client and the nurse; this ability aids the nurse in critical thinking and clinical judgement. A client approaching middle age may question the direction of life and decide whether adjustments should be made to achieve identified goals and plans. This is considered a normal developmental process for someone of this age.

The nurse presents a program at the community center about risk factors for colorectal cancer. Which client does the nurse identify as being at risk for colorectal cancer? 1. An 18-year-old client who exercises five times weekly. 2. A 54-year-old client who eats a diet high in fat. 3. A 35-year-old client whose cousin was diagnosed with colorectal cancer at age 32. 4. A 45-year-old client who had an appendectomy during the teen years.

2. A 54-year-old client who eats a diet high in fat.— This client has two risk factors. Those include age (over 50 years) and a high-fat diet. A diet high in fat or low in fiber is a risk for colorectal cancer.Think like a nurse: The nurse evaluates each client for the risk factors for colorectal cancer. Risk factors for the development of colorectal cancer include being over 50 years of age and ingesting a diet high in fat. The nurse should counsel this client on ways to decrease the dietary impact of the risk factor. The nurse should teach the client specific foods to limit in the diet (e.g. whole milk products, fried foods, meats with fat, regular salad dressing). Assist the client in learning how to read food labels to identify the fat content of foods. Assist the client in finding appropriate substitutes to foods that are high in fat. Schedule the client to meet with the dietitian, if needed.