111 - Contact Precautions

Contact precautions
 MDR organisms (eg, MRSA, VRE)

 Enteric organisms (eg, Clostridium difficile)
Organisms  Scabies
 Hand hygiene (soap & water for C difficile)

 Nonsterile gloves
Infection-control measures  Gown
 Private room preferred
MDR = multidrug-resistant; MRSA = methicillin-resistant Staphylococcus aureus; VRE = vancomycin-resistant Enterococcus.

Clostridium difficile is a highly infectious bacteria causing severe colitis in infected clients. When caring for a client with C
difficile, it is critical that the nurse implement contact isolation precautions to prevent transmission of microorganisms between
clients, including:
 Placing the client in a single-client room, if possible, or in a cohort with other clients infected with C difficile (Option 3)
 Wearing a single-use, disposable gown and clean gloves during all client care and discarding the equipment before
leaving the room (Option 5)
 Performing hand hygiene before and immediately after client care with soap and water
 Using dedicated medical equipment (eg, stethoscope, blood pressure cuff) that is not shared between clients and always
remains in the client's room
(Option 1) Clean, rather than sterile, gloves are required during care of a client with C difficile to prevent transmission of infection
to other individuals.
(Option 2) Surgical masks are required when caring for a client prescribed droplet isolation precautions but are needed only in
clients with contact isolation precautions if performing activities with the possibility of body fluid splashing (eg, suctioning, wound
care).
(Option 4) When caring for clients with C difficile, it is critical to perform hand hygiene with soap and water, rather than alcohol-
based sanitizers. Alcohol-based sanitizers are unable to effectively kill spore-forming bacteria (eg, C difficile, anthrax).
Educational objective:
Clostridium difficile is a highly infectious bacteria requiring contact isolation precautions, including a single-client room assignment
if available, disposable gowns and clean gloves, and hand hygiene with soap and water. Surgical masks are not necessary unless
performing client care with the possibility of body fluid splashing.
Open endotracheal (ET) suctioning is a skill performed to remove pulmonary secretions and maintain airway patency in clients
who are unable to clear secretions independently. ET suctioning is important to promote gas exchange and prevent alveolar
collapse, but inappropriate technique increases the client's risk for complications (eg, pneumonia, hypoxemia) or tracheal injury
(eg, trauma, bleeding). To reduce the risk of complications and injury during ET suctioning, the nurse should:
 Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes (Option 1)
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 Suction only while withdrawing the catheter from the airway (Option 2)
 Use strict sterile technique throughout suctioning (Option 5)
 Limit suctioning to ≤10 seconds on each suction pass

(Option 3) Instilling sterile normal saline solution or sterile water (ie, lavaging) in the client's airway, a practice no longer supported
by evidence, greatly increases the risk for infection by potentially transporting bacteria from the upper airway into the lower
airways.
(Option 4) Suctioning longer than 10 seconds increases risk for collapse of airway structures (eg, alveoli, bronchioles) and
hypoxemia (ie, oxygen saturation <90%).
Open endotracheal (ET) suctioning is a skill used to clear secretions and maintain airway patency. When performing ET
suctioning, the nurse preoxygenates with 100% oxygen, applies suction only while withdrawing the catheter, uses sterile technique,
and limits each suction pass to ≤10
Ventricular fibrillation (VF) is a lethal arrhythmia characterized by disorganized electrical activity in the heart ventricles.
Because of this erratic electrical activity, the heart's muscles lose the ability to contract, resulting in loss of blood flow and pulse
(eg, cardiac arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client
for defibrillation (Option 3).
(Option 1) Atrial fibrillation is a cardiac arrhythmia characterized by disorganized electrical activity in the atria and an irregular
pulse rate. Clients may experience this condition chronically or in response to other medical conditions (eg, electrolyte
imbalance). However, a client with VF has no pulse and is the priority for care.
(Option 2) Premature ventricular contractions are abnormal electrical impulses in the ventricles that may occur spontaneously or
in response to heart irritants (eg, stimulant medications, electrolyte alterations, pain). This arrhythmia is typically not harmful but
requires monitoring by the nurse.
(Option 4) Ventricular tachycardia, a potentially lethal dysrhythmia characterized by organized, rapid firing of electrical activity
within the ventricles, may impair perfusion and often leads to cardiac arrest and/or VF. However, clients may have a pulse with
ventricular tachycardia, making the client with VF and no pulse the priority.
Clients with ventricular fibrillation, a lethal arrhythmia, require immediate treatment with CPR and defibrillation. A pulse may be
present in ventricular tachycardia, so it should be addressed as soon as possible. Atrial fibrillation and premature ventricular
contractions are pulsatile rhythms.
A significant reduction in platelets after initiation of heparin or low-molecular-weight heparin (eg, enoxaparin [Lovenox]) therapy
can indicate heparin-induced thrombocytopenia (HIT), a severe, potentially lethal complication. HIT is an immune reaction to
heparin-based anticoagulants that causes a drastic decrease in platelet count (ie, ≤50% of pretreatment levels and/or platelet
count <150,000/mm3 [150 × 109/L]) and a paradoxical increase in risk for arterial and venous thrombosis (eg, deep venous
thrombosis, pulmonary embolism).
The nurse should notify the health care provider immediately of decreased platelet levels and anticipate stopping
enoxaparin therapy and initiating a nonheparin anticoagulant (eg, rivaroxaban, argatroban) (Option 2).
(Option 1) Beta-2 adrenergic agonists (eg, albuterol, salmeterol) are medications used to dilate the airways. The nurse should
clarify the prescription if hypokalemia or tachycardia, common adverse effects, are present.
(Option 3) Methylprednisolone is a glucocorticoid medication used to reduce airway inflammation in asthma. Glucocorticoids can
cause an expected, transient elevation in the white blood cell count during initiation of treatment.
(Option 4) Potassium chloride is an electrolyte replacement drug used to prevent and treat hypokalemia (<3.5 mEq/L [3.5
mmol/L]). The nurse should clarify the prescription if hyperkalemia or kidney injury is present. This client has an additional risk for
low potassium due to the continued use of albuterol.
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Heparin-induced thrombocytopenia is a reaction to heparin or low-molecular-weight heparin (eg, enoxaparin) that causes
decreased platelet levels and may result in thromboembolic events. The nurse should monitor platelet counts in clients receiving
enoxaparin and clarify the prescription if the platelet count decreases by >50% or is <150,000/mm3 (150 × 109/L)
The mnemonic VEAL CHOP may help nurses recall causes of fetal heart rate (FHR) changes noted on monitor tracings.
A late deceleration is a decrease in FHR that begins after a contraction, reaches its lowest point (nadir) after the contraction peak,
and then gradually returns to baseline. Late decelerations indicate impaired fetal oxygenation associated with decreased
uteroplacental perfusion (eg, due to maternal hypotension after epidural placement or uterine tachysystole). Chronic
uteroplacental insufficiency (eg, intrauterine growth restriction, preeclampsia, diabetes) may also cause late decelerations.
Nursing actions to improve fetal perfusion and oxygenation include:
 Discontinuing uterotonics (eg, oxytocin [Pitocin]) to reduce uterine activity (Option 3)

 Changing maternal position to the left side to relieve compression of the inferior vena cava. If the FHR tracing does not
improve, a right-side position may be attempted (Option 2)
 Administering oxygen at 8-10 L/min via nonrebreather face mask to promote fetal oxygenation (Option 1)
 Giving prescribed IV bolus of lactated Ringer solution or normal saline to improve placental perfusion, especially during
maternal hypotension
 Notifying the health care provider (Option 4)
(Option 5) Nitrazine pH tests are used to detect leaking amniotic fluid, most often if premature (prelabor) rupture of membranes is
suspected. This client is at term and in active labor.
Late decelerations are evidence of impaired fetal oxygenation. Discontinuing the oxytocin infusion, changing maternal position,
administering oxygen, and giving an IV fluid bolus are essential interventions.
Bell palsy is peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve (cranial nerve VII) in the
absence of a stroke or other causative agent/disease. Paralysis of the motor fibers innervating the facial muscles results in
flaccidity on the affected side.
Manifestations of Bell palsy include:
 Inability to completely close the eye on the affected side

 Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to weakness of the
lower eyelid muscle (Option 1)
 Flattening of the nasolabial fold on the side of the paralysis (Option 3)
 Inability to smile or frown symmetrically (Option 4)
Alteration in the sensory fibers can cause loss of taste on the anterior two-thirds of the tongue.
(Options 2 and 5) Electric shock–like pain in the lips and gums and severe pain along the cheekbone are symptoms of trigeminal
neuralgia (cranial nerve V). With Bell palsy, the trigeminal nerve may become hypersensitive and cause facial pain, but this is
uncommon and typically more indicative of trigeminal neuralgia.
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Bell palsy is unilateral facial paralysis due to inflammation of the facial nerve that is characterized by inability to close the affected
eye completely, changes in tear production, facial droop, and asymmetrical smile or frown.
A deep venous thrombosis (DVT) is a blood clot (ie, thrombus) formed in large veins, generally of the lower extremities. DVTs
occur commonly as a result of decreased activity or mobility (eg, prolonged travels, bed rest) or as a complication of hospitalization
or surgery.
Although clients with a DVT may have no symptoms, typical clinical manifestations include unilateral edema, localized pain (eg,
calf pain) or tenderness to touch, warmth, erythema, and occasionally low-grade fever (Options 2, 4, and 5). Recognition of a
potential DVT is critical because the thrombus can dislodge from the vessel and cause life-threatening pulmonary embolism.
(Option 1) Blue, cyanotic toes is an indicator of impaired arterial blood perfusion to the extremity, which may occur with acute
arterial occlusion (eg, arterial embolism) or severely reduced blood flow (eg, vasopressor-induced vasoconstriction,
atherosclerosis).
(Option 3) Dry, shiny, hairless skin are common clinical manifestations of chronic peripheral arterial disease. These characteristic
skin alterations occur from long-term impairment of blood flow to the extremity.
A deep venous thrombosis (DVT) is a blood clot formed in large veins, typically of the lower extremities, that occurs commonly from
decreased activity or mobility. Clinical manifestations of a lower-extremity DVT include unilateral edema, calf pain or tenderness to
touch, warmth, erythema, and low-grade fever.
Pulmonary embolism (PE) is a potentially life-threatening medical emergency occurring when a blood clot, fat or air embolus, or
tissue (eg, tumor) travels via the venous system into the pulmonary circulation and obstructs blood flow into the lung. This
prevents deoxygenated blood from reaching the alveoli, which leads to hypoxemia due to impaired gas exchange and cardiac
strain due to congested blood flow in the pulmonary arteries.
Clinical manifestations of PE range from mild (eg, anxiety, cough) to severe (eg, heart failure, sudden death). However, many
clients initially have mild, nonspecific symptoms that are often misdiagnosed and inadequately managed, greatly increasing the
likelihood of progression to shockand/or cardiac arrest. Clinical manifestations of PE include:
 Pleuritic chest pain (ie, sharp lung pain while inhaling) (Option 2)

 Dyspnea and hypoxemia (Options 3 and 4)
 Tachypnea and cough (eg, dry or productive cough with bloody sputum) (Option 5)
 Tachycardia
 Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis
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(Option 1) Tachycardia, rather than bradycardia, is expected with PE because the heart attempts to compensate for hypoxemia,
right ventricular overfilling, and decreased left ventricular cardiac output.
(Option 6) Tracheal deviation is a sign of tension pneumothorax (not PE), which occurs when pressure on the side of the
collapsed lung pushes organs toward the unaffected lung.
Pulmonary embolism is a potentially life-threatening medical emergency occurring when a pulmonary artery is obstructed.
Common clinical manifestations include pleuritic chest pain, dyspnea, hypoxemia, tachypnea, cough, tachycardia, and unilateral
leg swelling.
Clients receiving blood products are at risk for acute transfusion reactions (eg, hemolytic reaction), which may be life-
threatening without prompt recognition and intervention. Clients with symptoms of a blood transfusion reaction
(eg, anxiety, hypotension, tachycardia) require immediate assessment (Option 1).
Nifedipine is a calcium channel blocker often used to treat hypertension. Administration of nifedipine is contraindicated in clients
whose blood pressure is already low (ie, systolic <90 mm Hg), as this may cause potentially life-threatening hypotension.
Therefore, the nurse should promptly assess the client with a blood pressure 90/65 mm Hg who received nifedipine
for hemodynamic stability (Option 4).
(Option 2) Metoprolol is a beta blocker medication often used to manage hypertension and heart failure. An expected outcome of
metoprolol therapy is decreased heart rate and blood pressure.
(Option 3) Hydromorphone is an opioid medication used to treat pain. Pain relief may cause reduced blood pressure. Opioids
may also cause histamine release which may lead to vasodilation and hypotension.
(Option 5) Albuterol is a beta-adrenergic agonist often used in clients with bronchospasm to dilate the airways. Albuterol also
stimulates beta receptors in the heart and causes increased heart rate, an expected finding. If the pulse is within the normal range
for an adult, no additional action is needed.
Nurses caring for clients receiving blood products should immediately intervene upon signs of transfusion reaction (eg, anxiety,
hypotension, tachycardia). Clients should be monitored for hemodynamic instability if blood pressure medications are administered
during hypotension. Opioids may cause decreased blood pressure due to histamine release.
Appendicitis is inflammation of the appendix and often results from obstruction by fecal matter. Appendiceal obstruction traps
fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal
intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia.
These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis.
When prioritizing care of the client with appendicitis, the nurse should utilize the ABCs (ie, airway, breathing, circulation). Fluid
resuscitation with IV crystalloids (eg, normal saline, lactated Ringer solution) is an important intervention aimed at preventing
circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status (Option 3).
(Option 1) Pain medications may be administered to promote comfort, but should be administered via IV route to maintain NPO
status in case of emergency surgery. However, circulation takes priority over pain medication.
(Options 2 and 4) Blood and urine samples often are prescribed to assist with treatment and care decisions. However, the nurse
should prioritize circulatory status over obtaining laboratory specimens.
Nurses caring for clients with appendicitis should prioritize client care according to the ABCs (ie, airway, breathing, circulation).
Initiating IV crystalloids (eg, normal saline) is a priority action that prevents circulatory collapse resulting from fluid losses (eg,
vomiting, diarrhea) and NPO status.
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Scope of practice
RN LPN/LVN UAP
 Clinical assessment  Monitoring RN findings  Activities of daily living

 Initial client education  Reinforcing education  Hygiene
 Discharge education  Routine procedures (eg,  Linen change
 Clinical judgment catheterization)  Routine, stable vital signs
 Initiating blood transfusion  Most medication administrations  Documenting input/output
 Ostomy care  Positioning
 Tube patency & enteral feeding
 Specific assessments*
LPN = licensed practical nurse; LVN = licensed vocational nurse; RN = registered nurse;

UAP = unlicensed assistive personnel.
*Limited assessments (eg, lung sounds, bowel sounds, neurovascular checks).

Nurses preparing to delegate client care to a licensed practical nurse (LPN) and/or unlicensed assistive personnel (UAP) should
consider the 5 rights of delegation. The LPN can monitor and care for stable clients who have been initially evaluated by a
registered nurse (RN). Interventions LPNs may perform include:
 Administering oral and parenteral medications, but excluding administering IV medications, which vary by state
legislation (Options 1 and 2)
 Reinforcing teaching and skills that have been initially taught by the RN (Option 4)
 Focused assessments (eg, bowel sounds) after the RN's initial assessment
(Option 3) Performing admission or initial assessments is outside the scope of the LPN and UAP. The RN must perform initial
assessments in order to analyze the findings and formulate the client's plan of care before delegating tasks.
(Option 5) The LPN is capable of performing routine care (eg, calculating daily intake and output, toileting). However, the UAP
may also perform these tasks, which frees the LPN to perform more complex duties. Therefore, the most appropriate staff member
to assign the task of calculating intake and output to is the UAP.
Nurses preparing to delegate client care should consider the 5 rights of delegation. Appropriate tasks to delegate to a licensed
practical nurse include administration of oral and parenteral medications, excluding IV route, and reinforcement of teaching
previously provided by the registered nurse.
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Aortic stenosis (AS) is a type of valvular heart disease characterized by narrowing of the aortic valve opening, which limits the left
ventricle's ability to eject blood into the aorta. AS may occur from hardening (ie, calcification) of the valves, congenital heart
disorders, or inflammation. If left untreated, AS may result in heart failure and pulmonary hypertension as compensatory
mechanisms fail.
When assessing a client with AS, the nurse should auscultate in the aortic area (ie, second intercostal space at the right
sternal border) for a loud, systolic ejection murmur heard following the first heart sound. The aortic area, rather than directly over
the heart valve, is the preferred location for auscultation as the heart sounds travel in the direction the blood flows. Additional
clinical manifestations of aortic stenosis include chest pain, shortness of breath, and/or syncope that are worsened by exertion.
Aortic stenosis is a type of valvular heart disease causing narrowing of the valve between the left ventricle and aorta, impairing
ejection of blood from the heart. Nurses attempting to auscultate heart murmurs associated with aortic stenosis should listen at the
right sternal border, second intercostal space (ie, aortic area).
Clients with life-limiting diagnoses often experience anxiety, frustration, and the phases of grief. The nurse must assess the
client's knowledge and feelings regarding the illness. Use of therapeutic communication (eg, active listening, reflection, focusing)
allows the nurse to determine client needs and strengthens the nurse-client relationship, which is instrumental in helping the
client cope with difficult information (Option 2).
The health care provider (HCP) should inform the client of biopsy results so that the prognosis and plan of treatment can be
discussed. Although a cancer diagnosis may be difficult for the client to receive, a complete, factual discussion of the diagnosis
can help the client feel more in control.
(Option 1) Indicating knowledge of the client's feelings and changing the subject weaken the nurse-client relationship by making
the nurse seem uncomfortable with the situation, minimizing the client's feelings, and disregarding client concerns.
(Option 3) The HCP should be involved in informing the client about the biopsy results. It is best that both the HCP and nurse be
present to address all questions and concerns the client may have.
(Option 4) An automatic response is a nontherapeutic communication technique that deflects the client's feelings, thereby
weakening the nurse-client relationship. The nurse should encourage the client to share their thoughts.
Clients with life-limiting diagnoses experience anxiety, frustration, and grief as they cope. The nurse should use therapeutic
communication (eg, active listening, reflection, focusing) to determine the client's understanding and strengthen the nurse-client
relationship before discussing difficult news (eg, new cancer diagnosis).
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Buck traction is a type of skin traction used to immobilize hip fractures and reduce pain and spasm until the client can
undergo surgical repair of the fracture. A traction boot is applied to the leg, below the fracture site. A weight gently and
continuously pulls on the leg and hip, helping maintain alignment of the limb. The nurse should ensure that the traction boot is
fitted properly and that the limb remains straight in a neutral position (Option 3).
Skin traction exerts pressure on nerves, blood vessels, and soft tissue. The nurse should frequently assess neurovascular
status (eg, pulse, capillary refill, color, temperature, sensation, movement) and skin integrity in the limb to which the boot is
applied (Options 1 and 4). Overall pain level and efficacy of administered pain medications should be monitored closely, as
increasing pain in the limb in traction may indicate neurovascular compromise (Option 2).
(Option 5) Side-to-side repositioning of the client in Buck traction can cause injury. Side-to-side position changes cause the
affected leg to be adducted or abducted, which, when paired with the force of traction, can increase spasm and pain and contribute
to neurovascular and orthopedic compromise.
Buck traction is used to immobilize hip fractures and reduce pain and spasm until the fracture can be repaired surgically. The
nurse caring for a client in Buck traction should frequently assess the neurovascular status and skin integrity of the affected limb
and maintain it in a straight, neutral position.
Human immunodeficiency virus (HIV) is a viral infection of the CD4+ (helper T) cells, resulting in progressive immune system
impairment. When educating clients with HIV, the nurse should discuss health promotion and infection transmission prevention
strategies, particularly safe sex practices.
Unprotected sex increases the risk of transmitting HIV and other sexually transmitted infections (STIs). Protected sex is
important even with HIV-positive partners as HIV has multiple strains and coinfection results in HIV superinfection, which may
hasten progression to AIDS (Option 1).
Clients with HIV should use latex or synthetic condoms and/or dental dams during sexual activity involving mucous membrane
exposure (ie, oral, vaginal, anal) to semen or vaginal secretions. Natural barriers (eg, lambskin) do not prevent transmission of
STIs due to the presence of small pores (Option 4).
(Option 2) Sharing personal hygiene devices that may have been exposed to blood (eg, toothbrushes, razors) increases HIV
transmission risk and should be avoided.
(Option 3) Immunosuppressed clients should be educated to avoid raw or undercooked foods (eg, eggs, meats, seafood) to avoid
foodborne illnesses.
(Option 5) To prevent transmission of HIV, hepatitis B virus, and other bloodborne diseases, IV drug users should be taught to
avoid reusing or sharing needles or syringes.
Clients with HIV are educated to use latex or synthetic barriers during all sexual encounters (ie, oral, vaginal, anal) in which
nonintact skin or mucous membranes are exposed to semen or vaginal secretions. Unprotected sex increases the risk of
transmitting HIV and other sexually transmitted infections, as well as HIV coinfection/superinfection.
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Spina bifida, a neural tube defect occurring when spinal vertebrae do not close during fetal development, potentially allows spinal
cord contents to protrude through the opening. The mildest form is spina bifida occulta, usually located at the fifth lumbar or first
sacral vertebra. The newborn may have no impairments or may experience neurologic disturbances (eg, bowel/bladder
incontinence, sensory loss) of varying severity.
Manifestations of spina bifida occulta may include a tuft of hair, hemangioma, nevus, or dimple along the base of the spine.
The nurse should notify the health care provider because further assessment and surgical repair may be required (Option 3).
(Option 1) Caput succedaneum (mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to
prolonged pressure of the presenting part against the cervix during labor, resolves in a few days.
(Option 2) Flat, bluish, discolored areas on the lower back and/or buttocks indicate the benign finding, congenital dermal
melanocytosis (ie, Mongolian spots).
(Option 4) Vernix caseosa, a protective substance covering the fetus, is secreted by the sebaceous glands. This white,
cheesy/waxy substance is most likely seen in the axillary and genital areas of term newborns.
Spina bifida is a neural tube defect that occurs when spinal vertebrae do not close during fetal development, potentially allowing
spinal cord contents to protrude through the opening. A tuft of hair, hemangioma, nevus, or dimple at the base of the spine may
indicate the mildest form, spina bifida occulta.
Hypokalemia (<3.5 mEq/L [<3.5 mmol/L]) is a common, adverse effect of potassium-wasting diuretics (eg, furosemide,
bumetanide) that may cause muscle cramps, weakness, or paresthesia. Unmanaged hypokalemia can lead to lethal cardiac
dysrhythmias and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of
hypokalemia (Option 4).
Additional causes of hypokalemia include gastrointestinal losses (eg, vomiting, diarrhea, nasogastric suctioning) and medications
(eg, insulin). To combat hypokalemia in clients receiving potassium-wasting diuretics, supplemental potassium and/or a high-
potassium diet may be required.
(Option 1) Bruising is common with the use of antiplatelet agents (eg, aspirin, clopidogrel). However, the nurse should monitor for
and report signs of uncontrolled bleeding, such as bloody stools and signs of stroke (eg, headache, slurred speech).
(Option 2) Myocardial infarction and heart failure often cause activity intolerance and fatigue due to decreases in heart muscle
function. In addition, fatigue is a common side effect experienced on initiation of beta blocker (eg, metoprolol) therapy, but typically
improves over time.
(Option 3) Feelings of depression are common after an acute health-related event such as a myocardial infarction. The nurse
should further explore and evaluate feelings of depression; however, these symptoms are not immediately life-threatening unless
the client exhibits suicidal ideation.
Nurses caring for clients receiving potassium-wasting diuretics (eg, furosemide) should monitor for and report signs of hypokalemia
(eg, muscle cramps), as unmanaged hypokalemia may result in lethal complications. Bruising, a side effect of antiplatelet
medications, and fatigue, a side effect of beta blockers, should be monitored, but are not lethal.
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Epistaxis (nosebleed) is a common and rarely serious nasal condition that can be caused by dry mucous membranes, local injury
(eg, nose-picking), insertion of a foreign body, or rhinitis. Epistaxis usually involves the anterior nasal septum and often resolves
spontaneously or with simple home management.
Home management of epistaxis includes:
 Prioritizing application of direct, continuous pressure to the soft, compressible area below the nasal bone for 10
minutes to promote clot formation (Option 2)
 Holding a cold cloth or ice pack to the bridge of the nose to induce vasoconstriction and slow bleeding (Option 1)
 Attempting to keep the client with epistaxis quiet and calm as emotional outbursts and noncooperation create a
challenge to implementing interventions and stopping bleeding (Option 3)
(Option 4) Positioning a child with epistaxis in a horizontal position or with the head tilted backward promotes drainage of blood
into the throat, which increases the risk of swallowing or aspirating blood. Clients with epistaxis should sit upright and tilt the head
forward.
(Option 5) Epistaxis is typically managed at home. However, the caregiver should seek emergency care if the client's breathing is
impaired, or the bleeding is excessive or uncontrollable with home measures or resulted from a traumatic injury.
Epistaxis (nosebleed) is a nasal condition typically occurring from local injury (eg, nose-picking) or irritation. Initial epistaxis
management includes calming the client; tilting the head forward; applying direct, continuous nasal pressure for 10 minutes; and
applying cold packs to the nasal bridge.
Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an
increase in the amount of fluid in the pericardium (ie, pericardial effusion). Increased pericardial fluid places pressure on the
heart, which impairs the heart's ability to contract and eject blood. This complication (ie, cardiac tamponade) is life-
threatening without immediate intervention.
When assessing clients with pericarditis, it is critical for the nurse to observe for signs of cardiac tamponade (eg, muffled or distant
heart tones, hypotension, jugular venous distension) (Option 2). Development of cardiac tamponade requires emergency
pericardiocentesis (ie, needle insertion into the pericardium to remove fluid) to prevent cardiac arrest.
(Option 1) In acute pericarditis, the inflamed pericardium rubs against the heart, causing pain that often worsens with deep
breathing or when positioned supine. The client should be placed in the Fowler position with a support (eg, bedside table) to lean
on for comfort.
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(Option 3) ST-segment elevation in almost all ECG leads is a characteristic of acute pericarditis that typically resolves as
pericardial inflammation decreases. This is in contrast to acute myocardial infarction, in which ST-segment elevation is seen in
only localized leads (depending on which vessel is occluded).
(Option 4) Pericardial friction rub is an expected finding with acute pericarditis that occurs from the layers of the pericardium
rubbing together to create a characteristic high-pitched, leathery, and grating sound.
Nurses caring for clients with pericarditis should monitor for, and immediately report, signs of cardiac tamponade (eg, jugular
venous distension, distant heart sounds, hypotension), a life-threatening complication occurring from increased pericardial fluid
volume.
In peritoneal dialysis (PD), the abdominal lining (peritoneum) is used as a semipermeable membrane to dialyze clients with
decreased kidney function. A catheter is placed in the peritoneal cavity for infusing and draining dialysate (dialysis fluid).
Dialysate is infused and dwells in the abdomen, which allows waste products and electrolytes to cross the peritoneum into the
dialysate for removal. After the prescribed dwell time, the dialysate, electrolytes, and wastes are drained via gravity.
When administering PD, it is essential to use sterile technique when spiking and attaching bags of dialysate to the client's PD
catheter to prevent contamination and infection (Option 4). Bacterial peritonitis, an infection of the peritoneum, is a potential
complication of PD that may lead to sepsis. Signs of peritonitis should be reported to the health care provider.
(Options 1 and 2) Proper positioning of the catheter drainage bag (ie, below the abdomen) and the client (eg, Fowler or semi-
Fowler position) promotes effluent outflow but is not a priority over infection prevention.
(Option 3) Cloudy effluent may indicate infection, whereas bloody or brown effluent may indicate bowel perforation. Documenting
effluent characteristics is important but not a priority over maintaining asepsis.
Peritoneal dialysis (PD) uses the peritoneum as a semipermeable membrane to dialyze clients with decreased kidney function.
Bacterial peritonitis is a potential complication of PD. Using sterile technique when spiking or changing bags of dialysate is a
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priority to avoid contamination and reduce the risk of peritonitis.
Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins
to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of the central field of vision,
whereas the peripheral vision remains intact (Option 4).
Macular degeneration has two different etiologies. "Dry" macular degeneration involves ischemia and atrophy of the macula that
results from blockage of the retinal microvasculature. "Wet" macular degeneration involves the abnormal growth of new blood
vessels in the macula that bleed and leak fluid, eventually destroying the macula. Progression of macular degeneration may be
slowed with smoking cessation, intake of specific supplements (eg, carotenoids, vitamins C and E), laser therapy, and injection of
antineoplastic medications.
Risk factors for macular degeneration include advanced age, family history, hypertension, smoking, and long-term poor intake of
carotenoid-containing fruits and vegetables.
(Option 1) Seeing small flashes of light is associated with retinal detachment.
(Option 2) Inability to see things close up, known as presbyopia, occurs when the lens of the eye becomes less elastic with age
and therefore unable to adjust to near and far vision.
(Option 3) Poor peripheral vision, also called tunnel vision, can result from optic nerve damage seen in glaucoma.
Macular degeneration is a progressive, incurable eye disease that occurs when the central portion of the retina deteriorates, giving
rise to distortion (blurred or wavy visual disturbances) or loss in the center of the visual field.
12
Synchronized cardioversion is a procedure used to convert tachyarrhythmias (eg, supraventricular tachycardia, ventricular
tachycardia) with a pulse to stable cardiac rhythms via transcutaneous electrical shock. The shock in cardioversion is timed
by the defibrillator ("sync" feature enabled) to be delivered only during the R wave of the QRS complex, when the ventricles
depolarize.
Accidentally delivering shocks during the T wave, when heart ventricles are repolarizing, causes R-on-T phenomenon, which
frequently results in lethal arrhythmias (eg, ventricular fibrillation). The nurse must ensure that the defibrillator's "sync" feature is
enabled when preparing to perform synchronized cardioversion. Disabling or failing to enable the "sync" feature may result in a
potentially lethal, asynchronous shock being delivered to the client (Option 2).
(Option 1) During nonemergent cardioversion of a hemodynamically stable client, a sedative (eg, midazolam) is often
administered for client comfort.
(Option 3) Defibrillator pads should be placed on the right upper chest next to the sternum and on the left lower chest.
(Option 4) Prior to delivery of electrical shock (eg, cardioversion, defibrillation), oxygen should be turned off and moved away.
Oxygen is flammable and may explode when subjected to electric currents.
Synchronized cardioversion is a cardiac procedure used to convert tachyarrhythmias with a pulse to stable cardiac rhythms.
Nurses preparing to perform cardioversion must verify that the defibrillator's "sync" feature is engaged to prevent delivery of an
asynchronous shock, which may cause life-threatening arrhythmias.
A clean catch urine specimen is commonly performed in clients requiring urinalysis. The correct collection method for a female
client is as follows:
1. Perform hand hygiene and open the specimen container, leaving the sterile side of the collection lid
positioned upward to prevent contamination.
2. Spread the labia using the index finger and the thumb of the nondominant hand so that the specimen cup can be held
with the dominant hand.
3. Cleanse the vulva in a front-to-back motion with provided antiseptic wipes, using a new towelette with each wipe to
prevent contamination.
4. Initiate the urinary stream to flush any remaining microorganisms from the urethral meatus before passing the container
into the stream for the collection of 30-60 mL of urine.
5. Remove the specimen container from the stream before the urinary flow ends and the labia are released to prevent
contamination.
6. Replace the sterile cap without contaminating it and repeat hand hygiene.
A female client performs a clean catch urine specimen by completing hand hygiene and opening the specimen container,
spreading the labia using the index finger and the thumb of the nondominant hand, and cleansing the vulva in a front-to-back
motion. The client then initiates a urine stream before introducing the container midstream for urine collection. The container is
removed when well filled (30-60 mL) and before urinary flow ends.
This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart
is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin
from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6 or higher).
Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a
priority to ensure adequate kidney and other organ perfusion.
(Option 2) Testing for the presence of blood in the urine is important in determining if kidney damage has occurred, but circulation
stability is a priority.
(Option 3) A neurological assessment is essential, but circulation stability is a priority ("C before D" [disability]).
(Option 4) Bladder and stool impaction are etiologies for autonomic dysreflexia and generally occur in a client with a high-level
fracture at T6 or above with a stimulation below the fracture. Autonomic dysreflexia is a medical emergency that presents with
severe headache, hypertension, piloerection, and diaphoresis. It is seen weeks to years after the injury.
Neurogenic shock/distributive shock can occur from vasodilation soon after spinal injury. Classic symptoms are hypotension,
bradycardia, and pink and dry skin. The hypotension must be treated with isotonic fluids to maintain vital organ perfusion.
Clients with alcoholism can have hypoglycemia. They can also have thiamine (vitamin B1) deficiency related to poor nutrient
intake (a healthy diet contains enough thiamine) and alcohol-induced suppression of thiamine absorption. Thiamine deficiency can
result in Wernicke encephalopathy (WE). Untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis).
In the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the body; this can worsen
thiamine deficiency, which in turn can precipitate the development of WE in a previously unaffected individual. Because the signs
13
of alcohol intoxication and WE are similar, all intoxicated clients should be given IV thiamine before or with IV glucose (Options
2 and 4).
(Option 1) A blood draw for liver functions tests to rule out alcoholic hepatitis is important but not a priority.
(Option 3) Clients with alcoholism usually have additional nutritional deficiencies (eg, folic acid, magnesium). Magnesium and
multiple vitamins should also be given to these clients. However, thiamine is the essential vitamin to administer before or with IV
glucose in a client with suspected alcoholism.
IV thiamine is given before or with IV glucose to a client with alcohol intoxication to prevent Wernicke encephalopathy. Clients with
alcoholism often have thiamine deficiency.
Failure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in obstruction of the
tube, reduced medication absorption or efficacy, and medication toxicity. Before administering medications through a feeding tube,
the nurse should determine if any of the medications are available in a liquid form because liquid medications are less likely to
clog the tube (Option 3).
Medications should be crushed, dissolved, and administered separately to prevent interactions (eg, chemical reactions) between
medications or interference with absorption (Option 2). In addition, a feeding tube should be flushed before and after each
medication is given to avoid potential drug interactions and ensure tube patency (Option 4).
(Option 1) When using a feeding tube, each medication should be administered individually to prevent interactions between
medications.
(Option 5) Medications mixed with enteral feedings may form a thick consistency and clog the tube.
When using a feeding tube, medications should be crushed, dissolved, and administered separately to prevent interactions.
Feeding tubes should be flushed before and after each medication is given. Liquid medications should be used if possible.
Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin most often seen in newborns of
ethnicities with darker skin tones (eg, African American, Native American, Hispanic, Asian). Mongolian spots are usually bluish
gray and fade over the first 1-2 years of life. Because they are easily misidentified as bruises, it is important for the nurse to
measure and document the area for reference during future health care assessments.
(Option 1) Mongolian spots are common birthmarks and are not associated with abnormal laboratory values.
(Option 3) Mongolian spots are benign, so immediately notifying the health care provider is not indicated.
(Option 4) Although often mistaken for bruises, mongolian spots are normal skin variations and are not due to trauma.
Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin typically found on the back or buttocks. It
is most often seen in newborns of ethnicities with darker skin tones. The spots are usually bluish gray and may be misidentified as
bruising in future health care assessments. Proper documentation is essential to avoid misinterpretation of findings.
Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain. Although
antiemetic medications are typically administered immediately after surgery to control nausea and vomiting, nausea is still a
common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients are at high risk
for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by anesthesia. Clients
reporting nausea should be placed immediately on their side to prevent aspiration of vomit.
(Option 2) Mild oozing of blood from the surgical site is normal during the postoperative period. The nurse will note the amount
and appearance of the drainage, reinforce the dressings, and continue to monitor the client. This client would be seen third.
(Option 3) Pain control after surgery is important for client recovery. Because short-acting pain medications are given to minimize
respiratory depression, a client's pain can increase quickly. This client would be seen second.
(Option 4) After transurethral resection of the prostate, continuous bladder irrigation for 24-36 hours flushes out small clots and
prevents obstruction. Reddish-pink drainage is expected in the immediate postoperative period. This client would be seen last.
Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered level of consciousness (caused by
anesthesia). These clients should be placed on their side and should receive antiemetics to prevent potential airway and breathing
complications.
Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge to defecate
or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract
infections, spread of infection (eg, Clostridium difficile), and contamination of wounds. Therefore, maintenance of perineal and
perianal skin integrity is the highest priority.
14
Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled
area and apply a thick moisture barrier product to the skin (Option 3). Clean, dry linens and clothing should be provided.
(Option 1) Wound care and incontinence specialists are useful resources in developing a bowel and/or incontinence management
plan; however, the highest priority is promotion of skin integrity.
(Option 2) Rectal tubes and other indwelling containment devices can cause skin/mucosal breakdown, decreased response of the
anal sphincter, and infection. Skin integrity may be maintained without the risks associated with these devices; however, if other
measures fail, these devices may be used.
(Option 4) Absorptive incontinence products (eg, pads, undergarments) can be used after interventions to prevent incontinence
and maintain perineal hygiene have failed. Incontinence products such as adult briefs may cause chemical irritation of the skin,
further exacerbating skin breakdown. These products should wick moisture away from the client's skin.
Interventions to prevent and handle fecal incontinence should be implemented from least to most invasive. Maintenance of skin
integrity through perineal and perianal hygiene is the highest priority. Implementation of containment products (eg, absorbent
pads, adult briefs, rectal tubes) can be considered after hygiene practices fail.
Parkinson disease (PD) is characterized by decreased dopamine levels, uncontrolled acetylcholine, and formation of abnormal
protein clusters (Lewy bodies) in the brain. PD causes both physical and neurological (eg, mood alterations, dementia) symptoms.
Carbidopa-levodopa is a combination antiparkinsonian medication used to reduce physical symptoms of PD by increasing
dopamine levels in the brain. Levodopa is converted to dopamine in the brain but is largely metabolized before reaching the
brain. Carbidopa does not have a therapeutic effect on PD but prevents breakdown of levodopa before reaching the brain, which
makes levodopa more effective.
Client teaching for carbidopa-levodopa includes:
 Implementing fall precautions (eg, changing positions slowly, removing rugs), as orthostatic hypotension is a common
side effect (Option 1)
 Knowing that carbidopa-levodopa takes several weeks to reach its maximum effectiveness (Option 2)
 Understanding that harmless discoloration (eg, red, brown, black) of secretions (eg, urine, perspiration, saliva) may
occur while taking carbidopa-levodopa (Option 5)
 Avoiding high-protein meals, which interfere with the absorption of carbidopa-levodopa
(Option 3) Dyskinesia (eg, facial or eyelid twitching, tongue protrusion, facial grimacing) may indicate overdose or toxicity of
carbidopa-levodopa and should be reported immediately to the health care provider.
(Option 4) Carbidopa-levodopa often decreases, but does not eliminate, tremor and rigidity.
Carbidopa-levodopa is a medication used to reduce symptoms of tremor and rigidity in clients with Parkinson disease. Teach
clients that the medication takes several weeks to become effective; urine, perspiration, or saliva discoloration is a common side
effect; and fall precautions should be implemented for client safety.
Foreign body aspiration is an emergency that requires immediate intervention when witnessed or highly suspected. The primary
rescue intervention for adults and children over age 1 is abdominal thrusts, known as the Heimlich maneuver. This maneuver
entails applying upward thrusts with a fist to the upper abdomen just beneath the rib cage. The upward action causes the
diaphragm to forcefully expel air out of the airway, carrying the foreign body out with it.
If the child is conscious and able to cough or make sounds, the nurse should ask the child to forcefully cough before intervening.
These signs indicate a partial obstruction still allowing airflow, which may be cleared with strong coughing. However, any signs of
respiratory distress (eg, stridor, inability to speak, weak cough, and cyanosis) require immediate intervention.
(Option 2) Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Older children require
abdominal thrusts to clear an obstructed airway.
(Option 3) Blind sweeping a child's mouth can force a loosely obstructing object to fully block the airway or cause the object to fall
farther into the airway, requiring surgical removal.
(Option 4) This child is experiencing a blocked airway, which is a medical emergency that requires intervention at the skill level of
a nurse. The nurse can ask a bystander to contact 911 while attempting to clear the airway. This differs from a situation such as
anaphylaxis, in which the nurse would require epinephrine and would call 911 for immediate assistance.
The Heimlich maneuver (ie, upward abdominal thrusts under the rib cage) is the primary rescue intervention for children over
age 1with a foreign body airway obstruction causing respiratory distress. Back blows and chest thrusts are appropriate
interventions for a choking infant under age 1. Blind sweeping of a child's mouth should not be attempted.
15
Loop diuretics (eg, furosemide [Lasix], bumetanide [Bumex]) are "potassium-wasting" diuretics, meaning that clients may
experience potassium loss and hypokalemia. Hypokalemia in a client with heart failure creates a risk for life-threatening cardiac
dysrhythmias. Therefore, clients taking loop diuretics usually require potassium supplementation.
Potassium is an erosive substance that can cause pill-induced esophagitis. To prevent esophageal erosion, the client should
take potassium tablets with plenty of water (at least 4 oz [120 mL]) and remain sitting upright for ≥30 minutes after ingestion.
This prevents the tablet from becoming lodged in the esophagus or refluxing from the stomach (Option 4).
Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates ("dronates": alendronate,
ibandronate, pamidronate, risedronate), so clients taking these medications should be given similar instructions.
(Option 1) A diet rich in protein and vitamin D helps with calcium-supplement, not potassium, absorption.
(Option 2) Sustained-release medications should never be crushed as this would cause the client to absorb the medication too
rapidly.
(Option 3) Potassium should be taken during or immediately following meals to prevent gastric upset.
The nurse should teach the client to take potassium tablets with plenty of water (≥4 oz [120 mL]) and to sit upright after ingestion to
prevent pill-induced esophagitis. Potassium should be taken during or immediately following meals to prevent gastric upset.
Sustained-release tablets should not be crushed.
Perinatal mood disorders
Postpartum blues Postpartum depression Postpartum psychosis
Prevalence 40%-80% 8%-15% 0.1%-0.2%
2-3 days postpartum; resolves 4-6 weeks postpartum; up to 2 weeks postpartum; severity &
Onset & within 2 weeks 12 months postpartum; gradual duration can vary
duration improvement over first 6 months
postpartum
Emotional lability, mild Extreme sadness, irritability,

Hallucinations, delusions, impulsivity,
sadness, irritability, insomnia emotional outbursts, severe mood
Symptoms hyperactivity, confusion, delirium;
swings; can present with postpartum
often associated with bipolar disorder
anxiety
Supportive care, client & family Supportive care plus pharmacologic Emergent psychiatric hospitalization,
education, ongoing intervention &/or psychotherapy pharmacologic intervention
Treatment
assessment for worsening
symptoms
Perinatal mood disorders may occur at any time during pregnancy but are often precipitated in the postpartum period by the
sudden drop in estrogen and progesterone levels after birth. Clients with postpartum depression may feel intense and
persistentirritability, anxiety, anger, guilt, and sadness. Such feelings may affect the ability to care for the newborn or
themselves. A client showing irritability and disinterest in caring for the newborn should be further assessed for postpartum
depression and offered a referral for follow-up care.
(Option 1) Maternal fatigue or decreased energy is common after birth and while caring for a newborn. The nurse can reassure
the client that sleeping when the newborn sleeps is a good strategy as normal newborn sleep and feeding habits may require the
client's attention frequently day and night.
(Options 2 and 4) Postpartum blues ("baby blues") is a common, milder form of depression characterized by emotional lability,
sadness, anxiety, and difficulty sleeping. However, the client's ability to function properly is not affected, and symptoms subside
within 2 weeks without treatment. If symptoms persist after 2 weeks, further assessment may be necessary.
Perinatal mood disorders may occur at any time during pregnancy but are more common in the immediate postpartum period.
Clients with postpartum depression may feel intense and persistent anxiety, anger, guilt, and sadness. A client showing irritability
and disinterest in caring for the newborn should be assessed for postpartum depression and offered a referral for follow-up care.
The concerns presented by this child's parent are suggestive of a developmental delay and very possibly autism spectrum
disorder(ASD).
ASD is a complex neurodevelopmental disorder characterized by the onset of abnormal functioning before age 3. The 2 core
symptoms of ASD are abnormalities in social interactions and communication (verbal and nonverbal), and patterns of
behavior, interests, or activities that can be restricted and repetitive. Social skills, especially communication, are delayed more
significantly than other developmental functioning and are the focus during client assessment.
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The vast majority of children diagnosed with ASD lack the acquisition of communication skills during the first 2 years of life. A
healthy 2-year-old should have a vocabulary of about 300 words and should be able to string 2 or more words together in a
meaningful phrase. Assessing this child's language abilities would be the priority.
(Option 2) Assessing any 2-year-old's progress in toilet training is appropriate. However, it is not the priority assessment given
the parent's concerns.
(Option 3) A nutrition assessment is part of every well-child visit, but it is not the priority in this situation.
(Option 4) Although not the priority assessment, it would be important to ask the parent about the child's play activities. Children
with ASD often have a restricted interest in and preoccupation with a single toy, exhibit repetitive behaviors when playing with the
toy, and insist on the same play routine.
The 2 core symptoms of autism spectrum disorder are abnormalities in social interactions and communication (verbal and
nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. Social skills, especially
communication, are delayed more significantly than other developmental functioning.
Active TB is treated with combination drug therapy. Isoniazid causes hepatotoxicity and peripheral neuropathy. Rifampin (Rifadin)
also causes hepatotoxicity. Therefore, baseline liver function tests should be obtained. Clients should be advised to watch for
signs and symptoms of hepatotoxicity (eg, jaundice, anorexia). Ethambutol causes ocular toxicity, and clients will need frequent
eye examinations.
A teaching plan for a client prescribed rifampin includes these additional instructions:
 Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. Tears can turn red, making
contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenses while taking this
medication.
 Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of
oral contraceptives.
(Option 1) Red urine is an expected finding with rifampin use; clients should not be concerned.
(Option 2) Clients should be advised to not consume alcohol and drugs that can increase the risk for hepatotoxicity (eg,
acetaminophen) during long-term use of this drug.
(Option 4) The effectiveness of treatment for active TB is determined by 3 negative sputum cultures and chest x-ray. If the entire
course of therapy (6-9 months) is not completed, reinfection, spread to others, and development of resistant strains of TB bacteria
can result.
Common potential side effects of rifampin include hepatotoxicity, red-orange discoloration of body fluids, and increased metabolism
of some drugs (eg, oral contraceptives, hypoglycemics, warfarin).
17
The
client's ABGs have low pH consistent with acidosis. If it is a primary respiratory acidosis, pCO2 would be higher. If it is metabolic
acidosis, bicarbonate would be lower. Because this client has low pH coupled with low bicarbonate, the most likely diagnosis is
primary metabolic acidosis. Respiratory alkalosis is the body's natural compensation for metabolic acidosis. Respiratory alkalosis
is achieved by blowing more CO2 off from the system through rapid breathing.
(Option 1) Decreased bicarbonate reabsorption would produce metabolic acidosis; this would occur as a compensation for
primary respiratory alkalosis (decreased pCO2 and high pH).
(Option 2) When the respiratory rate is decreased, pCO2 would increase, creating a respiratory acidosis; this would occur in
response to a primary metabolic alkalosis.
(Option 3) Increased bicarbonate reabsorption would produce metabolic alkalosis; this would occur as a compensation for primary
respiratory acidosis (increased pCO2 and low pH).
Respiratory alkalosis is the body's natural compensation for metabolic acidosis. It is achieved by blowing more CO2 off from the
system through rapid breathing.
In this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are
those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a
head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is
unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and this should not
be postponed.
(Option 2) Maintenance doses of cyanocobalamin for vitamin B12 deficiency are usually administered every 4 weeks. Although
this client should receive the injection as soon as possible, postponing the home care visit for 1 or 2 days will not harm the client.
(Option 4) This client can be provided with telephonic care management; the nurse can perform medication reconciliation over the
phone and provide instructions regarding care.
During a weather-related emergency, home care visits are classified as:
18
1. High priority – unstable clients who need care and are at risk for hospitalization if not seen.
2. Moderate priority – clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care
management can be provided to these clients.
3. Low priority – clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with
care.
The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. The
65-year-old client should be assessed first.
(Option 1) Tachycardia can be caused by underlying infection and can resolve with treatment of the infection. Valve infections
can require several weeks of antibiotics. This client is not the priority.
(Option 2) Pancreatitis is a very painful condition and sinus tachycardia is expected. These clients are also at risk of developing
complications such as third spacing of volume and require large quantities of IV fluids. This client is the second priority.
(Option 4) Atrial fibrillation is commonly treated with calcium channel blockers such as diltiazem. The dosage needs to be
adjusted to achieve a goal heart rate of <100/min. Atrial fibrillation is usually not immediately life-threatening.
Liver biopsy can cause internal bleeding. Clients with internal bleeding require priority assessment.
Percutaneous kidney biopsy is an invasive diagnostic procedure. It involves inserting a needle through the skin to obtain a tissue
sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ;
therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the
client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using
antihypertensive medications before performing a kidney biopsy (Option 1).
(Option 2) An elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L) can be expected in a client with probable
renal disease. This is not the most important finding to report to the HCP.
(Option 3) A decreased hemoglobin level (normal adult male: 13.2-17.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL
[117-155 g/L]) can be expected in a client with probable renal disease due to decreased erythropoietin production. The nurse
should continue to monitor the client's hemoglobin post-procedure as it can decrease further (within 6 hours) if bleeding occurs.
(Option 4) Only neurosurgery and ocular surgery require a platelet count >100,000/mm3 (100 x 109/L). Most other surgeries can
be performed when the platelet count is >50,000/mm3 (50 x 109/L). Although the platelet count is low (normal 150,000-
400,000/mm3[150-400 x109/L]), it is not the most important finding to report to the HCP.
The kidney is a highly vascular organ and the risk of bleeding is a major complication after a percutaneous biopsy. The client
should have normal coagulation studies, an adequate platelet count, and well-controlled blood pressure prior to the procedure to
reduce bleeding risk.
Chronic heart failure involves the inability of the heart to fill and pump blood effectively to meet the body's oxygen demands. As a
result, clients can develop dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]), an electrolyte disturbance caused
by an excess of total body water in relation to total sodium content.
The nurse should question the prescription for the maintenance IV line. An infusion of an isotonic solution of 0.9% normal saline at
85 mL/h is contraindicated in this client as it would increase the circulating extracellular fluid volume, worsen the symptoms, and
exceed the <2 L/day fluid restriction (ie, 85 mL × 24 hours = 2040 mL). Converting the running IV line to a lock for medication
administration would be appropriate.
(Option 1) Furosemide (Lasix) is a fast-acting loop diuretic prescribed to decrease preload in clients with heart failure who are
fluid overloaded and experiencing manifestations of pulmonary congestion (eg, crackles, dyspnea). Appropriate diuresis in this
client would remove excess free water and correct dilutional hyponatremia.
(Option 3) Potassium chloride is administered to clients receiving furosemide to prevent or treat diuretic-associated hypokalemia.
The nurse should not question this prescription.
(Option 4) Fluid restriction is prescribed to correct dilutional hyponatremia (sodium <135 mEq/L [135 mmol/L]) in a client with
heart failure. In addition, all heart failure clients require a low-salt diet. Excess salt causes retention of more water. This client's
low sodium is due to excess free water and not to low dietary sodium.
Dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]) is an electrolyte disturbance caused by an excess of total body
water in relation to total sodium content and can occur in clients with heart failure. Treatment includes the administration of
diuretics and fluid/salt restriction.
19
The dosage of angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril, enalapril, ramipril) should be adjusted for clients
with renal impairment. A serum creatinine of 2.5 mg/dL (221 µmol/L ) indicates renal impairment (normal 0.6-1.3 mg/dL [53-115
µmol/L]). The nurse should notify the health care provider so that the dosage can be decreased or held.
(Options 1, 2, and 4) The client's blood pressure, heart rate, and serum potassium (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) are
within normal limits. They do not require immediate action. Hyperkalemia and hypotension are contraindications for giving ACE
inhibitors.
Evaluation of kidney function is essential for clients taking medications that are excreted renally or can worsen renal injury. These
include ACE inhibitors (eg, lisinopril, enalapril), aminoglycosides (eg, gentamicin), and digoxin.
When evaluating research for practice changes, the nurse must first determine if there is reasonable similarity between the nurse's
unit population and the study population to expect equivocal results. This should be the initial consideration to ensure that the
research is appropriate for a given setting. For instance, if the nurse cares for pediatric clients with acute pain, the protocol for
adult clients with terminal cancer might not translate effectively or safely to those clients.
Other aspects of the study to evaluate include whether all clinically relevant outcomes were addressed, if the benefits outweigh any
potential harm or costs, and if the protocol resulted in improved care.
(Option 1) An institutional review board (IRB) is a committee that reviews research before it is conducted to ensure that is it
ethical. Legally, any study of human subjects needs IRB approval to provide protection from unnecessary risk. Peer-reviewed
journals usually require a statement of IRB approval before accepting an article for publication. However, the IRB process does
not determine whether the findings are relevant for a particular setting.
(Option 3) The educational credentials of a researcher may be relevant, especially if a non-health care professional has
conducted a health care study. However, the integrity of the research process and findings is more important than the holding of
any particular degree.
(Option 4) Financial support can be considered, particularly when research finds favorably for a drug or product that is
manufactured or supported by a sponsor of the study. Although it is essential for a financial relationship to be disclosed, that alone
does not negate the usefulness of the study.
When seeking to apply research findings in practice, the nurse should consider the similarities between the research study
population and the client population.
Breast engorgement is often painful. The management of engorgement varies based on the client's breastfeeding status; for
clients who choose not to breastfeed, treatment focuses on managing symptoms while promoting reduced milk production.
Comfort measures include:
 Applying ice packs to both breasts for 15-20 minutes every 3-4 hours to reduce blood flow and swelling
 Applying chilled, fresh cabbage leaves to both breasts, replacing with fresh leaves after they wilt. The mechanism of
action is unclear but may be related to the cool temperature or to phytoestrogens from the leaves (Option 4).
 Taking an anti-inflammatory analgesic (eg, ibuprofen) as directed to reduce pain
 Maintaining firm breast support (eg, supportive bra, breast binder) until milk flow is diminished
(Option 1) Heat application increases blood flow and worsens engorgement. Although running warm water over the breasts may
make milk leak and temporarily relieve pressure, more milk is produced later, which is counterproductive in a client who has
chosen not to breastfeed.
(Options 2 and 3) Breastfeeding is a supply-and-demand process. Massaging the breasts or manually expressing milk stimulates
milk production, which exacerbates engorgement if the client is not breastfeeding.
Stimulation of milk production (eg, manual milk expression, breast massage) is avoided in clients who intend to exclusively formula
feed. Comfort measures for breast engorgement include application of ice packs and chilled, fresh cabbage leaves; analgesics;
and firm breast support.
Aspiration of a foreign body occurs most often in the toddler age group. Swallowing of objects such as buttons, small parts of
toys, or food particles can be life-threatening and result in airway obstruction due to the small diameter of the airway.
Manifestations include choking, gagging, cyanosis, and inability to speak when the object is lodged in the larynx.
(Option 1) Although the client has mild retractions with wheezing and a harsh cough, a patent airway is present. This client may
be experiencing expected manifestations of asthma, but this is not a life-threatening condition.
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(Option 3) The client's manifestations are consistent with laryngotracheobronchitis (croup), which is generally caused by a
parainfluenza virus. There is no respiratory challenge indicated by a 94% oxygen saturation on room air, and this not an
emergency situation.
(Option 4) Otitis media is an infection or inflammation of the middle ear with the highest incidence at age 6-36 months; it occurs
during the winter months. Acute onset presents with ear pain, irritability, fever, and pulling on the affected ear. Fluid can
accumulate in the middle ear and create an environment for bacterial growth. Respiratory distress is not seen.
Using the priorities of airway, breathing, and circulation, maintenance of airway function requires immediate intervention by a
nurse.
Hearing impairment in children may be related to family history, an infection, use of certain medications, or a congenital disorder.
Toddlers with hearing deficits may appear shy, timid, or withdrawn, often avoiding social interaction. They may seem extremely
inattentive when given directions and appear "dreamy." Speech is usually monotone, difficult to understand, and loud. Increased
use of gestures and facial expressions is also common.
(Option 2) Children typically begin to use well-formed syllables such as "mama" and "dada" by approximately age 7 months. A
referral for a hearing test should be made if there is an absence of well-formed syllables by age 11 months or intelligible speech is
not present by 24 months.
(Option 4) Lack of attentiveness and appropriate response when given a direction is characteristic of a toddler who has a hearing
impairment.
Hearing impairment in infants delays development of intelligible speech. As these infants become toddlers, they often have a loud
voice and monotone speech that is difficult to understand. They appear shy, timid, and inattentive.
This client is experiencing paroxysmal supraventricular tachycardia (PSVT). In PSVT, the heart rate can be 150-220/min. With
prolonged episodes, the client may experience evidence of reduced cardiac output such as hypotension, palpitations, dyspnea,
and angina.
Treatment includes vagal maneuvers such as Valsalva, coughing, and carotid massage. Adenosine is the drug of
choice for PSVTtreatment. Due to its very short half-life, adenosine is administered rapidly via IVP over 1-2 seconds and
followed by a 20-mL saline bolus. An increased dose may be given twice if previous administration is ineffective. Beta blockers,
calcium channel blockers, and amiodarone can also be considered as alternatives. If vagal maneuvers and drug therapy are
unsuccessful, synchronized cardioversion may be used.
(Option 2) Atropine is an anticholinergic agent used to increase heart rate in clients with symptomatic bradycardic (<60/min)
rhythms.
(Option 3) Defibrillation is used only in clients with ventricular fibrillation and pulseless ventricular tachycardia. Cardioversion
would be considered if drug therapy is ineffective for PSVT.
(Option 4) External pacing is indicated in symptomatic bradycardic (<60/min) rhythms.
The drug of choice in clients with PSVT is adenosine. It is given rapidly via IVP over 1-2 seconds and followed by a 20-mL saline
bolus. An increased dose may be administered 2 more times if previous administration is ineffective.
Clients with OCD engage in rituals and behaviors that help reduce the anxiety or stress rooted in their obsessions (recurrent
thoughts, impulses, or images that cause notable distress). If the ritual is interrupted, the client will experience increased anxiety.
A client with compulsive behavior often does not realize the amount of time or how many times the same activity has been
performed. By providing reflective feedback about the client's behavior, the nurse is acknowledging the behavior in a
nonjudgmental manner. The nurse should also help the client become involved in other activities and problem-solving skills.
(Option 1) Engaging other staff members to remove the client from the bathroom is confrontational and will increase the client's
and roommate's anxiety; this approach is not necessary or therapeutic.
(Option 3) Pointing out that the bathroom is clean does not change the client's obsessive thoughts. Saying that the client's
behavior is unreasonable conveys a message of disapproval and would increase the client's anxiety.
(Option 4) Telling the roommate to use a different bathroom allows the client to continue the ritualistic behavior, is non-
therapeutic, reinforces the behavior, and avoids the issue.
Clients with OCD engage in rituals and activities that help reduce the anxiety associated with unacceptable thoughts, images, and
impulses. Therapeutic approaches to a client with OCD include pointing out the amount of time the client has spent performing an
activity and redirecting the client to another activity.
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Postpartum psychosis is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including
genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous
discontinuation of mood-stabilizing medications (eg, lithium).
Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and
feelings that someone will harm the baby (Option 2). Postpartum psychosis is a psychiatric emergency requiring
hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are at
increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby.
(Option 1) Post-surgical constipation is caused by narcotic and anesthetic administration, decreased ambulation, and
manipulation of the bowels during surgery. Fluids, fiber, ambulation, and stool softeners should be encouraged. Absence of flatus
or associated nausea/vomiting would be more concerning. This is not an emergent issue; this client would be called third.
(Option 3) Urinary incontinence can occur after vaginal birth due to neuromuscular trauma and can improve with pelvic floor
exercises. This client would be called last.
(Option 4) Fatigue is common with a new baby. However, sleeping too much might indicate postpartum depression. The nurse
should call this client second for further assessment.
Postpartum psychosis is a rare but serious perinatal mood disorder characterized by hallucinations, paranoia, severe mood swings,
and feelings of harm toward the baby. This form of psychosis is an emergency and requires immediate assessment and
intervention.
A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to
the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding
strategies increase oral intake and decrease aspiration risk:
 Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of
aspiration (Option 3).
 Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft.
 Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices
allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows
the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5).
 These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach
distension and regurgitation (Option 2).
 Feeding slowly over 20–30 minutes reduces the risk of aspiration and promotes adequate intake of formula.
 Feeding every 3–4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to
be fed more frequently if they are not consuming adequate amounts of formula.
(Option 1) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area.
This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous
and the infant will sneeze or cough in order to clear the nose.
(Option 4) Feeding should take about 20–30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes
or more. In addition, the extra work of feeding will burn up calories that are needed for growth.
Children with cleft palates are at increased risk for inadequate intake as well as aspiration. Actions to promote intake and reduce
aspiration risk include feeding in an upright position, pointing the nipple away from cleft, feeding over no more than 20–30 minutes,
using special nipples or bottles, and feeding every 3–4 hours. The infant should be burped at regular intervals to reduce gastric
distension.
Activated charcoal is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for gastrointestinal
decontamination in clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, restlessness) as
well as in those who are asymptomatic. Activated charcoal binds to available salicylates, thus limiting further absorption in the
small intestine and enhancing elimination.
(Option 2) Similar to syrup of ipecac, gastric lavage is associated with risk of aspiration. In addition, there is no convincing
evidence that it decreases morbidity. It is not routinely recommended but may be performed for the ingestion of a massive or life-
threatening amount of drug. If necessary, it should be administered within 1 hour of ingestion and requires a protected airway and
possible sedation.
(Option 3) IV sodium bicarbonate is an appropriate treatment for aspirin toxicity after the administration of activated charcoal. It
is given to make the blood and urine more alkaline, therefore promoting urinary excretion of salicylate.
(Option 4) Syrup of ipecac has been shown to have minimal benefit in treating aspirin overdose; in addition, it is not
recommended due to the risk of aspiration pneumonia secondary to induced vomiting.
Activated charcoal is used as the initial treatment for aspirin overdose in clients with clinical signs of salicylate toxicity as well as in
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those who are asymptomatic. Activated charcoal binds with salicylate and therefore inhibits absorption by the small intestine. IV
sodium bicarbonate is also used for treating aspirin overdose after treatment with activated charcoal has been initiated.
Providing care establishes a legal caregiver obligation/relationship between the nurse and the visitor. If a relationship is
started, the nurse has a duty to continue care until the visitor is stable or other health care personnel can take over. If proper care
is not continued, the nurse could be accused of negligence (ie, failure to act in a prudent manner as would a nurse with similar
education/experience).
This visitor's symptoms are potentially serious as sudden onset of headache and numbness in half of the body may indicate
stroke. In the event of a visitor emergency, the nurse should not establish a caregiver relationship but rather implement facility
protocol to help the visitor get to the emergency department promptly to receive immediate assessment and further
evaluation (Option 2).
(Options 1 and 4) Asking the visitor to call the health care provider (HCP) or giving advice to lie down delays the essential
assessment and treatment that this visitor with potentially serious symptoms requires.
(Option 3) When a nurse provides care (eg, takes blood pressure), a client-caregiver relationship is established. The nurse caring
for a visitor is ill-equipped to provide care without any HCP prescriptions in place and risks being negligent.
Providing care establishes a legal caregiver obligation/relationship between the nurse and a visitor. In the event of a visitor
emergency, the nurse should refrain from actions that establish this relationship and instead implement facility protocol to help get
the visitor promptly to the emergency department.
Older individuals, diabetic clients, and women may have atypical angina symptoms rather than the characteristic crushing,

substernal type of chest pain. These symptoms include atypical pain (jaw or arm), shortness of breath, indigestion, nausea,
dizziness, and cold sweats. This client reports symptoms thought to be related to a dental problem, but the nurse needs to
gather more information. The symptoms can indicate a cardiac medical emergency (myocardial ischemia or acute myocardial
infarction) that requires immediate evaluation and intervention.
(Option 1) Minor expected adverse effects can occur 1-2 days after influenza vaccination. Symptoms include flulike symptoms
(eg, fever, aching, itching at the injection site); analgesia with ibuprofen or acetaminophen can help provide relief.
(Option 2) The client's symptoms began following a specific event and can indicate a rotator cuff injury. Imaging, treatment with
nonsteroidal anti-inflammatory drugs, and physical therapy may be indicated. Although further evaluation is necessary, this is not a
medical emergency.
(Option 4) Solifenacin (VESicare) is a cholinergic antagonist prescribed to treat symptoms associated with an overactive bladder
(eg, urge incontinence, frequency). Common expected adverse effects include dry mouth and constipation. The nurse should
caution the client about safety when performing activities until the response to the medication is determined, as it can also cause
dizziness and blurred vision. This is not a medical emergency.
Women with myocardial ischemia and acute myocardial infarction (AMI) often have atypical pain and nonspecific symptoms.
Evaluation and treatment for a suspected AMI are critical as it can be life-threatening.
Open endotracheal (ET) suctioning is a skill performed to remove pulmonary secretions and maintain airway patency in clients
who are unable to clear secretions independently. ET suctioning is important to promote gas exchange and prevent alveolar
collapse, but inappropriate technique increases the client's risk for complications (eg, pneumonia, hypoxemia) or tracheal injury
(eg, trauma, bleeding). To reduce the risk of complications and injury during ET suctioning, the nurse should:
 Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes (Option 1)
 Suction only while withdrawing the catheter from the airway (Option 2)
 Use strict sterile technique throughout suctioning (Option 5)
 Limit suctioning to ≤10 seconds on each suction pass
(Option 3) Instilling sterile normal saline solution or sterile water (ie, lavaging) in the client's airway, a practice no longer supported
by evidence, greatly increases the risk for infection by potentially transporting bacteria from the upper airway into the lower
airways.
(Option 4) Suctioning longer than 10 seconds increases risk for collapse of airway structures (eg, alveoli, bronchioles) and
hypoxemia (ie, oxygen saturation <90%).
Open endotracheal (ET) suctioning is a skill used to clear secretions and maintain airway patency. When performing ET
suctioning, the nurse preoxygenates with 100% oxygen, applies suction only while withdrawing the catheter, uses sterile technique,
and limits each suction pass to ≤10 seconds.
Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long history of
antibiotic use, or invasive tubes or lines (hemodialysis clients). Clients in the intensive care unit (ICU) are especially at risk for
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MRSA. The 80-year-old client with COPD in the ICU on the ventilator has several of these risk factors. COPD is a chronic illness
that can affect the immune system, and clients experience exacerbations that may require frequent antibiotic and corticosteroid
use. This client is elderly and also has an invasive tube from the ventilator.
(Option 1) A student athlete could be colonized with MRSA from time spent in locker rooms and around athletic equipment.
MRSA more often appears as skin infections in this age group. Unless this client has an open fracture, there is no break in skin
integrity.
(Option 2) This client does have an incision (portal of entry) and invasive lines but is younger and has no evidence of suppressed
immunity.
(Option 3) This client is older and does have a small surgical incision but is not as high risk as the client with COPD. All clients
undergoing pacemaker placement will receive a prophylactic antibiotic to prevent surgical site infection just before surgery.
Clients at highest risk for developing hospital-acquired MRSA are older adults and those with suppressed immunity, long history of
antibiotic use, invasive tubes or lines, or in the ICU. Nurses should follow infection control procedures diligently with these clients.
Nursing priorities when implementing a chemical contamination emergency response plan include the following:
1. Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the
health care facility from the contaminant
2. Donning personal protective equipment to protect the nurse when providing care (Option 3)
3. Decontaminating the clients outside the facility before initiating treatment. If the chemical is not removed, it will
continue to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating
staff and other clients (Option 2).
4. Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing), regardless of
the specific cause (Options 1 and 4).
The nurse should always protect other clients, staff, and the health care facility first in a chemical contamination. Personal
protective equipment should be put on before decontamination. Victims should be decontaminated outside the facility before care
is administered.
A sharp object that pierces the skin and lodges in the body may result in penetrating trauma to nearby tissue and organs.
Common types of impaled (embedded) objects include bullets or blast fragments from firearms as well as sharp objects such as
scissors, nails, or knives. The embedded object creates a puncture wound and then controls potential bleeding by putting pressure
on the wound. First responders should not manipulate or remove the impaled object. Manipulation or removal may cause
further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client
assessment (Option 4) and later during transport to a health care facility where skilled trauma care is available.
Exception to the rule: First responders (EMS providers) may remove the impaled object if it obstructs the airway and prevents
effective cardiopulmonary resuscitation.
(Option 1) An IV line may be inserted and fluids begun on scene after stabilization of the object and initial assessment.
(Option 2) Blood may be drawn after stabilization of the object and initial assessment.
(Option 3) Clothing may be removed on scene after stabilization of the object and initial assessment.
An impaled object should not be manipulated or removed at the scene as further trauma and bleeding of soft tissue and
surrounding organs may occur. The embedded object is stabilized on scene to allow for initial client assessment and later
transport to a health care facility where skilled trauma care is available.
The rhythm strip of a client with a single-chamber atrial pacemaker displays a pacer spike before the P wave, followed by a QRS
complex, on an electrocardiogram (ECG). The P wave may appear normal or somewhat distorted following the spike. Atrial
pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart
blocks).
(Option 2) In first-degree atrioventricular block, every impulse is conducted to the ventricles, but the time of atrioventricular
conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. Ventricular bigeminy is a rhythm in which
every other heartbeat is a premature ventricular contraction (PVC). Unlike the QRS complexes in this client's ECG, PVCs are not
associated with P waves, and the QRS complexes are wide and distorted.
(Option 3) Normal sinus rhythms do not have pacer spikes. Unlike the QRS complexes in this client's ECG, PVCs are not
associated with P waves, and the QRS complexes are wide and distorted.
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(Option 4) Failure to sense appears on an ECG as asynchronous pacer spikes in inappropriate or random locations (eg, pacer
spike on the T wave). It should not be confused with failure to capture, in which pacer spikes are located appropriately but there is
no electrical response elicited from the heart (eg, no QRS complex after a pacer spike).
An atrial paced rhythm displays a pacer spike followed by a normal or distorted P wave, then a QRS complex. Atrial pacemakers
are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart blocks).
An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the
brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake
with or without stimulation.
Teaching for the parent includes the following:
1. Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be
removed. Hair may need to be washed after the procedure to remove electrode gel.
2. Avoid caffeine, stimulants, and central nervous system depressants prior to the test.
3. The test is not painful, and no analgesia is required.
(Option 1) Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine.
(Option 3) This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin.
(Option 4) A routine EEG is not performed under sedation, and so the child should remember the procedure.
An EEG is used to diagnose the presence of a seizure disorder. Electrodes are secured to the scalp to observe for abnormal
electrical discharges in the brain. Preprocedure teaching includes avoiding stimulants and CNS depressants and washing the hair.
A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations
generally are classified into 4 phases:
1. The prodromal phase is the period with warning signs that precede the seizure (before the aural phase).
2. The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all
clients experience or can recognize a prodromal or aural phase before the seizure.
3. The ictal phase is the period of active seizure activity.
4. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also
experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In
syncope, there will be only a brief loss of consciousness without prolonged post-event confusion.
Clients may experience confusion after a seizure during the postictal phase. The client should be observed for safety and
abnormalities documented before and during this phase.
Common characteristics of anorexia nervosa
 Significantly low body weight

 Extreme fear of weight gain
 Inappropriate perception of body weight or size
Clinical features  Subtypes
o Binge/purge (eg, self-induced vomiting, diuretics, laxatives)
o Restricting (dieting, fasting, excessive exercise)
Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients commonly become
extremely underweight and protein-energy malnourished. Clients admitted for anorexia nervosa are typically in a crisis state, and
the priority is restoring physiological integrity through appropriate weight gain and nutritional intake.
Nursing care includes:
 Assisting the client in reflecting on triggers for dysfunctional eating and fears and feelings related to gaining
weight (Option 2)
 Maintaining strict documentation of dietary protein and calorie intake to ensure healthy weight gain (Option 3)
 Remaining with the client during and 1 hour following meals to ensure intake and prevent purging behaviors (Option 4)
 Establishing a weekly weight-gain goal (typically 2-3 lb/wk [0.91-1.36 kg/wk])
 Weighing the client at the same time each morning (after voiding and before any oral intake) and wearing the same
clothing to assess efficacy of nutritional support (Option 5)
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 Limiting physical activity initially and gradually increasing as oral intake improves
 Not focusing on food initially, but encouraging participation in meal planning as the client nears target weight
(Option 1) Clients admitted with anorexia nervosa should not continue to exercise, because this would cause further energy deficit
and worsen malnutrition and end-organ damage (eg, renal failure).
Clients admitted with anorexia nervosa must increase caloric intake and stop exercising to promote weight gain. The nurse should
record consumed calories, weigh the client daily, remain with the client during and for 1 hour following meals, and encourage
discussion about dysfunctional eating triggers.
Prolonged morning stiffness of the affected joints is a major complication of rheumatoid arthritis (RA). Taking a warm shower or
bathfirst on awakening would be the best intervention as heat decreases stiffness and promotes muscle relaxation and mobility.
With increased flexibility and decreased stiffness, the client's usual morning activities (eg, dressing, making breakfast) would be
easier and less painful and tiring to perform.
(Option 1) A balanced diet and weight control are important. Diet and exercise should be proportional, especially during periods
of disease exacerbation and decreased physical activity as excess weight exerts additional stress on weight-bearing joints.
(Option 2) Range of motion exercises are more effective after a warm bath or shower as stiffness is decreased, thereby improving
flexibility.
(Option 4) Nonsteroidal anti-inflammatory drugs (NSAIDS) (eg, naproxen [Naprosyn], ibuprofen [Motrin]) should not be taken on
an empty stomach as these can cause gastrointestinal upset. If prescribed once daily, these are probably best taken in the
evening after dinner as RA symptoms slowly increase during the night and worsen in the morning. A higher serum drug level in the
morning can help to reduce inflammation and stiffness. Therefore, if NSAIDS are prescribed twice daily, taking them in the
morning with breakfast and in the evening with dinner is recommended.
A nonpharmacologic intervention such as taking a warm bath/shower or applying heat can decrease morning stiffness and improve
flexibility in clients with RA.
External fixation stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the
skin. The nurse should assess this client first as any signs and symptoms of an infection (eg, low-grade fever, drainage, pain,
redness, swelling) warrant immediate evaluation and treatment. Localized pin tract infection can progress to osteomyelitis, a
serious bone infection that requires long-term treatment with antibiotics.
(Option 1) The dose of levothyroxine, a thyroid replacement drug that raises the metabolic rate, may need to be adjusted as the
client is now exhibiting manifestations of hyperthyroidism (eg, nervousness, sweating, insomnia).
(Option 2) Hemoptysis can sometimes be seen with pneumonia, lung abscess, tuberculosis, and lung cancer, as well as in
bronchiectasis. Unless there is a significant amount of blood, this is not a concerning finding.
(Option 4) Epigastric abdominal pain and steatorrhea (voluminous, foul-smelling, fatty stools) due to fat malabsorption are
expected findings in chronic pancreatitis. Appropriate pain medication and pancreatic enzyme supplements (prior to each meal)
are administered for prevention.
An external fixator stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the
skin. Signs and symptoms of infection (eg, fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment
with antibiotics as these can progress to osteomyelitis, a serious bone infection.
The unconscious client requires a thorough head-to-toe assessment on admission to assess for foreign objects, devices, or
belongings that have potential for harm. This includes checking for:
 Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status (Option 2)
 Contact lenses: Remove to prevent corneal injury (Option 5)
 Medication patches: To prevent drug interactions and determine conditions currently being treated
 Tampons (in female clients): Remove to prevent toxic shock syndrome or infection (Option 4)
 Rings and jewelry: Remove to prevent constrictive injury or vascular damage if edema develops (Option 3)
(Option 1) Medication patches should not be removed without first consulting the health care provider. Clients are often
prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and
discarding a medication patch without additional information may harm the client.
When caring for an unconscious client during admission, the nurse should assess for medical alert devices and any prescriptive
materials (eg, medication patches, contact lenses). The nurse should remove personal belongings and foreign objects that could
harm the client if not removed (eg, tampons, rings/jewelry).
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Involuntary bedwetting at night in a child beyond the age of expected bladder continence is known as nocturnal enuresis.
Certain medications (eg, oral desmopressin) may be useful in treating nocturnal enuresis;
however, nonpharmacologic techniques should be attempted first. The nurse should educate the child's parents about the
following strategies:
 Limit the child's intake of caffeine and sugar

 Instruct the child to void before going to bed
 Avoid punishing, scolding, or ridiculing the child
 Encourage the child to assist with changing soiled pajamas and linens, which helps them feel more control over the
situation, but provide reassurance that it is not punishment (Option 2)
 Use positive reinforcement to motivate the child (eg, calendar showing wet and dry nights, rewards) (Option 3)
 Awaken the child nightly at a specified time to void (Option 5)
 Use an enuresis alarm (ie, a moisture-sensitive alarm worn on sleep clothes that awakens the child when voiding occurs)
(Option 1) The nurse should remind parents to avoid disposable training pants or diapers at bedtime because these discourage
motivation to get up and void during the night.
(Option 4) Rather than restrict fluids throughout the day, parents should restrict fluids only after the evening meal (ie, take small
sips).
Nocturnal enuresis, or involuntary bed-wetting at night, is managed with a variety of interventions. Initial strategies for addressing
nocturnal enuresis should include positive reinforcement, awakening the child at a specified time to void, and encouraging the child
to assist with wet linen changes.
Insulin is a medication commonly used to control and lower blood glucose levels in clients with diabetes mellitus. Clients may
require a combination of long-acting insulin (eg, glargine) with rapid- (eg, lispro) or short-acting (eg, regular) insulin to manage
glucose levels. The different onsets, peaks, and durations mimic the body's natural insulin levels and enhance glycemic control.
Insulin glargine, a long-acting (basal) insulin, has no peak and may last 24 hours or longer. Short-acting insulins peak 2-5
hours after administration and last approximately 5-8 hours.
Regular or rapid-acting insulins may be given on a sliding scale at prescribed intervals (eg, before meals and at bedtime) and are
dosed based on the client's blood glucose measurement. Insulin glargine and regular insulin may be safely given concurrently
due to the differences in onset, peak, and duration (Option 2).
(Option 1) Insulin glargine has no peak effect and should not potentiate hypoglycemia, whereas regular insulin may cause
hypoglycemia. Concurrent administration of regular insulin with insulin glargine will not increase the risk of hypoglycemia as each
medication has a different onset, peak, and duration; therefore, a snack is not required.
(Options 3 and 4) Insulin glargine should not be mixed in a single syringe with any other insulin as the mixture may alter the
pharmacodynamics of the drug.
Sliding-scale regular insulin can be administered safely with scheduled insulin glargine without potentiating hypoglycemia if both
medications are properly dosed and administered as separate injections. Insulin glargine should not be mixed in a syringe with any other
insulin.
Sign 0 points 1 point 2 points
Appearance/ Completely Body pink, Completely

A
color blue/pale extremities blue pink
P Pulse Absent <100/min >100/min
Grimace/ Grimace/ Cough/

G Absent
reaction whimper sneeze/cry
Activity/ Active/
A Limp Some flexion
muscle tone spontaneous
Respiratory Regular,
R Absent Slow, weak cry
effort good cry
The Apgar score is an assessment tool used to describe how well a newborn is transitioning to extrauterine life. Apgar scoring
is done at 1 and 5 minutes of life. Apgar scores do not predict future neurologic outcomes, nor should assigning Apgar scores
delay the decision to initiate resuscitation.
An Apgar score of 6 at 1 minute of life is appropriate for a newborn with the following findings:
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 Completely blue (0 points for appearance/color of skin)
 Heart rate >100/min (2 points for pulse)
 Grimaces during stimuli (eg, nasal suction) (1 point for grimace/reaction)
 Actively moves with good tone (ie, flexion of arms and legs) (2 points for activity/muscle tone)
 Emits a weak cry (1 point for respiratory effort)
Apgar scoring is repeated every 5 minutes for up to 20 minutes if the 5-minute Apgar score is <7. Scores <7 indicate difficulty
transitioning and may require further interventions (eg, oxygen, suctioning) in addition to typical supportive measures (eg,
stimulating, drying, warming).
(Options 1 and 2) An Apgar score of 4 or 5 is too low for a newborn with these findings.
(Option 4) An Apgar score of 8 is too high for a newborn with these findings.
The Apgar score is an assessment tool used to describe how well a newborn is transitioning to extrauterine life. Scores are
assigned at 1 and 5 minutes of life. If the 5-minute Apgar score is <7, it is repeated every 5 minutes for up to 20 minutes.
A cleft palate is a malformation of the roof (palate) of the mouth occurring from incomplete fusion of the palatine bones and maxilla
during fetal development. Cleft palate causes an opening (cleft) in the mouth into the nasal cavity, which leads to difficulty in
sucking and feeding.
Clients with cleft palate typically undergo surgical repair between age 6-24 months. Postoperative nursing interventions for
clients with a cleft palate repair include:
 Implementing pharmacological and nonpharmacological pain management (eg, encouraging caregiver soothing), as

uncontrolled pain leads to crying, which stresses the surgical site and promotes hemorrhage (Option 1)
 Positioning the child in an upright, supine position, particularly after feedings, to prevent airway compromise
and obstructionfrom secretions and/or feedings (Option 3)
 Utilizing elbow restraints to prevent the child from disrupting the surgical site by placing hands or objects into the mouth,
and monitoring skin and neurovascular status by removing elbow restraints per agency policy (Option 4)
(Options 2 and 5) Hard objects (eg, utensils, tongue depressors, pacifiers, straws) should not be placed into the mouth as they
may damage the surgical site, which can lead to hemorrhage.
Following cleft palate repair, the nurse should position the client supine with elevated head of bed, implement pain reduction
measures, and remove elbow restraints per facility policy for skin and neurovascular assessment. To prevent damage to the
surgical site, hard objects should not be placed into the mouth.
An RN is appropriately assigned to the client who is most unstable. Following this client's orthopedic surgery, the nurse must
perform frequent neurovascular, pain, drain, wound, and respiratory assessments; assess for potential risk factors (eg, pulmonary
embolus); and provide emotional support as well. Good critical thinking skills are needed to develop, implement, and evaluate an
appropriate plan of care for this client.
(Option 1) Administration of blood is not within the scope of the LPN's practice.
(Option 2) A student nurse may not be able to administer medications independently and/or would require close supervision by
either nursing faculty or an RN preceptor. The student nurse may not be able to provide adequate pain relief in a timely manner.
The nurse who assesses the pain should administer the medication and evaluate the response.
(Option 3) A postoperative client requires thorough education and evaluation prior to discharge. This level of client education
should be performed by an RN; an LPN may reinforce prior teaching completed by an RN but is not able to provide initial teaching
or evaluate learning outcomes.
An RN is appropriately assigned to the client who is most unstable. The LPN's scope of practice does not include new discharge
teaching or the administration of blood.
Intimate partner violence (IPV) is physically, emotionally, verbally, sexually, or economically abusive behavior inflicted by one
partner against another in an intimate relationship, to maintain power and control. Nurses must be aware of the risk factors and
signs of IPV to recognize victims of abuse and to intervene (eg, separating the victim from the abuser during the health history
interview, providing information about community resources). Features of IPV include:
 The abusive partner exhibits intense jealousy and possessiveness (Option 3).

 The victim of IPV chooses to stay in the relationship for a variety of reasons (eg, fear for life, financial or child custody
concerns, religious beliefs) (Option 4).
 The abuse begins or intensifies during pregnancy (Option 5).
(Options 1 and 2) IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-
sex partnerships.
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Intimate partner violence (IPV) is abusive behavior inflicted by one partner against the other in an intimate relationship. IPV occurs
in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships. IPV often
begins or intensifies during pregnancy. Victims often stay in the relationship due to fear, financial or child custody concerns, or
religious beliefs, among other reasons.
Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is
common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the
client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results.
Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and
cause inaccurate test results.
(Option 2) Pre-oxygenation should occur prior to suctioning and possibly before position changes. It will affect ABG results.
(Option 3) The head of the bed should be maintained at 30 degrees or higher in an intubated client to prevent aspiration and allow
for adequate chest expansion. This position will not affect ABG results.
(Option 4) If a client is being weaned from the ventilator, sedation may be reduced. A client with reduced sedation may become
anxious and have an increased activity level; these could affect the ABG results.
If the client's condition allows, the nurse should avoid suctioning or changing activity or oxygenation levels prior to drawing of
ABGs. These actions can result in inaccurate ABG results.
Too rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. If the
client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. Slow
infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel
evacuation.
(Option 1) Having the client take slow, deep breaths may be helpful, but the infusion should be stopped first.
(Option 3) This response disregards the client's cramping and pain and is not appropriate.
(Option 4) Withdrawing the tube will risk not instilling the fluid high enough into the rectum/colon to be effective.
If a client reports cramping or pain during instillation of an enema, the infusion should be stopped for 30 seconds and then
resumed at a slower rate.
Iron is absorbed better on an empty stomach; ascorbic acid (vitamin C), such as found in citrus fruits and juices, increases the
absorption of iron. However, milk products decrease iron absorption and should be avoided (Option 1).
Metronidazole (Flagyl) is used to treat trichomoniasis and amebiasis. Consuming alcohol while taking the medication may elicit
a disulfiram (Antabuse)-like reaction. Alcohol should be avoided for at least 48 hours after treatment is completed (Option 4).
Many antihistamines also have anticholinergic effects. Anticholinergics have an antimuscarinic effect that can increase
intraocular pressure and are therefore contraindicated in closed-angle glaucoma. Other contraindications include urinary
retention (benign prostatic hyperplasia) and bowel obstruction related to the anticholinergic drug's effect on the smooth muscle
in the urinary and gastrointestinal tract (Option 5).
(Option 2) Enteral nutrition decreases levothyroxine absorption; as a result, it should be taken early in the morning on an empty
stomach (at least 30 minutes before food intake).
(Option 3) Phenazopyridine (Pyridium) is used as a local anesthetic in the treatment of urinary tract infection. The azo dye turns
the urine an orange-red color. The client needs to be reassured that this is an expected result and could stain clothing.
Clients taking metronidazole (Flagyl) should avoid alcohol. Those with glaucoma or urinary retention should avoid anticholinergic
drugs. Oral iron is better absorbed on an empty stomach and with vitamin C. Phenazopyridine (Pyridium) will turn urine an
orange-red color.
A small fire can quickly become very dangerous. During an emergency situation, such as a fire, anxiety can narrow a person's
focus, causing hesitation or difficulty in responding to the situation, especially when operation of unfamiliar equipment (eg, fire
extinguisher) is involved. The mnemonic PASS is often used to help people remember the steps used in operating a fire
extinguisher:
P – Pull the pin on the handle to release the extinguisher's locking mechanism
A – Aim the spray at the base of the fire
S – Squeeze the handle to release the contents/extinguishing agent
S – Sweep the spray from side to side until the fire is extinguished
(Option 3) The extinguisher does not need to be shaken before use, and doing so would delay extinguishing the fire.
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PASS is a mnemonic to help people remember the steps used in operating a fire extinguisher: P - Pull the pin; A - Aim the spray at
the base of the fire; S - Squeeze the handle; and S - Sweep the spray.
Miscommunication between health care providers may cause serious medical errors when clients are handed off or transferred.
Medical errors can be effectively reduced by employing strategies (eg, Situation, Background, Assessment, and
Recommendation [SBAR] reporting technique, nurse-to-nurse change of shift reports, multi-professional bedside rounds) to
improve communication and collaboration. Nurses should be as proficient in their communication skills as they are in their clinical
skills.
(Options 1, 2, and 3) Improved communication may aid in assessing a client's educational needs and meeting less obvious
needs; it can also contribute to a shorter length of stay. However, these are not the most important outcomes.
Effective communication among caregivers is necessary to deliver safe client care and reduce the number of medical errors.
Developmental dysplasia of the hip (DDH) is a set of hip abnormalities ranging from mild dysplasia of the hip joint to full
dislocation of the femoral head. Because it is much easier to treat during infancy, DDH screening is a standard
assessment for newborns and infants. Manifestations in infants age <2-3 months include:
1. The presence of extra inguinal or thigh folds

2. Laxity of the hip joint on the affected side. Hip laxity/instability is tested through the Barlow and Ortolani maneuvers.
However, these tests must only be performed by an experienced health care provider to avoid further hip injury. If DDH is
not treated, these signs disappear after age 2-3 months due to the development of muscle contractures.
(Option 1) Limited hip abduction occurs as contractures develop, particularly once the infant is age >3 months.
(Option 3) In children with one-sided DDH, the affected leg may be shorter than the opposite leg. However, this is also
apparent after age 3 months.
(Option 4) If DDH is not corrected in infancy, additional manifestations develop when the child learns to walk. These signs include
a notable limp, walking on the toes, and a positive Trendelenburg sign (pelvis tilts down on unaffected side when standing on the
affected leg). In the case of bilateral DDH, the child may also develop a waddling gait and severe lordosis.
Screening for developmental dysplasia of the hip is a standard part of infant assessment. Manifestations in infants age <2-3
monthsinclude the presence of extra inguinal or thigh folds and laxity of the hip joint on the affected side. After age 3 months,
limited hip abduction and limb shortening on the affected side are evident. A pelvic tilt is noted once the child learns to walk.
Phototherapy is the use of fluorescent lights to treat hyperbilirubinemia or jaundice in newborns. The light is absorbed by the
newborn's skin and converts bilirubin into a water-soluble form, allowing it to be excreted in the stool and urine.
The newborn should be fully exposed, except for a diaper, when placed under the phototherapy lights. Lotions and ointments
should not be applied as they can absorb the heat and cause burns. Maintaining skin integrity is important as bilirubin products
in the stool can cause loose stool with frequency and produce skin excoriation and breakdown.
(Option 1) Allowing parents to feed the newborn promotes bonding. The newborn should not be removed from the lights except
during feedings for optimal effect of the phototherapy. Adequate hydration with human milk or infant formula (not water) is
important as infants are prone to dehydration from phototherapy.
(Option 3) Temperature should be monitored closely, with the incubator placed on a low-heat setting.
(Option 4) The newborn's eyes should be covered with patches or guards to prevent retinal damage or cataracts when under
the phototherapy lights.
The newborn should be fully exposed, except for a diaper, when placed under phototherapy lights. Lotions and ointments should
not be applied as they can absorb heat and cause burns. Newborns should wear eye shields and be monitored for adequate
hydration and urine output.
Polypharmacy and physiologic changes associated with aging (eg, decreased renal and hepatic function, orthostatic hypotension,
decreased visual acuity, balance and gait problems) place the elderly at increased risk of adverse drug effects.
The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the
high incidence of drug-induced toxicity, cognitive dysfunction, and falls. Some commonly used medications in this list
include antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and
sliding insulin scales.
Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may
cause dry mouth, constipation, blurred vision, and dysrhythmias (Option 1).
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Chlorpheniramine (ChlorTrimeton) is a sedating histamine H1 antagonist used to treat allergy symptoms. Increased central nervous
system effects (eg, drowsiness, dizziness) may occur due to its reduced clearance in the elderly (Option 2).
Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness, ataxia, and
confusion (Option 5).
(Option 3) Docusate is a stool softener and does not increase risk of injury in the elderly.
(Option 4) Donepezil (Aricept) is an acetylcholinesterase inhibitor used to treat Alzheimer dementia. It does not place the elderly
at increased risk of adverse effects.
The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the
high incidence of adverse effects and potential for injury. The list includes antipsychotics, anticholinergics, antihistamines,
antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales.
Disturbance in logical form of thought is characteristic and one of the positive symptoms of schizophrenia. The client will often
have trouble concentrating and maintaining a train of thought. Thought disturbances are often accompanied by a high level of
functional impairment, and the client may also be agitated and behave aggressively.
Types of impaired thought processes seen in individuals with schizophrenia include the following:
 Neologisms – made-up words or phrases usually of a bizarre nature; the words have meaning to the client only.
Example: "I would like to have a phjinox."
 Concrete thinking – literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase,
"The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally
greener (Option 1).
 Loose associations – rapid shifting from one idea to another, with little or no connection to logic or rationality (Option 2)
 Echolalia – repetition of words, usually uttered by someone else
 Tangentiality – going from one topic to the next without getting to the point of the original idea or topic (Option 3)
 Word salad – a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table,
sky, apple." (Option 4)
 Clang associations – rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed
the bike near the tyke."
 Perseveration – repeating the same words or phrases in response to different questions
Disturbance in thought process (form of thought) is one of the positive symptoms of schizophrenia. The nurse needs to be able to
recognize and identify the various types of thought disturbances experienced by clients with schizophrenia. These include loose
associations, neologisms, word salad, echolalia, tangentiality, clang association, and perseveration.
When reviewing obstetric history, the GTPAL notation system gives the health care provider information about a client's past
pregnancies. This notation may be shortened to gravida (ie, number of previous pregnancies) and para (ie, number of births after
20 weeks). For example, a G2P0 indicates 1 prior pregnancy ending before 20 weeks and 1 current pregnancy.
The nurse should be cautious of discussing obstetric history with a client in front of the partner or family and not assume that
others have knowledge of the client's past pregnancies. If there is a discrepancy between what the client discloses in the interview
and the medical record, the information should be clarified when the client is alone to maintain confidentiality (Option 3).
(Option 1) The nurse should not change information in the medical record until the information is clarified appropriately with the
client.
(Option 2) Although the client's medical record indicates a previous pregnancy, it is not appropriate to ask if the pregnancy was an
abortion or a miscarriage in front of the client's partner.
(Option 4) Explaining the need for accurate information is not appropriate at this time and does not assist with clarifying the
client's obstetric history in a private manner.
The nurse should be cautious of discussing a client's obstetric history in front of the client's partner or family to avoid breaching
confidentiality. Clarification or further questioning about the client's history should take place when the client is alone.
Hypomagnesemia, a low blood magnesium level (normal 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), is associated with alcohol abuse due
to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated
with 2 major issues:
1. Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority).

2. Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated
by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and
seizures.
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(Option 1) Constipation and polyuria indicate hypercalcemia. Calcium has a diuretic effect.
(Option 2) Increased thirst with dry mucous membranes indicates hypernatremia.
(Option 3) Hypokalemia results in muscle weakness/paralysis and soft, flabby muscles. Paralytic ileus (abdominal distension,
decreased bowel sounds) is also common with hypokalemia. However, the most serious complication is cardiac arrhythmias.
Clients who abuse alcohol often have low magnesium levels that manifest as ventricular arrhythmias and/or neuromuscular
excitability (similar to hypocalcemia), which includes tremors, positive Chvostek and Trousseau signs, hyperactive reflexes, and
seizures.
Urinary tract infections (UTIs) can occur in the kidneys (pyelonephritis), bladder (cystitis), and/or urethra
(urethritis). Pyelonephritis(inflammation of the kidney parenchyma) causes flank pain that is experienced in the back at
the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus. Cystitis
alone does not cause nausea/vomiting or chills. Presence of these, fever, and signs and symptoms of a lower UTI (dysuria,
urgency, and frequency) indicate pyelonephritis.
(Option 1) The client with a distended bladder experiences constant pain increased by any pressure over the bladder. Bladder
distension is found through palpation (firmness, pain, urgency) and percussion (dullness) over the suprapubic area.
(Option 2) Bladder and urethral pain is usually dull and continuous and may be experienced as spasms. The detrusor muscle of
the bladder may spasm if cystitis is present.
(Option 4) Renal colic pain (in response to renal calculi) is excruciating, sharp, and stabbing; the client would be tossing in the
bed unable to find a comfortable position. Pain radiates down to the groin area as the stone travels down the ureter.
Pain in pyelonephritis is dull, constant, and maximal at the costovertebral angle area. Pain from renal stones is excruciating,
sharp, and often radiates toward the groin from the flank. Suprapubic pain indicates bladder distension or cystitis. Spasms can be
seen with infection (cystitis) or manipulation of the bladder.
The child with a recent tonsillectomy is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon but
may occur up to 14 days after surgery. During the healing process, white scabs will form at the surgical sites. Sloughing then
occurs approximately 7 days after the procedure, increasing the risk for bleeding. Caregivers should be taught to observe for signs
of bleeding (eg, frequent swallowing or throat clearing). The child may also experience increased pain. The nurse should instruct
this parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post surgery.
(Option 1) Tympanostomy tubes or grommets are pressure-equalizing tubes placed in the tympanic membrane to facilitate
drainage of middle ear fluid (eg, for eustachian tube dysfunction or recurrent otitis media with effusion). One of this child's tubes
has most likely fallen out of the eardrum. No immediate intervention is required; however, the health care provider should be
notified.
(Option 2) Clients often report ear pain (otalgia) following adenotonsillectomy due to irritation of the 9th cranial nerve
(glossopharyngeal) in the throat, causing referred pain to the ears. This is a normal, expected finding.
(Option 3) The contagious period for strep throat starts at the onset of symptoms and lasts through the first 24 hours of beginning
antibiotic treatment. This client is able to return to activities and does not require an immediate call back.
The risk of post-tonsillectomy hemorrhage persists for up to 14 days after surgery, and resuming strenuous activity too early
increases this risk. The potential for bleeding is higher 7-10 days postoperatively while sloughing occurs.
Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins
to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of the central field of vision,
whereas the peripheral vision remains intact (Option 4).
Macular degeneration has two different etiologies. "Dry" macular degeneration involves ischemia and atrophy of the macula that
results from blockage of the retinal microvasculature. "Wet" macular degeneration involves the abnormal growth of new blood
vessels in the macula that bleed and leak fluid, eventually destroying the macula. Progression of macular degeneration may be
slowed with smoking cessation, intake of specific supplements (eg, carotenoids, vitamins C and E), laser therapy, and injection of
antineoplastic medications.
Risk factors for macular degeneration include advanced age, family history, hypertension, smoking, and long-term poor intake of
carotenoid-containing fruits and vegetables.
(Option 1) Seeing small flashes of light is associated with retinal detachment.
(Option 2) Inability to see things close up, known as presbyopia, occurs when the lens of the eye becomes less elastic with age
and therefore unable to adjust to near and far vision.
(Option 3) Poor peripheral vision, also called tunnel vision, can result from optic nerve damage seen in glaucoma.
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Macular degeneration is a progressive, incurable eye disease that occurs when the central portion of the retina deteriorates, giving
rise to distortion (blurred or wavy visual disturbances) or loss in the center of the visual field.
Clients with seizures are at increased risk for injury during seizure activity. Seizure precautions are nursing interventions that can
help protect a client during a seizure. These precautions typically include:
1. Raising the upper side rails on the bed to prevent the client from falling to the floor during a seizure. The side rails are
also padded to prevent client injury due to hitting the hard plastic rails during a seizure (Option 1).
2. During a seizure, a client may be unable to control secretions, increasing the risk for an impaired airway. Suction
equipment and oxygen equipment are set up at the bedside (Options 2 and 5). Some facilities also encourage the use
of a continuous pulse oximeter.
(Option 3) Clients may experience urinary incontinence during a seizure, but unless the health care provider prescribes a urinary
catheter, it is not typically used as part of seizure precautions. Inserting a urinary catheter puts the client at risk for a urinary tract
infection.
(Option 4) It is not necessary to remove all linen from the client's bed. If a client has a seizure, any blankets or pillows that are in
the way or pose a threat can be removed, but the client may have linen on the bed while on seizure precautions.
Seizure precautions are safety measures that typically include raising the upper side rails, placing padding on the side rails, and
preparing bedside suction and oxygen equipment
Infertility is the inability to conceive after unprotected intercourse (ie, no contraceptive use) for >12 months. Female fertility
declines as women age, with the first significant decrease seen after age 35 (Option 3). Hormonal dysfunction (eg, polycystic
ovarian syndrome) can cause ovarian cysts and anovulatory cycles (ie, lack of ovulation during a menstrual cycle), which impair
fertility (Option 4).
Some sexually transmitted infections (eg, chlamydia) may be asymptomatic in females, which can delay treatment (eg,
antibiotics). Untreated or recurrent infections cause inflammation (eg, pelvic inflammatory disease), scarring, and damage to the
reproductive tract, leading to infertility (Option 5).
Endometriosis is characterized by endometrial tissue (ie, inner lining of the uterus) depositing outside the uterus. These
endometrial lesions can result in chronic inflammation, pelvic pain, menstrual cycle abnormalities, and infertility (Option 2).
(Option 1) Optimal female fertility is achieved at a BMI of 18.5-24.9 kg/m2; a BMI of 22 kg/m2 is within this normal range. Very
low or very high BMI is associated with hormonal dysfunction and impaired fertility.
Infertility is the inability to conceive after unprotected intercourse for >12 months. Factors contributing to female infertility include
hormonal dysfunction (eg, polycystic ovarian syndrome) with anovulation, high or low BMI, and conditions that can lead to
reproductive tract scarring and damage (eg, infection, endometriosis).
Testicular enlargement, including scrotal changes, is the first manifestation of puberty and sexual maturation. This typically
occurs at age 9½-14. It is followed by the appearance of pubic, axillary, facial, and body hair. The penis increases in size and the
voice changes. Some boys also experience an increase in breast size. Growth spurt changes of increased height and weight may
not be apparent until mid-puberty.
Sexual maturation in boys begins with an increase in testicular size, followed by changes in the scrotum, appearance of pubic,
axillary, facial, and body hair, and voice changes.
Radioactive iodine (RAI) treats hyperthyroidism by partially damaging or destroying the thyroid gland. RAI has a delayed
response, requiring up to 3 months for maximal effect. After treatment, the client emits radiation, and excreted bodily
fluids are radioactive. The nurse teaches home precautions to protect those who come in contact with the client. Depending on
the dosage, clients should use the following precautions for up to 1 week:
 Limit close contact and time spent with pregnant women and children (Option 1).
 Use a separate toilet, and flush 2 or 3 times after each use to remove urine residue (Option 3).
 Use disposable cups, plates, and utensils, and do not share foods that could transfer saliva (Option 4).
 Isolate personal laundry (eg, clothing, linens) and wash it separately (Option 5).
 Sleep in a separate bed from others.
 Do not sit near others for a prolonged time (eg, train or flight travel).
(Option 2) After RAI therapy, breast milk excreted by the client is radioactive and can permanently damage an infant's thyroid.
Breastfeeding should be stopped 6 weeks before treatment to prevent RAI from accumulating in the breasts after treatment.
Breastfeeding is not resumed with the current child but can be resumed with future pregnancies.
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Radioactive iodine treats hyperthyroidism by damaging or destroying the thyroid gland. After ingesting radioactive iodine, clients
and their bodily secretions are radioactive. They should avoid pregnant women and children, use a separate toilet and disposable
tableware, sleep in a separate bed, and isolate personal laundry.
The nurse should plan to assess the toddler client in a nonthreatening environment, taking time to develop rapport prior to
beginning the examination. This can be achieved by talking to the toddler about favorite objects and slowly initiating
contact. Parent involvement, such as holding the child and assisting the child with examination activities, reduces anxiety and
encourages cooperation in toddler clients. Age-appropriate games or toys may be used if needed to gain the client's cooperation.
(Option 2) Use minimal physical contact initially, and have the parent remove the outer clothing.
(Option 3) Medical equipment may appear frightening to a toddler and should remain out of sight until needed. It may also be
beneficial to allow the child to inspect and touch new pieces of equipment as they are used.
(Option 4) It is best to order a physical examination for a toddler from least to most invasive, which commonly means assessing
ears, nose, and mouth toward the end of a visit. Head-to-toe ordered assessments are more appropriate for school-age children.
The nurse should allow a parent to interact with the toddler and assist with the examination process to encourage client
cooperation. Examination of a toddler should proceed from least to most invasive, allowing the client to inspect pieces of
equipment before use. Use minimal physical contact initially
The proper method of delivering a dose via MDI includes the following steps:
1. First shake MDI and attach it to the spacer.

2. Exhale completely to optimize inhalation of the medication.
3. Place lips tightly around the mouth piece.
4. Deliver a single puff of medication into spacer.
5. Take a slow, deep breath and hold it for 10 seconds to allow for effective medication distribution.
6. After the dose, rinse mouth with water to remove any left-over medication from oral mucous membranes. Spit out the
water to ensure no medication is swallowed.
Any child under age 12 should use a spacer with the MDI to ensure the entire dose is inhaled appropriately.
Constipation is a common discomfort of pregnancy and is due to an increase in the hormone progesterone, which causes

decreased gastric motility. Ferrous sulfate (iron) supplementation may also cause constipation.
Interventions to prevent or treat constipation include:
1. High-fiber diet: High amounts of fruits, vegetables, breakfast cereals, whole-grain bread, prunes
2. High fluid intake: 10-12 cups of fluid daily
3. Regular exercise: Moderate-intensity exercise (eg, walking, swimming, aerobics)
4. Bulk-forming fiber supplements: Psyllium, methylcellulose, wheat dextrin
(Option 1) Dairy is a great source of calcium, which is essential for fetal bone development. However, dairy products should be
consumed at least 2 hours before or 1 hour after iron supplements as they bind to iron and decrease absorption.
(Option 4) Laxatives are not recommended during pregnancy due to the risk of dehydration and electrolyte imbalance, which can
lead to uterine cramping and contractions. The client should consult with the health care provider before using any over-the-
counter stool softeners or laxatives.
(Option 5) Caffeine consumption in pregnancy should be limited to 200-300 mg/day. Coffee may contain 100-200 mg caffeine per
cup and should therefore be consumed in moderation during pregnancy.
Constipation in pregnancy may be caused by increased progesterone levels and iron supplementation. It is best treated with 10-12
cups of fluid daily, a high-fiber diet/supplementation, and regular exercise. Clients should not take laxatives without first discussing
this with the health care provider.
Sodium polystyrene sulfonate (Kayexalate) retention enema is a medicated enema administered to clients with high serum
potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes
evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level. Kayexalate can also be given
orally and is much more effective. Kayexalate can rarely be associated with intestinal necrosis.
(Option 1) A barium enema uses contrast medium (barium) administered rectally to visualize the colon using fluoroscopic x-ray.
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(Option 2) A fleet enema relieves constipation by infusing a hypertonic solution into the bowel, pulling fluid into the colon and
causing distension and then defecation.
(Option 4) A neomycin enema is a medicated enema that reduces the number of bacteria in the intestine in preparation for colon
surgery.
Kayexalate retention enemas are medicated enemas administered to clients with high serum potassium levels. The resin in
Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from
the body, thereby lowering the serum potassium level.
A nursing diagnosis associated with anorexia nervosa is disturbed body image/low self esteem. There is often a large disparity
between actual weight and the client's perceived weight. Clients with anorexia nervosa think of themselves as overweight and fat.
The nursing care plan should include helping the client develop a realistic perception of weight and body image. The nurse can
confront the client about the misinterpretation of body weight by presenting reality without challenging the client's illogical
thinking. The client's weight should be discussed in the context of overall health.
The nurse also needs to be aware of his/her own reaction to the client's behaviors and statement. It is not uncommon for
caregivers and care providers to feel frustrated or even angry when caring for a client with an eating disorder. The nurse must
maintain a neutral attitude and approach, avoiding arguing or disagreeing with the client's statements.
(Option 1) This response is judgmental, reinforces the idea of "thinness," and does not help the client develop a more realistic
body image.
(Option 3) Establishing a goal weight is part of the nursing care plan for the client with anorexia nervosa; clients are usually not
discharged from inpatient treatment until goal weight is achieved. However, this response does not address the client's
misperception of body weight.
(Option 4) This response dismisses the client's concern and does not present the reality of the situation.
Clients with anorexia nervosa have disturbed body image and see themselves as being fat or overweight even when they are
severely underweight or even at a normal body weight. The nurse can help the client develop a more realistic self image by
presenting the situation realistically and discussing weight in terms of the client's health.
Venous thrombosis involves the formation of a thrombus (clot) and the inflammation of the vein. Anticoagulant therapy such as
heparin does not dissolve the clot. The clot will be broken down by the body's intrinsic fibrinolytic system over time. The heparin
slows the time it takes blood to clot, thereby keeping the current clot from growing bigger and preventing new clots from forming.
(Option 1) Anticoagulants do not dissolve clots. Thrombolytic agents (fibrinolytics), such as tissue plasminogen activator (tPA),
are used to break the clots, but they also carry the risk of serious intracranial hemorrhage and are used only for acute life-/organ-
threatening conditions. The body will break down the clot over a period of time.
(Option 2) Heparin does not prevent the clot from breaking off but will deter the clot from growing larger.
(Option 4) The nurse should be able to answer client questions regarding medications being administered. The HCP can answer
any further questions the client may have.
The nurse should teach the client that the purpose of unfractionated heparin infusion in the treatment of DVT is to slow the time it
takes blood to clot, thereby keeping the current clot from getting bigger and preventing new clots from forming.
Flushing the lumen of a central venous access device (central venous catheter [CVC]) with normal saline is recommended to
assess patency before medication infusion, prevent medication incompatibilities after infusion, and prevent occlusion after blood
sampling.
A 10-mL syringe is generally preferred for flushing the lumen of a CVC (Option 3). The smaller the syringe, the greater the
amount of pressure per square inch exerted during injection, increasing the risk for damage to the CVC. The "push-
pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any resistance. Injecting against
resistance can damage the CVC, which may result in complications, including embolism and malfunction. The nurse should
always consult the specific manufacturer guidelines and facility policy when caring for a CVC.
(Options 1 and 2) A smaller syringe (eg, 1 mL, 3 mL) creates more pressure, which increases the risk for damage to the CVC.
(Option 4) A 30-mL syringe is unnecessarily large to flush a CVC.
When flushing the lumen of a central venous catheter, the nurse should use the safest syringe possible and the "push-pause"
method to avoid exerting too much pressure, which may damage the catheter. The smaller the syringe, the greater the amount of
pressure exerted during the flush. A 10-mL syringe is generally recommended; however, it is also important to consult the
manufacturer's guidelines.
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Common causes of sudden cardiac arrest in pregnant clients include embolism, eclampsia, magnesium overdoses, and uterine
rupture. If cardiopulmonary resuscitation (CPR) is required, several modifications must be made to ensure efficacy of the rescue
efforts. During pregnancy, the heart is displaced toward the left because the growing uterus pushes upward on the diaphragm,
particularly in the third trimester. To accommodate this displacement, the hands should be placed on the sternum slightly
higherthan usual for chest compressions during CPR (Option 2). In addition, a gravid uterus can significantly compress the
client's vena cava and aorta, thereby hindering effective blood flow during CPR. The uterus should be manually displaced to the
client's left to reduce this pressure. The nurse can also place a rolled blanket or wedge under the right hip to displace the uterus.
If return of spontaneous circulation (ROSC) does not occur after 4 minutes of CPR, emergency cesarean section is usually
initiated. Delivery should occur within 5 minutes of initiating CPR.
(Option 1) Compressions to the right sternal border will lack effectiveness as the heart is displaced to the left side during
pregnancy.
(Option 3) Chest compressions given below the diaphragm are not effective for ROSC and greatly increase the risk of injury to the
client's uterus, spleen, or liver.
(Option 4) In the supine position, the vena cava and aorta are compressed by the uterus, hindering effective blood flow during
CPR. The uterus should be displaced to the left to reduce pressure.
Two important modifications for cardiopulmonary resuscitation of a pregnant client include performing chest compressions slightly
higher on the sternum and displacing the uterus to the client's left side.
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation.
All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following:
1. Gastrointestinal (GI) toxicity - symptoms of GI bleeding such as black tarry stools should be reported. Gastrointestinal
upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food.
2. Kidney injury - long-term use is associated with kidney injury
3. Hypertension and heart failure - NSAIDs can cause fluid retention, which can exacerbate conditions such as heart
failure, cirrhosis/ascites, and hypertension
4. Bleeding risk - clients should notify the HCP if taking concurrently with aspirin, other NSAIDs, or anticoagulant or
antiplatelet drugs as they can increase the risk of GI bleeding.
(Option 1) Clients should not drive when taking sedating medications (eg, antihistamines, benzodiazepines). However, sedation
is not associated with NSAID use.
(Option 2) Orthostatic hypotension is common with blood pressure medications (eg, ACE inhibitors, alpha blockers) but not with
NSAIDs.
(Option 3) Suicidal thoughts are commonly associated with selective serotonin reuptake inhibitors (antidepressants) and
varenicline (Chantix), a smoking cessation medication.
All NSAIDs (eg, indomethacin, ibuprofen, naproxen) are associated with gastrointestinal toxicity, kidney injury, exacerbation of fluid
overload/hypertension, and bleeding risk. They should be used at the lowest dose and for the shortest period possible.
Child neglect occurs when a caregiver purposely withholds or does not adequately provide necessary resources to fulfill the basic
needs of a child (eg, adequate nutrition, security, hygiene). Supervisory neglect, leaving children without adequate
guardianshipto ensure safety, is one form of child neglect (Option 4). Children age <12 lack formal operational reasoning and
cannot anticipate safety risks or respond appropriately to emergencies, and should therefore not be left to supervise other children.
It is a priority for the nurse to intervene, as this is an unsafe situation for the young children. The nurse, or social services,
should report the situation to an appropriate government child protective service and/or law enforcement.
(Option 1) Potential job loss indicates that the parent may be overwhelmed. The nurse should alert a social worker about the
situation at a later time to discuss potential assistance.
(Option 2) Transitioning to the role of a single parent can present mental and financial stressors, possibly requiring assistance
from a social worker. However, this does not require immediate intervention.
(Option 3) A parent stealing food may warrant calling the police or security, but the children's safety is a priority requiring
immediate action.
Supervisory neglect (eg, leaving a young child to supervise other children) is a type of child neglect and represents an immediate
risk to the safety of younger children. The nurse should ensure that the children are safe and report the child neglect incident to
social services, the appropriate child protective service, and/or law enforcement.
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Critical laboratory results (eg, positive blood cultures, severe electrolyte derangements) require immediate intervention for
client safety. The nurse receiving a critical laboratory result should notify the health care provider (HCP) as soon as possible.
Hospital organizations have individual policies regarding the time frame for notification of the HCP and HCP response, usually ≤60
minutes. Bacteremia requires timely treatment to prevent further complications (eg, septic shock) (Option 1).
(Option 2) The critical laboratory result should be documented in the client's medical record, but only after immediate
communication with the HCP.
(Option 3) The nurse must make direct contact, either via telephone or in person, when reporting a critical result. A telephone
message may not be received promptly, and a critical value requires immediate intervention.
(Option 4) Even if the HCP usually makes rounds early in the morning, a critical value requires immediate, real-time notification to
prevent delay of potentially urgent intervention.
Critical laboratory results, such as positive blood cultures, require immediate communication with the health care provider (HCP)
and timely intervention for client safety. The nurse must contact the HCP directly as soon as possible to avoid life-threatening
complications (eg, septic shock).
The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age,
educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows:
 Using pictures and simplified text is beneficial to the older adult with low literacy.
 Including a family member in the teaching process will assist the client in reinforcement of the material at a later date.
 Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of
auditory content in lay person's language.
(Option 2) Older adults are using the internet in increasing numbers as are clients with low literacy. Several organizations are
developing and promoting user-friendly websites. Society in general relies heavily on web-based health information. It is important
for the nurse to teach the client and possibly supply a list of reputable sites for the client to view.
(Option 5) Unless the client is hard of hearing, speaking slowly and loudly is unnecessary and demeaning.
For a client with low literacy, the nurse should use multiple teaching strategies including professionally produced educational
programs, pictures with simplified text, and inclusion of a family member during teaching sessions.
Peripheral IV (PIV) catheter sites should be changed usually no more frequently than every 72-96 hours unless signs of
complications develop. Signs of phlebitis include erythema, edema, warmth, pain, and palpable venous cord. Manifestations
of infiltration include edema and coolness to the touch around the insertion site (Option 1). The nurse should also monitor for
edema related to infiltration under the involved limb. Infiltrated fluid may leak into loose skin, causing edema in dependent
areas without obvious signs of infiltration at the PIV site, particularly in the elderly (Option 3).
If a PIV site is leaking fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible
problems include infiltration/extravasation, a thrombus at the catheter tip, or damage to the catheter; all of these issues require a
site change (Option 5).
(Option 2) Potassium is a known irritant to veins. Discomfort is not a sign of infiltration, although the site should be regularly
monitored for complications.
(Option 4) Locations where flexion occurs (eg, antecubital region) are generally avoided; however, these sites may be required for
certain medications or situations. Unless a problem develops, PIV sites are not changed based solely on location.
Peripheral IV catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications develop.
The nurse should check for signs of infiltration by assessing the insertion site and areas dependent from it (ie, edema, cool skin).
An important part of the nursing role is to advocate for the health and safety of the client. This client has fallen and lost weight
when living in the child's home, prompting the nurse to advocate for the client by bringing in other members of the interdisciplinary
team to assess the home situation.
When a nurse is concerned about the client's living situation, the social worker is the most appropriate team member to consult
with first. The role of the social worker includes assessing the client's living situation and arranging for an alternate living situation
or support services as needed.
(Option 1) Adult protective services would be notified when abuse or neglect is suspected. In the hospital setting, a social worker
should be contacted to do a detailed assessment of the situation before adult protective services is notified.
(Option 2) The physical therapist should be consulted when there is concern about the client's ability to function safely in the
home environment.
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(Option 3) The physician would not be the most appropriate person to appoint when a detailed assessment of the home living
situation needs to be conducted. However, the physician should be notified if a social worker is assigned to assess the home living
situation.
Nursing advocacy for the safety of the client includes the appropriate use of interdisciplinary team members, such as the social
worker. Advocacy is especially important in younger and elderly clients and those who are cognitively challenged or have mental
health concerns.
Marfan syndrome is a connective tissue disorder that causes visual and cardiac defects and a distinct long, slender body type.
In Marfan syndrome with aortic vessel involvement, the root of the aorta is dilated or weakened, increasing the risk of aortic
dissection and aortic rupture. Increases in blood volume and cardiac workload that occur during pregnancy may worsen aortic
root dilation and further increase the risk of aortic dissection/rupture.
Pregnancy in clients with Marfan syndrome, especially those with aortic root dilation, poses a high risk of maternal mortality.
Clients should be instructed about the importance of consistently using reliable birth control methods to prevent pregnancy
(Option 3).
(Option 1) Beta blockers are commonly used to treat clients with Marfan syndrome to limit aortic root dilation. Such medications
are generally safe to use during pregnancy, so the client should not discontinue therapy unless directed to do so by the health care
provider.
(Option 2) Clients with Marfan syndrome considering pregnancy should be counseled to complete childbearing in early adulthood
because aortic root dilation and the risk of aortic dissection/rupture increase with time.
(Option 4) Marfan syndrome is an autosomal dominant condition with a 50% chance of inheritance in offspring.
Marfan syndrome affects the connective tissues and is associated with dilation of the aortic root. Clients with Marfan syndrome are
at high risk of mortality during pregnancy due to the potential for aortic dissection. Consistent use of reliable birth control is
essential for preventing pregnancy.
The nurse is most likely palpating the diamond-shaped anterior fontanelle of the fetal head, which is in cephalic (ie, head
down) presentation. Therefore, the nurse should document the fetal presentation as cephalic. The posterior fontanelle is
triangular and separated from the anterior fontanelle by the sagittal suture. By identifying the location of these fetal skull
landmarks, an experienced examiner can determine the fetal head position, or the direction the occiput is facing.
(Option 1) With breech presentation, the fetal buttocks, legs, or feet may be palpated. Fetal buttocks do not feel as round,
smooth, or firm as the head during vaginal examination. Although the anus could be mistaken for a fontanelle, the anal sphincter
feels firmer to palpation than a fontanelle and is circular, rather than triangular or diamond shaped.
(Option 3) A prolapsed cord would feel soft and rubbery on palpation and may be pulsating. If the cord is prolapsed, an
emergency cesarean delivery is usually required.
(Option 4) Palpating the anterior fontanelle should reassure the nurse that the fetus is in a cephalic presentation, so there is no
indication for informing the health care provider.
Fetal head position can be determined by the sutures and fontanelles (eg, diamond-shaped anterior fontanelle) of the fetal skull.
In pneumonia, the lung is filled with infectious debris and exudate. This increase in secretions and a simultaneous decrease in
mucociliary clearance result in possible airway obstruction.
Interventions to facilitate airway clearance include the following:
 Hydration - IV fluids, oral intake (2-3 L/day), and respiratory humidification help thin secretions, maintain moisture of
mucous membranes, and promote mucociliary clearance.
 Huff coughing technique - the most effective way to raise secretions from the lower to the upper airway for expectoration.
If pain limits deep breathing and coughing, analgesia can be prescribed (Option 3).
 Chest physiotherapy (percussion, vibration, and postural drainage) to open airways and break up thickened
secretions (Option 1)
 Fowler's position - Sitting upright with the head of the bed at 45-60 degrees promotes lung expansion and facilitates
coughing and secretion removal.
(Option 2) Cough suppressants can be administered for treatment of a dry, hacking cough or persistent cough that interferes with
sleep. They do not facilitate secretion removal.
(Option 4) Positioning on the right side, with the good lung in the dependent position, increases ventilation to perfusion
matching due to gravity and improves oxygenation.
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(Option 5) Pursed lip breathing prolongs exhalation, prevents airway collapse, and decreases air trapping to help alleviate
dyspnea, but it does not facilitate secretion removal. This form of breathing is helpful in clients with chronic obstructive pulmonary
disease.
Ineffective airway clearance related to increased sputum production due to a respiratory infection is a priority nursing diagnosis in
clients with pneumonia. Interventions to mobilize secretions, clear an airway obstruction, and maintain airway patency include
coughing and deep breathing, chest physiotherapy, positioning (Fowler's or side lying with good lung down), hydration, and
administration of medications.
Auditory hallucinations are the most common type of hallucination and are typically experienced by individuals with a diagnosis of
schizophrenia, bipolar disorder, or other psychotic illness.
Antipsychotic medication therapy is the first-line treatment of hallucinations and other psychotic symptoms. However, most
psychotropic drugs may take some time to be completely effective and may not eliminate hallucinatory episodes entirely. Clients
should be encouraged to develop alternate methods for coping with the hallucinations.
One approach is increasing the amount of external auditory stimulation in the environment. Individuals with auditory hallucinations
have reported that increasing the amount of external sound (eg, watching TV or listening to music through headphones) makes it
easier to ignore internal sounds from the hallucinations.
Other methods of managing auditory hallucinations include voice dismissal (telling the voices to go away) and cognitive behavioral
therapy (assists clients in learning new ways to think about and deal with their symptoms).
(Option 1) Reading a book may provide some distraction, but it does not increase external auditory stimulation.
(Option 3) The medication may not start to work for another 2 weeks and may not eliminate these symptoms entirely.
(Option 4) The client is hearing voices all day long; ignoring them is not as effective as an activity that distracts the client from the
hallucinations.
Although antipsychotic medication is the first-line treatment for diminishing or eliminating psychotic symptoms, such as
hallucinations, clients need other strategies for coping with distressing symptoms. Increasing external auditory stimulation often
helps distract the client from the internal voices and focus on reality.
Risk factors for esophageal cancer
Squamous cell carcinoma Adenocarcinoma
 Alcohol use  Barrett esophagus

 Tobacco smoking  Gastroesophageal reflux disease
 N-nitroso–containing foods  Obesity
 Underlying esophageal disease (achalasia, prior injury)  Tobacco use
Esophageal cancer is a rare, rapidly growing malignancy of the esophageal lining with a low 5-year survival rate. Squamous cell
carcinoma usually develops in the upper part of the esophagus, whereas adenocarcinoma usually develops in the lower part.
Major risk factors include smoking (eg, cigarettes, pipe, cigars) and excessive alcohol consumption (ie, approximately >15
drinks/week for men, >8 drinks/week for women) (Options 1 and 3).
Barrett esophagus is also a significant risk factor for esophageal cancer; this condition occurs when the distal portion of the
esophagus develops precancerous changes. Obesity (which allows stomach acid to flow upward into the esophagus due to
increased abdominal pressure) and uncontrolled gastroesophageal reflux disease contribute to the development of Barrett
esophagus; they are both closely linked with esophageal cancer (Options 2 and 4).
(Option 5) Consumption of salty foods is not associated with an increased risk of esophageal cancer but increases the risk of
gastric cancer. Dietary factors that may increase a client's risk of esophageal cancer include high intake of nitrosamine-containing
foods (eg, pickled foods, beer), frequent ingestion of extremely hot beverages (thermal injury), and deficient intake of fruits and
vegetables.
Esophageal cancer is a rapidly growing malignancy of the esophageal lining. Risk factors for esophageal cancer include smoking,
excessive alcohol consumption, obesity, and gastroesophageal reflux disease.
The nurse should first assess the client with asthma who reports shortness of breath 15 minutes after receiving a nebulizer
treatment with albuterol. Asthma exacerbations may require repeat nebulization every 20 minutes, or continuous nebulization
for 1 hour, to relieve severe bronchoconstriction until the administered corticosteroids take effect and start to reduce the
39
inflammation (Option 2). The nurse should assess the client for wheezing, decreased breath sounds, use of accessory muscles to
breathe, capillary refill, respiratory rate, and pulse oximeter reading and pulse.
(Option 1) Subcutaneous emphysema is air that leaks into the tissue surrounding the chest tube insertion site. The amount is
usually small and reabsorbs spontaneously. The nurse should auscultate for lung sounds, assess for a popping sound, and
palpate the site for a crackling sensation. However, this client does not have the most urgent need.
(Option 3) Clients with an exacerbation of COPD are prescribed noninvasive positive pressure ventilation with a BIPAP device to
treat hypercapnia and hypoxemia and improve gas exchange. An oxygen saturation of 88-92% is adequate in clients with COPD.
The nurse should perform a thorough pulmonary assessment, but this client does not have the most urgent need.
(Option 4) The nurse should follow institution policy and either start the IV or notify the IV team to restart the infusion. Although it
is important to initiate antibiotic therapy as soon as possible to treat an existing infection, this client does not have the most urgent
need.
Nurses should prioritize assessing clients with asthma who report unrelieved shortness of breath within 15 minutes of nebulizer
treatment with albuterol as their needs are urgent due to the risk for severe pulmonary complications.
The initial management of a near-drowning victim focuses on airway management due to potential aspiration (leading to acute
respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia is managed and
prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary (Option 3).
Careful handling of the hypothermic client is important because as the core temperature decreases, the cold myocardium
becomes extremely irritable. Frequent turning could cause spontaneous ventricular fibrillation and should not be performed
during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated (Option 2).
There are passive, active external, and active internal rewarming methods. Passive rewarming methods include removing the
client's wet clothing, providing dry clothing, and applying warm blankets. Active external rewarming involves using heating
devices or a warm water immersion. Active internal rewarming is used for moderate to severe hypothermia and involves
administering warmed IV fluids and warm humidified oxygen (Options 1 and 5).
(Option 4) Unless blood loss has occurred from trauma during the near-drowning incident, administration of blood products is not
indicated.
Emergency department care of near-drowning victims includes advanced airway management, aggressive oxygenation,
establishing IV access and administering IV fluids (warmed if hypothermic), and monitoring for cardiac arrhythmias and fluid
imbalances.
Clients with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve anxiety.
Impaired social and interpersonal functioning (eg, social withdrawal, poor social interaction skills) are common negative symptoms
of schizophrenia. These are more difficult to treat than the positive symptoms (eg, hallucinations, delusions) and contribute to a
poor quality of life.
Nursing interventions directed at improving the social interaction skills of a client with schizophrenia include the following:
 Making brief, frequent contacts

 Accepting the client unconditionally by minimizing expectations and demands
 Assessing the client's readiness for longer contacts with the nurse and/or other staff and clients
 Being with or close by the client during group activities
 Offering positive reinforcement when the client interacts with others
(Option 1) Asking where this client is going is nontherapeutic as it requires an explanation of the client's actions.
(Option 2) Following this client out the door could increase the client's anxiety.
(Option 3) Directing this client to come back to the room is placing a demand that may be unrealistic and does not help develop a
sense of trust.
Social isolation and impaired social interaction are common negative symptoms of schizophrenia. The client will seek to be alone
to relieve anxiety associated with being around others. The nurse needs to be accepting of the client's behavior and continue
attempts at brief contact until the client is comfortable.
Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects,
including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the
effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has
cardiovascular disease or takes NSAIDs routinely or for a long time. In addition, long-term use of NSAIDs is associated
40
with peptic ulcers and chronic kidney disease. These clients should use NSAIDs cautiously, at the lowest dose necessary and
for a short time. The nurse should notify the health care provider that this client is routinely taking ibuprofen.
(Option 1) Taking docusate sodium occasionally for constipation is appropriate.
(Option 3) Hydrochlorothiazide is a weak diuretic and is commonly used to treat hypertension.
(Option 4) Omeprazole for heartburn is appropriate for this client.
NSAIDs may cause heart attack, stroke, high blood pressure, and possible heart failure after long-term use. NSAIDs decrease the
effectiveness of diuretic and blood pressure medications. Long-term use is also associated with chronic kidney disease and peptic
ulcers.
The nurse should use a sterile glove during vaginal examination in the presence of ruptured membranes to prevent infection.
Use of nonsterile gloves and instruments during vaginal examinations increases the risk of infection in the laboring client or fetus
(eg, chorioamnionitis).
(Option 1) A nitrazine pH test strip inserted into the vagina can differentiate between amniotic fluid, which is alkaline, and vaginal
fluid, which is acidic. A blue-green, blue-gray, or deep blue color indicates a positive result and probable rupture of membranes. A
yellow, olive-yellow, or olive green color indicates a negative result and suggests that membranes are intact.
(Option 3) Leopold maneuvers help determine fetal presentation and involve systematic palpation of the client's abdomen. These
maneuvers assist the nurse in locating the fetal back for optimal placement of the ultrasound transducer for external fetal heart
monitoring.
(Option 4) Hospital policy, provider preference, and the client risk profile will dictate appropriate oral intake during labor.
However, there is no evidence to support NPO status of low-risk laboring clients, and most clients benefit from hydration provided
by oral clear liquids during labor.
Vaginal examinations of the laboring client with ruptured membranes should be performed using a sterile glove to decrease the risk
of infection (eg, chorioamnionitis) to the client and fetus. Other labor admission interventions include application of external fetal
monitoring and performance of a nitrazine pH test to determine if membranes have ruptured.
Anencephaly is a severe neural tube defect (NTD) resulting in little to no brain tissue or skull formation in utero. Many
newborns with anencephaly are stillborn, and those born alive are not compatible with life. Comfort care for the newborn and
emotional support for the family is priority at the time of birth. Drying, bundling, and placing the newborn skin-to-skin provides
warmth, and administering oxygen may decrease discomfort to the newborn. Allowing the family to hold the newborn will assist
with the grieving process.
(Option 1) The nurse should ensure the family's privacy but should also consider the parents' preferences, as they may benefit
from the support of friends and family, a religious leader, or a hospital chaplain.
(Option 2) Information about future genetic and preconception counseling is important discharge teaching as NTDs may be
related to both genetic and environmental (eg, folic acid deficiency) factors. However, this intervention is not appropriate at this
time.
(Option 3) The parents may benefit from a perinatal loss support group, and this referral should be made prior to discharge.
However, immediately after birth is probably not the most appropriate time to provide information about this resource.
Anencephaly is a severe neural tube defect resulting in little to no brain tissue or skull formation in utero. The newborn may be
stillborn or born alive, although death occurs shortly thereafter. Nurses should facilitate a therapeutic environment for grieving
parents and provide newborn comfort care such as warmth and oxygen.
Current respiratory status is essential to include in handoff report, as it is objective information related to the client's current
condition. Information communicated during report should allow the oncoming nurse to prioritize care and obtain baseline
measurements of the client's current status and response to treatment. It is especially important to include information that may
not be documented in the medical record. Respiratory status can change rapidly, and the most current measurements may not be
documented, as vital signs are often documented every 4, 8, or 12 hours (Option 3).
Handoff report typically includes:
 Client's name, location, age, gender, health care provider, and diagnoses
 Client's current baseline measurements, treatment plan, goals, and response to treatment
 Priority and outstanding tasks and changes from previous days
(Option 1) Lung infiltrates and elevated WBC count are expected findings with pneumonia and are found in the medical record.
Diagnostic findings are significant if there is an ongoing trend, but isolated, expected results are not as helpful in planning care.
(Option 2) Personal opinions are not pertinent to providing care.
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(Option 4) The client's IV site is assumed to be patent without complication, or the offgoing nurse would have changed it. The
oncoming nurse should make an individual assessment.
Handoff report should include objective information related to the client's current condition. It is especially important to include
baseline measurements that may not be documented in the medical record (eg, current respiratory status) so that the oncoming
nurse can prioritize care.
Sodium polystyrene sulfonate (Kayexalate) is used to treat mild to moderate hyperkalemia. Potassium is exchanged for

sodium in the intestines and excreted in the stool, thereby lowering the serum potassium. In clients without normal bowel function
(eg, post surgery, constipation, fecal impaction), there is a risk for intestinal necrosis. During sodium polystyrene sulfonate
therapy, severe hypokalemia (palpitations, lethargy, cramping) can develop. Frequent monitoring of electrolyte status is required.
Because potassium exchanges with sodium content of the resin, excess sodium absorption could put clients at risk
of developing volume overload(water follows sodium). The client should be monitored for signs of fluid overload (eg, crackles,
jugular venous distension, edema) and have daily weights and intake and output assessment.
(Option 2) The client will experience frequent, loose stools at the beginning of therapy. Some clients may be more comfortable
with a bedside commode. Assisting the client onto the commode is important, but assuring normal bowel function is the priority.
(Option 3) Client teaching about necessary laboratory testing is important, but assuring normal bowel function is the priority.
(Option 4) Daily weights are important in the evaluation of potential edema from the medication's sodium content, but assuring
normal bowel function is the priority.
Clients receiving sodium polystyrene sulfonate must have normal bowel function to avoid the risk of intestinal necrosis. The nurse
must assess for constipation, signs of impaction, and recent bowel patterns.
failure to thrive (FTT) in a child is characterized by a low weight/height ratio and/or falling below the 5th percentile on the growth
curve due to inadequate caloric intake, inadequate absorption of calories, or excess caloric expenditure. Most children with a
diagnosis of FTT have inadequate caloric intake caused by multiple behavioral or psychosocial factors, including disturbances in
child-parent interaction. Risk factors for FTT include:
 Young parent age

 Unplanned or unwanted pregnancy
 Lower levels of parental education
 Single-parent home
 Social isolation
 Chronic life stresses/anxiety in the home
 Disordered feeding techniques
o Prolonged breast or bottle feeding
o Unstructured meal times
o Negative or difficult interactions at meal time
o Poor parental feeding skills
o Negative attitudes toward food – fear of obesity or an overweight child
 Substance abuse
 Domestic violence and/or parental history of child abuse
 Poverty, food insecurity
 Parents who have a negative perception of the child
(Option 1) Having siblings is not a risk factor for FTT.

(Option 4) A parent working outside the home is not a risk factor for FTT.
Risk factors for FTT include poverty, lack of structured meal times, negative attitudes toward food, domestic violence, and
substance abuse.
Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction during sleep that occurs from
relaxation of the pharyngeal muscles. The result is repeated episodes of apnea (≥10 seconds) and hypopnea (≤50% normal
ventilation), which cause hypoxemia and hypercarbia.
Common symptoms include frequent periods of sleep disturbance, snoring, morning headache, daytime sleepiness, difficulty
concentrating, forgetfulness, mood changes, and depression.
42
Interventions include:
 Continuous positive airway pressure device at night to keep the structures of the pharynx and tongue from collapsing
backward
 Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax and lead to airway
obstruction (Option 2)
 Weight loss and exercise can reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the
development of OSA (Option 3).
 Avoiding sedating medications (eg, benzodiazepines, sedating antidepressants, antihistamines, opiates) as they may
exacerbate OSA and worsen daytime sleepiness
(Option 1) Eating before bedtime can interfere with sleep and contribute to excess weight.
(Option 4) Sedatives at bedtime can relax the muscles of the oral airway and lead to airway obstruction.
(Option 5) Stimulants such as modafinil may be prescribed for daytime sleepiness but should be avoided at bedtime as they can
cause insomnia.
(Option 6) Napping during the day can make it more difficult to sleep through the night.
Obstructive sleep apnea is characterized by partial or complete airway obstruction during sleep. Interventions to relieve symptoms
include a continuous positive airway pressure device during sleep and lifestyle changes (eg, weight loss; exercise; avoiding food,
alcohol, and sedatives at bedtime).
A central line or central venous catheter (CVC) is inserted by the health care provider in a "central" vein (eg, subclavian, internal
jugular, femoral) and is used to administer fluids, medications, and parenteral nutrition and for hemodynamic monitoring.
Proper hand hygiene should be performed when caring for a CVC to prevent infection, and nonsterile gloves should be worn to
protect the nurse from blood or body fluids at the port site as one or more lumens are often used to draw blood (Option 3).
The Centers for Disease Control and Prevention recommend that catheter hubs always be handled aseptically to prevent catheter-
associated infections. The hubs should be disinfected with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5%
chlorhexidine with alcohol; 10% povidone-iodine). Always allow the antiseptic to dry before using the hub/port (Option 4).
(Option 1) CVCs may have multiple lumens. These are used to administer incompatible drugs simultaneously, for blood draws,
and for hemodynamic monitoring.
(Option 2) Enteral nutrition is given only through the GI tract (orally or through a feeding tube). Parenteral nutrition is
administered through the IV route via a central vein.
A central venous catheter is used to administer fluids, for simultaneous infusion of incompatible drugs, for parenteral nutrition, and
for hemodynamic monitoring. The nurse should always handle the lumen ports and hubs aseptically with facility-approved
antiseptics to prevent catheter-associated infections.
Opioids (eg, morphine, hydromorphone, fentanyl) are controlled medications, regulated in the United States by the Controlled
Substances Act and in Canada by the Controlled Drugs and Substances Act. These laws contain regulations (eg, methods of
disposal) for various controlled substances.
To properly dispose of leftover opioid medication in a patient-controlled analgesia pump, the nurse must have a second
licensed nurse witness the waste of the medication (Option 3). Hospital policy should be followed to properly waste the
medication and discard the empty cartridge. When a controlled substance is discontinued, the nurse documents the date, time,
amount used, reason for the waste, and amount wasted.
(Option 1) Unlicensed assistive personnel (UAP) cannot witness the waste of medication as it is outside their scope of practice.
Two licensed nurses must document this process.
(Option 2) Simply documenting that another nurse is not available does not follow government regulations for wasting controlled
substances. Disposal should occur only when a second licensed nurse is available as a witness.
(Option 4) It is never appropriate to waste a controlled substance without the witness of another nurse. In addition, nurses should
never document or sign off on anything that was not personally witnessed or completed as this constitutes falsified documentation.
Waste of controlled substances (eg, opioids) must be witnessed by two licensed nurses to comply with facility policy and
government regulations.
Total knee replacement (knee arthroplasty) is a surgery that replaces the knee joint with an artificial implant. Knee arthroplasties
are primarily performed for clients with severe pain or mobility impairment from arthritis. Following a knee arthroplasty, the nurse
must plan care to reduce the client's risk of complications while promoting comfort and recovery.
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Contracture of the operative joint is a serious complication of knee arthroplasty that impairs the client's mobility. To prevent
contracture formation, the nurse should maintain the operative knee in an extended position with a knee immobilizer or pillow
placed under the lower leg or heel. Placing a pillow behind the knee causes joint flexion, which increases the risk of
contracture (Option 4).
(Option 1) Cold packs may be applied intermittently over the operative joint to reduce postoperative swelling and pain.
(Option 2) Using a continual passive motion device, if prescribed, may improve range of motion through knee flexion and
extension and prevent contractures.
(Option 3) Applying a leg immobilizer during ambulation provides support, maintains alignment, and prevents dislocation of
unstable operative joints.
Knee arthroplasty is the surgical replacement of the knee joint. Following a knee arthroplasty, the nurse should avoid placing a
pillow behind the client's operative knee due to the risk of contracture. Proper postoperative care includes applying intermittent
cold packs to reduce pain and edema, using a continual passive motion device for flexibility, and obtaining a leg immobilizer for
joint stability during ambulation.
A reddened area on the sacrum puts the client at risk for skin breakdown. The nurse should first perform an assessment on the
client's skin to see if there are any other reddened areas or skin breakdown present. This should be compared to previous
assessments or serve as a baseline assessment of skin integrity. The Braden Scale, a tool for predicting pressure sore risk, would
be appropriate to use as part of the assessment.
(Option 1) After the nurse has performed a skin assessment, it may be appropriate to direct the UAP to apply a protective foam
dressing to the area.
(Option 2) Documentation should occur after the client has been assessed thoroughly and received care.
(Option 3) After assessing the client, the nurse can decide whether to notify the HCP.
When the nurse receives report of a change in client condition from the UAP, the nurse should reassess the client before
completing other interventions.
A critical part of self-care for a person with a history of anaphylactic reaction is the use of emergency epinephrine injection
(EpiPen or EpiPen Jr). The client and/or caregiver should be taught the following principles:
 The EpiPen should always be available for emergency use and so should be taken along (in purse, pocket, backpack)
when the client leaves home (Option 1)
 The EpiPen should be given when the client first notices any anaphylactic symptoms, such as tightening or swelling of the
airway, difficulty breathing, wheezing, stridor, or shock (Option 2)
 The injection should be given in the mid-outer thigh and can be given through clothing (Options 3 and 4)
 The client should receive emergency care as soon as possible by calling 911 or going to the emergency department to
monitor for further problems (Option 5)
Emergency self-injection of epinephrine (EpiPen) can be done through clothing into the mid-outer thigh when the client first notices
any anaphylactic symptoms.
Terazosin is an alpha-adrenergic blocker that can relieve urinary retention in clients with BPH. It relaxes the smooth muscle in
the bladder neck and prostate gland; however, it also relaxes smooth muscle in the peripheral vasculature, which can cause
orthostatic hypotension, syncope (blacking out), and falls. This is particularly common when the drug is started (first-dose
hypotension) or when the dosage is increased. The serious effects can be avoided by instructing the client to take the medication
at bedtime, change positions slowly when going from lying to standing, and avoid any medications that also increase smooth
muscle relaxation (eg, phosphodiesterase-5 inhibitors [sildenafil or vardenafil] used to treat erectile dysfunction). Some clients
may also experience ejaculatory dysfunction (decreased or absent ejaculation).
(Option 2) Grapefruit juice can cause significant interactions with drugs such as calcium channel blockers and sildenafil.
However, it does not appear to interact with alpha blockers such as terazosin.
(Option 3) Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the
morning, to avoid orthostatic hypotension.
(Option 4) Oral iron tablets and bismuth salts (Pepto-Bismol) can turn stools dark, an expected side effect. This can be confused
with upper gastrointestinal bleeding, which can also cause melena.
Alpha blockers are commonly used to treat symptoms of urinary retention in clients with BPH. Orthostatic hypotension is a
common side effect that can be avoided by teaching the client to take the medication at bedtime, avoid abrupt position changes,
and avoid medications for erectile dysfunction, which can worsen hypotension.
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Many individuals diagnosed with cancer experience anxiety and fear related to death and desire to talk with someone about these
feelings. To promote a therapeutic relationship, the nurse should initiate conversations by acknowledging clients' fears,
use open-ended statements to invite them to talk about death, and actively listen as they verbalize their feelings.
(Option 1) The nurse offers false reassurance by making this statement. Providing false reassurance is not part of a therapeutic
relationship or an effective communication strategy.
(Option 2) This statement does not acknowledge the client's concerns and blocks communication. The nurse should first assess
the client's cultural and spiritual practices. If the client requests spiritual support, then the nurse may make a referral to the
chaplain's office.
(Option 4) By changing the subject, the nurse is attempting to redirect the conversation away from the client's desire to talk about
death; this does not promote a therapeutic relationship.
Fear of dying is a common concern for many clients with a terminal disease. The nurse should acknowledge these feelings and
use open-ended statements and active listening to invite clients to talk about death.
Kawasaki disease is treated with aspirin and IVIG to prevent coronary artery aneurysms. Antibodies acquired from the IVIG
therapy will remain in the body for up to 11 months and may interfere with the desired immune response to live vaccines.
Therefore, live vaccines (eg, varicella, MMR) should be delayed for 11 months after IVIG administration as this therapy may
decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity (Options 3 and 5).
(Option 1) Hib vaccine is not a live vaccine, and final dose (fourth) is recommended between age 12-15 months, according to the
Centers for Disease Control and Prevention (CDC).
(Option 2) Hep B vaccine is not a live vaccine; the CDC recommends that the final dose (third) be administered between age 6-18
months.
(Option 4) PCV is also not a live vaccine, and the final dose (fourth) is recommended between age 12-15 months, according to
the CDC.
Live vaccines (eg, varicella, MMR) should be delayed for up to 11 months after IVIG administration as IVIG therapy may decrease
the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity.
Mitral valve stenosis often produces a diastolic murmur heard best at the apex of the heart (5th intercostal space,
midclavicular line) with a stethoscope.
When auscultating for a murmur associated with mitral valve stenosis, the nurse should place the stethoscope at the 5th intercostal
space, midclavicular line.
To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the
transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at
the 4th ICS, at the midway point of the AP diameter (½ AP)of the chest wall. If the transducer is placed too low, the reading will
be falsely high; if placed too high, the reading will be falsely low. This concept is similar to the positioning of the arm in relation to
the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-
monitoring device. The upper arm should be at the level of the phlebostatic axis.
(Option 1) The angle of Louis is the palpable raised notch where the manubrium and sternum are joined. This anatomical location
is useful in counting the ICSs and in finding auscultatory areas.
(Option 2) The aortic area is an auscultatory area located at the 2nd ICS to the right of the sternal border.
(Option 4) The mitral area (apex), an auscultatory area, and the point of maximal impulse are located at the 5th ICS at the MCL.
The anatomical location of the phlebostatic axis is the 4th ICS, at the midway point of the AP diameter (½ AP) of the chest wall.
The stopcock nearest the transducer is placed here to assure accurate pressure measurements.
Droplet precautions are used to prevent transmission of respiratory infection. These precautions include the use of a mask and a
private room. When the client is in the room, staff should wear masks and follow standard precautions. The client on droplet
precautions should wear a mask at all times when outside the hospital room.
(Option 2) Gloves are not required as part of droplet precautions. Standard precautions should guide the use of gloves in clients
on droplet precautions.
45
(Option 3) The transporter does not need to wear a mask outside of the client's room as long as the client keeps a mask on to
prevent transmission of infection.
(Option 4) An isolation gown is not required for droplet precautions.
Droplet precautions require the use of regular masks to prevent the transmission of infection. A mask should be worn by the client
when outside the hospital room and by staff when in the client's room.
Bupropion hydrochloride (Wellbutrin) is an atypical antidepressant used to treat depressive disorders, including major depressive
disorder, seasonal affective disorder, and persistent depressive disorder (dysthymia). Preparations of bupropion hydrochloride
include immediate-release, sustained release (SR), and extended-release (XL) tablets.
Any medication marked SR or XL should not be chewed, cut, or crushed due to the risk of adverse effects from too rapid
absorption of the drug. No form of bupropion hydrochloride should be altered; tablets should be swallowed whole, with or without
food. Seizures are of particular concern if a client takes a high or toxic dose of bupropion hydrochloride.
Clients on any kind of antidepressant need to be monitored closely for worsening depression, sudden or unusual behavior or mood
changes, and the emergence of suicidal thoughts and behaviors. Clients with a diagnosis of depression and/or their family
members need education and information on the increased risk of suicide (Option 1).
Additional instructions to a client about the use of bupropion hydrochloride include the following:
 Limit alcohol; inform the health care provider if you are used to consuming large amounts of alcohol
 Do not double up on the medication if a scheduled dose is missed (Option 3)
 Take the medication at the same time each day
 It may take several weeks to feel the effects of bupropion hydrochloride (Option 4)
 Weight loss may occur when taking this medication
No form of bupropion hydrochloride should be crushed, chewed, or cut due to the risk of seizures and other adverse effects caused
by the more rapid absorption and resulting higher serum levels of the drug. No medications labeled SR or XL should be altered
before they are administered. This type of medication preparation should be swallowed whole.
Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients (eg,

anorexia nervosa, chronic alcoholism). The client's lack of oral intake results in the pancreas making less insulin. After the client
receives food or IV fluids with glucose, insulin secretion is increased, leading to phosphorous, potassium, and magnesium shifting
intracellularly. Phosphorus is the primary deficient electrolyte as it is required for energy (adenosine
triphosphate). Hypophosphatemia causes muscle weakness and respiratory failure. Deficiencies in potassium and magnesium
potentiate cardiac arrhythmias. Therefore, aggressive initiation of nutrition without adequate electrolyte repletion can quickly
precipitate cardiopulmonary failure.
(Option 1) Daily weights and periodic serum albumin level are indicated to evaluate the efficacy of nutritional replenishment but
are not the most important assessment as failure to monitor these does not result in death.
(Option 3) Dumping syndrome is seen after surgery for stomach cancer or bariatric surgery, which results in decreased storage
area in the stomach. Eating concentrated carbohydrates or excess fluids causes the food to be "dumped"/emptied rapidly into the
small intestine. Symptoms include diaphoresis, cramping, weakness, and diarrhea within 30 minutes of eating. Dumping
syndrome is not seen with anorexia nervosa.
(Option 4) The central lines carry a risk of infection. The signs of infection include leukocytosis and left shift. However, risk of
infection is not greatest in the first few days of parenteral nutrition.
Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients. Electrolytes,
especially phosphorous, potassium, and magnesium, must be monitored frequently during the first few days of nutritional
replenishment.
A cervical cerclage is placed to prevent preterm delivery, usually in clients with histories of second trimester loss or premature
birth. A heavy suture is placed transvaginally or transabdominally to keep the internal cervical os closed. Placement occurs at 12–
14 weeks gestation for clients with a history of cervical insufficiency (ie, painless, premature cervical dilation and miscarriage or
preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (eg, short cervix) are noted.
Discharge instructions include activity restriction and recognition of signs of preterm labor (eg, low back aches, contractions,
pelvic pressure) and rupture of membranes (Option 2).
(Option 1) Bed rest is usually recommended for a few days after the procedure. Long-term bed rest is individualized but
uncommon and increases the risk for complications (eg, deep vein thrombosis). Pelvic rest (eg, avoiding sexual intercourse) is
determined by the health care provider.
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(Option 3) Mild abdominal cramping following cerclage placement is common; however, regular contractions, pelvic pressure, and
low back aches may indicate preterm labor.
(Option 4) The cerclage remains in place until 36–37 weeks gestation. Early removal is indicated by rupture of membranes (to
prevent infection) or preterm labor (to prevent damage to the cervix as it dilates).
Following cerclage placement, discharge teaching includes recognizing and reporting signs of preterm labor (eg, low back aches,
contractions, pelvic pressure) or rupture of membranes and understanding activity restrictions (eg, bed rest for a short time after
placement).
NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any
number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this
change. Visit NCSBN® NCLEX FAQs for more information.
The second trimester (14 wk 0 d to 27 wk 6 d) is a time of positive changes for many pregnant clients (eg, improved nausea) and
when physical evidence of the pregnancy is noted (eg, increased fundal height). The nurse should prepare clients for
expected physical changes and discuss prevention of potential complications.
 Quickening, or a client's first perception of light fetal movement, is expected around 16-20 weeks gestation, depending
on parity (Option 1).
 Weight gain increases by approximately 1 lb (0.5 kg) per week if pre-pregnancy BMI has been normal (Option 3).
 Increasing intake of iron-rich foods (eg, meat, dried fruit) and continuing prenatal vitamins both help to
prevent anemiacaused by increased fetal iron requirements after 20 weeks gestation (Option 4).
 Preterm labor warnings and signs of preeclampsia should be reviewed beginning at 20 weeks gestation.
The nurse should also discuss routine screening/diagnostic tests performed during the second trimester.
 An ultrasound is performed around 18-20 weeks gestation to evaluate fetal anatomy and the placenta (Option 2).
 Screening for gestational diabetes mellitus (GDM) occurs between 24-28 weeks gestation (ie, 1-hour glucose
challenge test) (Option 5). GDM is a complication of pregnancy caused by hormonally related maternal insulin
resistance.
During the second trimester, the nurse should provide guidance regarding fetal movements, weight gain, screening/diagnostic tests
(eg, fetal anatomy ultrasound, 1-hour glucose challenge test), and increased requirements for iron to maintain maternal and fetal
health.
During the school-age years (6-12), sleep needs of a child depend on health status, activity level, and age. Children in this age
group need approximately 11 hours of sleep daily at age 5 and 9 hours at age 12 (Option 4). Children are often unaware of their
level of fatigue. Bedtimes should be established to prevent fatigue the next day. Bedtime issues are usually not a concern,
although many children retain bedtime rituals such as reading or listening to music.
(Option 1) Quiet activity (eg, coloring, reading) prior to bedtime should be planned to promote restful sleep.
(Option 3) Growth rate is slowed during the school-age years, which accounts for variations in sleep needs.
Sleep needs of school-age children are dependent on health status, activity level, and age. Required sleep averages 11 hours (for
5-year-olds) to 9 hours (for 12-year-olds). It is important to establish bedtime hours and bedtime rituals. These children usually do
not need daytime naps if they have slept well at night.
The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected
abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or
intimidate them from providing truthful responses. In this case, the spouse appears angry and should, as a priority, be removed
from the room to prevent further potential harm to the client or staff (Option 3).
(Option 1) Notifying social services of suspected abuse should occur with the client's permission after any immediate threats are
removed and after physiological needs are met. This should not be done in the presence of any potential abusers.
(Option 2) Cleaning the laceration and preparing for sutures are appropriate interventions but are done after a suspected abuser
is removed. The nurse also follows facility guidelines for documenting, gathering evidence, and/or photographing injuries before
cleaning and further treatment.
(Option 4) The arm should be x-rayed to assess for fractures and may require a sling for immobilization, but potential sources of
harm are removed from the room first.
47
If a client shows possible signs of abuse or neglect, the priority is to remove any sources of immediate danger (eg, suspected
abuser) from the room to prevent further harm. Assessments and further interventions can occur after ensuring the client's safety.
Factor Xa inhibitors (eg, rivaroxaban [Xarelto], edoxaban, apixaban) are anticoagulants used to prevent and treat venous
thromboembolism. Factor Xa inhibitors are being prescribed more frequently than other oral anticoagulants (eg, warfarin), as they
have a lower risk of bleeding and require less ongoing monitoring (eg, PT/INR).
Clients prescribed rivaroxaban should be educated to avoid taking over-the-counter medications or supplements that increase
bleeding risk, such as NSAIDs (eg, aspirin), garlic, and ginger. The combined effects of rivaroxaban and other anticoagulants
may greatly increase the risk of uncontrolled bleeding (eg, epidural, intracranial, gastrointestinal) and hemorrhage (Option 3).
(Option 1) Unlike warfarin, factor Xa inhibitors are not affected by vitamin K, which is found in many green, leafy vegetables (eg,
spinach, kale).
(Option 2) Anticoagulants, particularly factor Xa inhibitors, increase the risk for spontaneous intracranial bleeding or formation of
epidural hematomas. Clients taking factor Xa inhibitors should be instructed to immediately contact their health care provider for
symptoms of neurological impairment (eg, extremity weakness, altered sensation, numbness).
(Option 4) Routine monitoring of clotting times (eg, PT/INR, PTT) is unnecessary for clients prescribed factor Xa inhibitors.
The nurse should instruct clients receiving factor Xa inhibitors (eg, rivaroxaban, edoxaban, apixaban), which are anticoagulants, to
avoid taking additional medications or supplements with anticoagulant effects (eg, NSAIDs, garlic, ginger). The combined
anticoagulant effects increase the risk for uncontrolled bleeding and hemorrhage.
Clients requiring mechanical ventilation receive care from many members of the health care team. Nurses must often delegate
tasks to ensure that care is provided in a timely manner. When delegating, nurses must consider the stability of the client and
the experience level of unlicensed assistive personnel (UAP). In accordance with the five rights of delegation, nurses
may delegate the following client care tasks to the UAP:
 Performing routine oral care, which will not affect medical stability in a client with a tracheostomy tube (Option 1)
 Measuring and obtaining vital signs (Option 4)
 Testing blood glucose (per hospital policy)
 Performing personal hygiene and skin care (eg, bathing)
 Performing passive and/or active range-of-motion exercises (Option 5)
 Measuring output (eg, urinary, drainage)
(Option 2) The tracheostomy is a surgically created airway with a high risk of infection. Only licensed individuals (eg, registered
nurse, licensed practical nurse) should perform tracheostomy care.
(Option 3) Although an elevated head of bed (HOB) is necessary to prevent ventilator-acquired pneumonia and improve chest
expansion, teaching is not within the scope of the UAP and should be performed only by nurses. However, after nurses provide
teaching, the UAP may remind the family to keep the HOB elevated.
When caring for a ventilated client, nurses may consider delegating the following tasks to unlicensed assistive personnel: vital sign
measurement, oral care, personal hygiene, blood glucose testing, passive or active range-of-motion exercises, and measurement
of urine and drainage output.
The client with abdominal pain has abnormal vital signs, which is a sign of a systemic condition. Adult criteria apply to adolescent
clients in terms of physiological signs/symptoms. A pulse of 120/min signals dehydration and this client's respirations are above
normal. This is the most serious acuity.
(Option 1) The client with a history of CF would be treated second as clients with CF have chronic respiratory issues related to the
thick mucus plugging the airways. This client will probably need antibiotics but is stable and can wait. The severity of the situation
is considered when prioritizing client care based on airway, breathing, and circulation (ABC). The seriousness of the adolescent
client's condition related to "C" (dehydration) is a priority over a relatively stable "B." There is nothing indicating that this client is in
respiratory distress.
(Option 2) The infant has diaper dermatitis from irritation of urine and stool on the skin. A secondary infection with Candida
albicanscan occur. Diaper dermatitis is most common in infants age 9-12 months. Ointment will be provided. Mild diaper
dermatitis is treated with a topical water-impermeable barrier (eg, zinc oxide). If the infant has an infection with Candida albicans,
an antifungal topical medication is also used. When care must be prioritized, young children do not automatically go first.
Prioritization is decided by the client's acuity.
(Option 3) The grade-school client has a limited extremity injury and the priority principle is always "life before limb." Therefore,
the client with abdominal pain is more important.
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In prioritization, the severity of ABC is more important than absolute order. As a result, a severe "C" client comes before a stable
"B" client. The priority principle is to take "life before limb" in this order. When care must be prioritized, young children do not
automatically go first.
Cystic fibrosis (CF) is an inherited disorder (autosomal recessive) characterized by thickened secretions due to impaired
chloride and sodium channel regulation that causes exocrine gland dysfunction. Management of a client with CF should primarily
address potential complications related to the following body systems:
 Pulmonary: Alterations in respiratory secretions (ie, thick sputum) make it difficult to clear the airway and can result in
frequent respiratory infections and sinusitis (Option 3). Frequent infections and inflammation damage lung tissue and
may lead to chronic hypoxemia (Option 1).
 Gastrointestinal: Thickened secretions obstruct the release of pancreatic enzymes, causing malabsorption of fat-
soluble vitamins (eg, A, E, D, K) and other nutritional deficiencies (Option 5). High-protein, high-calorie foods and
supplemental enzymes with meals are necessary.
 Reproductive: Thickened reproductive secretions (eg, seminal fluid, cervical mucus) or the absence of the vas deferens
in men contributes to CF-related infertility.
(Option 2) Diabetes mellitus, not diabetes insipidus, is a potential complication for clients with CF due to pathologic pancreatic
changes (eg, fibrosis).
(Option 4) Due to impaired gastrointestinal absorption, weight loss and failure to thrive are more common and a greater concern
than obesity.
Cystic fibrosis is an inherited disorder that results in impaired exocrine gland function and is characterized by thickened secretions
that affect the pulmonary, gastrointestinal, and reproductive systems. When planning care, the nurse should monitor for priority
concerns, including development of respiratory infections, chronic hypoxemia, nutritional deficiencies, and abnormal growth (failure
to thrive).
All of the choices are appropriate options to reduce falls in the home, but the one with the greatest impact is the removal of all
area rugs and installation of grab bars in the bathroom. Area rugs can still cause falls for the client with a walker, with new
glasses, and with someone present. In addition, many falls occur in the bathroom while toileting and bathing, making grab bars
highly beneficial.
(Option 1) Not leaving the client alone is preferable and could decrease the incidence of falls while the spouse is away. However,
it is less effective than the removal of area rugs and installation of grab bars in the bathroom.
(Option 2) A walker would be beneficial for this client but could get caught on an area rug.
(Option 4) Poor eyesight can contribute to falls, but the removal of rugs and installation of grab bars will have a greater impact.
The nurse should educate the client and family about removing area rugs and installing grab bars in the bathroom to reduce the
risk of falls in the home.
Asthma is an inflammatory condition in which the smaller airways constrict and become filled with mucus. Breathing, especially on
expiration, becomes more difficult. Pharmacologic treatment for acute asthma includes the following:
1. Oxygen to maintain saturation >90%

2. High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer
treatments every 20 minutes
3. Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an
effect.
(Option 2) Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen, indomethacin) and aspirin can worsen asthma
symptoms in some clients and are not indicated unless necessary.
(Option 4) Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute
episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide) to provide
long-term asthma control.
(Option 5) Tobramycin is an aminoglycoside antibiotic. It is used in aerosolized form to treat cystic fibrosis exacerbation
when Pseudomonas is the predominant organism causing lung infection.
Inhaled corticosteroids and leukotriene inhibitors are typically used to achieve and maintain control of inflammation for long-term
management of asthma. Quick-relief medications (eg, albuterol, ipratropium) are used to treat acute symptoms and exacerbations.
49
The suction control chamber (Section A) maintains and controls suction to the chest drainage system; continuous, gentle
bubbling indicates that the suction level is appropriate. The amount of suction is controlled by the amount of water in the chamber
and not by wall suction. Increasing the amount of wall suction would cause vigorous bubbling but does not increase suction to the
client as excess suction is drawn out through the vent of the suction control chamber. Vigorous bubbling would increase water
evaporation and therefore decrease the negative pressure applied to the system. The nurse should check the water level and add
sterile water, if necessary, to maintain the prescribed level.
(Option 1) The air leak monitor (Section C) is part of the water seal chamber. Continuous or intermittent bubbling seen here
indicates the presence of an air leak.
(Option 2) The collection chamber (Section D) is where drainage from the client will accumulate. The nurse will assess amount
and color of the fluid and record as output.
(Option 4) The water seal chamber contains water, which prevents air from flowing into the client. Up and down movement of
fluid (tidaling) in Section B would be seen with inspiration and expiration and indicates normal functioning of the system. This will
gradually reduce in intensity as the lung reexpands.
The nurse should observe gentle, continuous bubbling in the suction control chamber. This indicates patency and the appropriate
level of suction being applied to the drainage system.
Raynaud phenomenon is a vasospastic disorder resulting in an episodic vascular response related to cold temperatures or
emotional stress. It most commonly affects women age 15-40. Vasospasms induce a characteristic color change in the
appendages (eg, fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from
decreased perfusion, followed by a bluish-purple appearance due to cyanosis. Clients usually report numbness and coldness
during this stage. When blood flow is subsequently restored, the affected area becomes reddened and clients experience
throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the hands in warm water.
Client teaching regarding prevention of vasospasms includes:
 Wear gloves when handling cold objects (Option 5).

 Dress in warm layers, particularly in cold weather.
 Avoid extremes and abrupt changes in temperature.
 Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine).
 Avoid excessive caffeine intake (Option 1).
 Refrain from use of tobacco products (Option 4).
 Implement stress management strategies (eg, yoga, tai chi) (Option 3).
If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole smooth
muscle and prevent recurrent episodes.
(Option 2) Cold water will cause vasoconstriction and worsen the condition.
Raynaud phenomenon is a vasospastic disorder triggered by exposure to cold or stress. Key elements of client teaching include
management of acute attacks, avoidance of vasoconstrictive substances (eg, tobacco, cocaine, caffeine), stress reduction, and
appropriate clothing (eg, gloves, warm layers).
Tetralogy of Fallot is a congenital cardiac defect that typically has 4 characteristics: pulmonary stenosis, right ventricular
hypertrophy, overriding aorta, and ventricular septal defect.
This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can
happen when a child cries, becomes upset, or is feeding. The child should first be placed in a knee-to-chest position. Flexion
of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through
the overriding aorta and the ventricular septal defect.
(Option 1) Morphine may be considered if the dyspnea is not relieved by the knee-to-chest position.
(Option 2) If oxygen saturation remains low, oxygen may need to be administered.
(Option 3) Vital signs and pulse oximetry may be checked after the infant has been placed in the knee-chest position.
To relieve a hypercyanotic episode, or "tet spell," the nurse should place the infant or child in the knee-chest position.
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According to the Centers for Disease Control and Prevention, 1 out of 3 adults aged >65 experience a fall every year. Walking
barefoot or while wearing stockings increases the risk of slipping on slick surfaces. Shoes or slippers with non-skid soles should
be worn inside and outside of the home. There are multiple simple strategies that can help reduce falls in the home environment
and these include:
 Exercising regularly for 30 minutes 3 times/week increases strength, balance, coordination, and flexibility; therefore,
decreasing fall risk.
 Maintaining a well-lit, clutter-free environment (eg, adding nightlights and removing or securing area rugs to the floor
with double-sided tape) (Options 1 and 4).
 Using grab bars and non-skid bath mats in the bathroom.
 Wearing shoes or slippers with non-skid soles, both inside and outside of the home.
 Periodically reviewing medications and side effects (eg, orthostatic hypotension) with a pharmacist and/or health care
provider (HCP).
 Getting regular vision exams.
 Wearing an electronic fall alert device. The fear of falling increases fall risk and these devices provide the security of
knowing help is available immediately if a fall occurs (Option 2).
Many falls in the home can be prevented by exercising regularly, getting regular vision exams, maintaining a well-lit, clutter-
free environment, using grab bars in the bathroom, periodically reviewing medications and side effects with a pharmacist and/or
HCP, and wearing an electronic fall alert device.
Atropine is given to the client experiencing symptomatic bradycardia. In symptomatic bradycardia, the heart rate
is <60/min and is inadequate for the client's condition, causing symptoms such as hypotension, chest pain, or syncope. Atropine
acts to increase the heart rate by inhibiting the action of the vagus nerve (parasympatholytic effect). A normal sinus rhythm and
reversal of clinical symptoms indicate that the medication has had the desired effect.
(Option 1) A continuation of sinus bradycardia would not indicate that the atropine had been effective.
(Option 3) Sinus tachycardia would be an undesirable effect of atropine as the heart rate would be >100/min.
(Option 4) The client with first-degree atrioventricular block may have a normal heart rate, but the atrioventricular conduction time
is prolonged.
Atropine is given to the client with symptomatic bradycardia. The desired outcome would be an increase in heart rate, evidence of
normal sinus rhythm on the cardiac monitor, and reversal of any clinical symptoms associated with the bradycardia.
Clients with infective endocarditis IE usually have fever for several days during the initial stages of antibiotic therapy. By the time
they are discharged, fever subsides or becomes occasional and low-grade. The nurse should teach the client to
monitor temperature regularly at home. Persistent temperature elevations may mean that the antibiotic therapy is ineffective
or complications have developed. The client should notify the HCP if a fever persists at home.
(Option 1) A client who has had IE is at risk for reoccurrence. This client should receive prophylactic antibiotics for certain high-
risk procedures (eg, manipulation of gingival tissue).
(Option 2) IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can
occur. Slurred speech could indicate that embolization has caused a possible stroke.
(Option 4) IE can require IV antibiotics for up to 4-6 weeks. The client may be discharged home once hemodynamically stable,
and a home health nurse will come to administer the antibiotics through the client's PICC line.
The nurse should teach the client with IE to expect to receive IV antibiotics for several weeks after returning home and to report
a persistent fever; any signs of embolization such as slurred speech, one-sided weakness, or paralysis; or a painful, cold
extremity. Prophylactic antibiotics will be required for certain high-risk procedures.
The nurse should recognize the following characteristics associated with histrionic personality disorder:
 Self-dramatizing, exaggerated or shallow emotional expression

 Attention-seeking, needs to be the center of attention
 Overly friendly and seductive, attempts to keep others engaged
 Demands immediate gratification and has little tolerance for frustration
An individual with histrionic personality disorder displays these behaviors and characteristics persistently. The signs and
symptoms are maladaptive and have a negative impact on the client's social, interpersonal, and occupational life.
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(Option 1) Clients with dependent personality disorder fear separation and tend to be indecisive and unable to take the initiative.
They are often preoccupied with the thought of being left to fend for themselves and want others to assume responsibility for all
major decision making.
(Option 3) Clients with schizoid personality disorder exhibit social detachment and an inability to express emotion. They do not
enjoy close relationships and prefer to be aloof and isolated.
(Option 4) Clients with antisocial personality disorder have a pattern of disregard for and violation of the rights of others. They
manipulate others for personal gain and lack empathy.
Histrionic personality disorder is characterized by persistent attention-seeking behavior and exaggerated emotionality. The client
with this disorder demands immediate gratification and has little tolerance for frustration.
Scope of practice
RN LPN/LVN UAP
 Clinical assessment  Monitoring RN findings  Activities of daily living

 Initial client education  Reinforcing education  Hygiene
 Discharge education  Routine procedures (eg,  Linen change
 Clinical judgment catheterization)  Routine, stable vital signs
 Initiating blood transfusion  Most medication administrations  Documenting input/output
 Ostomy care  Positioning
 Tube patency & enteral feeding
 Specific assessments*
LPN = licensed practical nurse; LVN = licensed vocational nurse; RN = registered nurse;

UAP = unlicensed assistive personnel.
*Limited assessments (eg, lung sounds, bowel sounds, neurovascular checks).

Nurses preparing to delegate client care to a licensed practical nurse (LPN) and/or unlicensed assistive personnel (UAP) should
consider the 5 rights of delegation. The LPN can monitor and care for stable clients who have been initially evaluated by a
registered nurse (RN). Interventions LPNs may perform include:
 Administering oral and parenteral medications, but excluding administering IV medications, which vary by state
legislation (Options 1 and 2)
 Reinforcing teaching and skills that have been initially taught by the RN (Option 4)
 Focused assessments (eg, bowel sounds) after the RN's initial assessment
(Option 3) Performing admission or initial assessments is outside the scope of the LPN and UAP. The RN must perform initial
assessments in order to analyze the findings and formulate the client's plan of care before delegating tasks.
(Option 5) The LPN is capable of performing routine care (eg, calculating daily intake and output, toileting). However, the UAP
may also perform these tasks, which frees the LPN to perform more complex duties. Therefore, the most appropriate staff member
to assign the task of calculating intake and output to is the UAP.
Nurses preparing to delegate client care should consider the 5 rights of delegation. Appropriate tasks to delegate to a licensed
practical nurse include administration of oral and parenteral medications, excluding IV route, and reinforcement of teaching
previously provided by the registered nurse.
Eyelids should sit above the pupils symmetrically with irises showing. Ptosis (drooping of the eyelid below the level of the pupil)
could indicate paralysis of the oculomotor nerve. This finding warrants further investigation. At the time of birth, there should be no
cranial nerve abnormalities.
(Option 1) Crackles (rales) indicate fluid in the lungs and are expected immediately after birth. Rales will clear as the neonate
transitions to extrauterine life. However, wheezes, stridor, or persistence of crackles after the first few hours of birth are abnormal
and should be reported.
(Option 2) Percussing dullness in the hypogastric area is a normal finding when the bladder is full. The neonate should void
spontaneously within a few hours after birth.
(Option 4) An undescended testicle (cryptorchidism) at birth is not concerning. Most undescended testes descend spontaneously
by age 6 months.
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At the time of birth, there should be no cranial nerve abnormalities. Rales (crackles) indicate fluid in the lungs and will clear as the
neonate transitions to extrauterine life. Most undescended testes descend spontaneously by age 6 months.
Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as
submissive and clinging behaviors and fear of separation. Additional characteristics of dependent personality disorder may
include:
 Difficulty in making day-to-day decisions

 An excessive need for advice, reassurance, and nurturance from others
 Lack of self-confidence - afraid to do things on one's own
 Afraid of confrontation or expressing disagreement with others
 Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself
A client making a decision about and carrying out a daily activity on his/her own would be indicative of progress toward a
therapeutic outcome.
(Option 1) Clients with dependent personality disorder will often express appreciation or make flattering comments to the
nurse/therapist to gain approval.
(Option 2) Clients with dependent personality disorder lack confidence in their own abilities; this client is expressing self-doubt
and is not showing evidence of improvement.
(Option 4) The need to stay with someone while the client's parents are away is not evidence of progress toward a therapeutic
outcome; the client cannot tolerate being alone.
Clients with dependent personality disorder have an extreme need to be taken care of by another person, cannot make decisions
on their own, and have intense fear of separation and being left alone. The ability to make a decision and act on one's own would
indicate progress toward a therapeutic outcome.
Overflow urinary incontinence occurs due to compression of the urethra (eg, uterine prolapse, prostate enlargement)
or impairment of the bladder muscle (eg, spinal cord injury, diabetic neuropathy, anticholinergic medications). Both types involve
incomplete bladder emptying and urinary retention, which lead to overdistension and overfilling of the bladder and frequent
involuntary dribbling of urine. When caring for clients with overflow incontinence, the nurse should:
 Implement a fixed voiding schedule (eg, every 2 hours) to prevent bladder overfilling.
 Instruct the client to use the Valsalva maneuver (ie, "bearing down") and Credé maneuver (ie, gently applying pressure
to the lower abdomen) to help facilitate bladder emptying (Option 2).
 Assess the perineal area for skin breakdown related to incontinence (Option 3).
 Measure postvoid residual volumes as prescribed to ensure that the client is not retaining large amounts of
urine (Option 4).
 Instruct the client to wait 20-30 seconds after voiding and then attempt to void a second time (ie, double voiding) to help
empty residual urine (Option 5).
(Option 1) Fluid restriction can lead to dehydration with concentrated urine, which irritates the bladder and increases the risk for
urinary tract infection. Dehydration also contributes to constipation, which worsens incontinence by compressing the bladder.
When caring for clients with overflow incontinence, the nurse should implement a fixed voiding schedule, teach the client
techniques that assist with bladder emptying (eg, Valsalva maneuver, Credé maneuver, double voiding), monitor for perineal skin
breakdown, and measure postvoid residual volumes as prescribed.
The occipital lobe of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision. The nurse
should notify the health care provider immediately and document the finding.
The frontal lobe controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often
results in behavioralchanges.
The temporal lobe integrates visual and auditory input and past experiences.
The parietal lobe integrates somatic and sensory input.
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The occipital lobe receives visual images. The frontal lobe controls executive function and personality. The temporal lobe
receives auditory input. The parietal lobe receives sensory input.
Hepatitis B virus infection is a bloodborne disease that poses a significant infection risk to the newborn because of exposure
to maternal blood and bodily fluids during birth. The most important interventions to prevent maternal-to-newborn transmission
after birth include initiation of the hepatitis B vaccine series and administration of hepatitis B immune globulin (HBIG) within 12
hours of birth.
Clients who desire to breastfeed should be encouraged to do so if possible because very few absolute contraindications to
breastfeeding exist. Breastfeeding has not been shown to affect newborn infection rates and is not contraindicated as long as the
client's nipples are intact (eg, not bleeding) and immunoprophylaxis (ie, HBIG, hepatitis B vaccine) is appropriately
administered (Option 4).
(Option 1) To protect the newborn from further exposure to maternal blood and bodily fluids, the nurse should wash the newborn's
skin prior to any procedures that puncture the skin (eg, vaccination).
(Option 2) All newborns of mothers with a positive hepatitis B surface antigen (HBsAg) test should receive the HBIG injection and
hepatitis B vaccination to prevent infection and ensure long-term immunity.
(Option 3) Skin-to-skin contact promotes maternal-newborn bonding, breastfeeding initiation, and temperature regulation and is
not contraindicated for clients with hepatitis B.
Hepatitis B virus infection is a bloodborne disease that poses a significant infection risk to the newborn. It is not a contraindication
to breastfeeding. However, the hepatitis B immune globulin and vaccine should be administered to the newborn within 12 hours of
birth.
Licorice root is an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn, colitis, and
chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. When used in
combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia
can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting" diuretics, so this client is
already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should discourage the
client from using this herbal remedy and report the client's use to the PHCP.
(Option 1) Bananas are rich in potassium. Eating one each morning is beneficial.
(Option 2) Diuretics and calcium channel blockers (eg, nifedipine, amlodipine, felodipine) commonly cause postural hypotension
or dizziness on rising. The nurse should encourage the client to rise slowly and sit on the side of the bed for a few minutes before
getting up. Persistent dizziness should be reported to the PHCP.
(Option 4) Diuretics should be taken in the morning as nighttime dosing will cause nocturia and interrupted sleep.
The nurse should discourage the client from using the herbal remedy licorice root when taking thiazide diuretics. Licorice root can
potentiate potassium loss and increase the client's risk for hypokalemia. Use of licorice root should be reported to the PCHP.
IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function.
The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the
dose above, use the following formula:
(160 mg) / (4 mg/min) = 40 min
(Option 1) Bradycardia is an adverse effect of beta blockers (eg, metoprolol, atenolol), calcium channel blockers (eg, verapamil),
and digoxin. It is not an adverse effect of furosemide.
(Option 2) Hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic.
However, slower infusion is unlikely to prevent this adverse effect.
(Option 3) Although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of
administration.
High doses of IV furosemide should be administered slowly to prevent ototoxicity.
An elevated carbon dioxide (CO2) level (normal: 35-45 mm Hg [4.7-6.0 kPa]) is usually an indicator of hypercapneic respiratory
failure. The bilevel positive airway pressure (BIPAP) machine will provide positive pressure oxygen and expel CO2 from the lungs.
This client is already showing signs of lethargy and confusion, which is usually a late indicator of respiratory decline. Therefore,
the nurse's priority should be to get the client on the BIPAP machine as soon as possible.
(Option 1) Nebulizer treatments are commonly part of the treatment plan for a client with chronic obstructive pulmonary disease
(COPD). However, these do not take priority when the client has CO2 retention and is deteriorating. If mental status worsens
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further (due to continued CO2retention), the client will need intubation. Many BIPAP machines are able to deliver nebulizer
treatment while providing positive pressurized oxygen.
(Option 2) Steroid therapy is a common pharmaceutical intervention for COPD exacerbation, but it does not take priority over
BIPAP in this deteriorating client. In addition, steroids take hours to days to have an effect.
(Option 3) In a client with an elevated CO2 level and a history of COPD, the nurse should not increase the oxygen level as this
could cause an increase in CO2 retention, resulting in further respiratory failure.
BIPAP therapy is an effective treatment to decrease CO2 levels in clients with hypercapnic respiratory failure.
A handoff of care report is the critical communication that occurs when transferring client care to another nurse (eg, shift change,
department transfer). Transitions of care require thorough, precise communication to ensure client wellness and safety.
Appropriate handoff communication allows for continuity of care and provides a synopsis of client needs and details of the client's
care.
To ensure appropriate and effective handoff communication, the nurse should:
 Provide identifying information (eg, client's name and room number).

 Note care priorities and upcoming or outstanding tasks (eg, time to replace a medication infusion bag, need to perform
delayed wound care and cause of delay) (Option 1).
 Provide exact, pertinent information (eg, medication dose, time, measurable outcomes) (Option 3).
 Include multidisciplinary plans (eg, radiology examinations, family meetings, physical therapy) (Option 5).
 Relay significant client changes in a clear manner (ie, assessment, interventions, outcomes, evaluation).
(Option 2) Report statements should include exact information (ie, time medication is administered, measurable outcome using a
pain scale). "Good relief" is a vague term.
(Option 4) Handoff should not include biased information or personal opinions (eg, "rude") and should include visitor information
only if the visitor is involved in client care and/or teaching. It is appropriate to include information about a client's medication list.
Nurse-to-nurse handoff of care reports should clearly communicate identifying information; care priorities and upcoming or
outstanding tasks; exact, pertinent information; multidisciplinary plans; and significant client changes.
Childhood development usually occurs in an orderly and predictable manner, with more complex skills being acquired as age
increases. Fine (eg, grasp) and gross (eg, posture, balance, movement) motor skills are assessed during routine well-child visits
to identify normal development and detect delays.
During infancy, gross motor development begins with head and neck control and progresses to skills such as turning over, bearing
weight on the arms in a prone position, sitting with the head erect, standing, crawling (ie, abdomen touching floor), creeping (ie,
abdomen lifted off floor), and walking. By age 7 months, infants should be able to bear their full weight while standing with
caregiver support and sit with minimal supportfrom their hands (ie, tripod sitting) (Options 1 and 4).
(Option 2) By age 7 months, infants can roll over, but the ability to move from a prone to a sitting position is not expected until age
10 months.
(Option 3) Some infants learn to pull themselves up into a standing position early, but this is not expected until age 9-10 months.
(Option 5) Walking while holding on to furniture is not expected until age 11 months.
Childhood development of gross motor skills usually follows a predictable pattern, with more complex skills being acquired as age
increases. A 7-month-old client should be able to sit with minimal support and bear their full weight while standing with caregiver
support.
Health promotion during pregnancy includes the administration or avoidance of certain vaccines to decrease risks to mother and
fetus. Pregnant women have suppressed immune systems and are at increased risk for illness and subsequent complications.
Some viruses (eg, rubella, varicella) can cause severe birth defects if contracted during pregnancy.
Inactivated vaccines contain a "killed" version of the virus and pose no risk of causing illness from the vaccine. Some vaccines
contain weakened (ie, attenuated) live virus and pose a slight theoretical risk of contracting the illness from the vaccine. For this
reason, women should not receive live virus vaccines during pregnancy or become pregnant within 4 weeks of receiving such
a vaccine.
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The tetanus, diphtheria, and pertussis (Tdap) vaccine is recommended for all pregnant women between the beginning of the 27th
and the end of the 36th week of gestation as it provides the newborn with passive immunity against pertussis (whooping
cough) (Option 4).
During influenza season (October-March), it is safe and recommended for pregnant women to receive the injectable inactivated
influenza vaccine regardless of trimester (Option 1).
(Options 2, 3, and 5) The influenza nasal spray; measles, mumps, and rubella (MMR) vaccine; and varicella vaccine contain live
viruses and are contraindicated in pregnancy.
Inactivated vaccines (eg, inactivated influenza; tetanus, diphtheria, and pertussis) may be given during pregnancy to protect
pregnant clients from illness and provide the fetus with passive immunity. Live virus vaccines are contraindicated in pregnancy.
Nephrotic syndrome, an autoimmune disease, affects children age 2-7 and is characterized by increased permeability of the
glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). Loss of albumin in urine leads
to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid to leak out of the vascular spaces.
Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (via the renin-angiotensin-aldosterone system).
Clients experience generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output.
The loss of immunoglobulins causes increased susceptibility to infection. Caregivers should minimize the risk of infection
during relapses (eg, limiting visitors) (Option 2).
Treatment typically includes:
 Corticosteroids and other immunosuppressants (eg, cyclosporine)

 Loss of appetite management (eg, making foods fun and attractive)
 Infection prevention (eg, limiting social interaction until the child is in remission)
(Option 1) A regular diet without added salt is prescribed to prevent edema while in remission. More stringent sodium restrictions
are necessary when symptoms are present.
(Option 3) Fluid restriction is needed in cases of edema or rapid weight gain.
(Option 4) There is a high risk for recurrence after recovery, and relapses may occur several times per year. The parent/caregiver
should test daily for proteinuria, weigh the child weekly, and keep a diary of results.
Nephrotic syndrome is characterized by massive proteinuria, edema, and hypoalbuminemia. Home management includes a low-
sodium diet with attractive foods; infection prevention; fluid restriction for severe edema; and monitoring of weight gain and
proteinuria to detect relapse.
"Tell me about how you feel about your surgery," is the most appropriate statement to encourage the client to express the source
of anxiety. Using an open-ended question enables the client to take control of the conversation and direct it to concerns about the
surgery. The nurse can then address the specific concerns identified and provide individualized explanations and support.
(Option 1) This statement is nontherapeutic as giving false reassurance minimizes the client's concerns and diminishes trust
between the nurse and client.
(Option 3) This statement is nontherapeutic and intimidating. Asking "why" and "how" is an ineffective method of gathering
information.
(Option 4) A client may share a decision with the nurse in an effort to discuss feelings. This statement is nontherapeutic because
giving approval of the client's decision does not encourage the client to express concerns about the surgery.
Therapeutic conversation techniques (eg, active listening, using open-ended questions) encourage the client to express feelings
and ideas and establish an open, trusting relationship with the nurse. Nontherapeutic communication techniques (eg, expressing
approval or disapproval, giving advice, asking why) discourage expression of feelings and ideas and close down the conversation
between the nurse and client.
Congenital hypothyroidism
Clinical manifestations  Initially normal at birth

 Symptoms develop after maternal T4 wanes:
o Lethargy
o Enlarged fontanelle
o Protruding tongue
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o Umbilical hernia
o Poor feeding
o Constipation
o Dry skin
o Jaundice
 ↑ TSH & ↓ free T4 levels

Diagnosis  Newborn screening
 Levothyroxine
Treatment
Congenital hypothyroidism occurs when abnormal development of the thyroid gland causes complete or decreased secretion
of thyroid hormone (TH). Untreated hypothyroidism can cause severe intellectual disability in infants if undetected. Screening
occurs after birth for all infants in the United States and Canada to prevent disability and encourage
early treatment (ie, levothyroxine).
TH plays an important role in growth, development, and regulation of many bodily functions (eg, heat production, muscle tone, skin
function, cardiac function, metabolism). Clinical manifestations in affected infants reflect the pathophysiology of decreased TH and
may include:
 Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function (Option 1)
 Dry skin due to alterations in skin function (Option 2)
 Hoarse cry caused by swelling of the vocal cords due to fluid retention (Option 4)
 Constipation due to slowed metabolism
 Bradycardia due to the effect of TH on cardiac function
(Options 3 and 5) Hyperthyroidism (Graves disease) is an autoimmune condition related to increased production of TH. Neonatal
Graves disease is uncommon and usually occurs secondary to maternal hyperthyroidism. Tachycardia and increased bowel
motility (frequent or loose stools) are features of hyperthyroidism and are related to an increase in metabolic processes.
Congenital hypothyroidism is a partial or complete loss of thyroid function that affects growth, development, and regulation of bodily
functions. Clinical manifestations in affected infants may include dry skin, hoarse cry, or difficulty awakening beginning a few
months after birth. If untreated, intellectual disability may occur.
FLACC scale (face, legs, activity, cry, consolability)
0 1 2
 Frequent to constant
 Normal/usual  Occasional grimace or frown, quivering chin,
expression frown clenched jaw
Face  Smile  Withdrawn or disinterested  Mouth open
 Eyes closed
 Uneasy, restless, tense

 Normal position &  Kicking or legs drawn up
 Intermittent limb
Legs relaxed  Tremors
flexion/extension
 Lying quietly  Squirming, shifting back &  Arching, rigidity, or jerking

 Normal position or forth, tense  Fixed position
Activity moves easily  Pressure on body part  Rubbing body part
 Steady cry, screams, or

 Moans or whimpers
 No cry sobs
Cry  Occasional complaint
 Frequent complaints
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 Easy to console
 Content & relaxed  Difficult to console
Consolability  Distractible
The FLACC scale (face, legs, activity, cry, and consolability) can be used to assess pain in the child who is nonverbal. This
includes assessment for:
 Facial grimacing
 Leg movement, tension, or bending up toward the chest
 Activity, including squirming, arching, jerking
 Crying or moaning
 Difficulty consoling or comforting the child
The nurse will provide teaching on signs that should prompt the parent to administer as-needed pain medication to the child.
(Option 1) A child who is comfortable will usually have a neutral facial expression. A child in pain is likely to exhibit grimacing,
frowning, or clenching of the jaw, based on the FLACC face assessment.
(Option 5) A child who is comfortable will be lying quietly. A child who is squirming and moving is more likely to be in pain, based
on the FLACC activity assessment.
It is difficult to assess for pain in the nonverbal client, particularly if the person is unresponsive at the end of life. The FLACC scale
is an accurate method of assessing pain in the nonverbal child. This tool should be used to teach parents how to promote comfort
for their nonverbal child.
Preschool children (age 3-5) are magical thinkers. Night fears are common during this period, and distinguishing between
reality and fantasy is difficult. It is appropriate for parents to acknowledge the child's fears. A preschooler would be comforted
and fears would be allayed if the parents looked under the bed and reassured the child that no tigers were there (Option 3).
(Option 1) This reply does not educate the parents about normal growth and development. It is not a therapeutic response.
(Option 2) Fantasy fears are normal during the preschool years. They are not common during other developmental periods.
(Option 4) The parents should be told that magical thinking is common during the preschool period. This is not an accurate or
therapeutic response.
Magical thinking is common during the preschool period. It is not unusual for a child to have an imaginary friend, and parents
should be taught that this is a normal part of development. Magical thinking satisfies children's questions about the world they live
in.
Lactational mastitis (infection and inflammation of breast tissue) may result from inadequate milk duct drainage or poor
breastfeeding technique. Bacteria from the infant's nasopharynx or mother's skin can enter the nipple, especially if it is damaged,
and multiply in stagnant milk. Manifestations include fever, muscle aches, and breast pain and inflammation (eg, warmth,
redness, edema).
Staphylococcus aureus is the most common causative organism and requires antibiotic treatment (eg, dicloxacillin, cephalexin).
In addition, the nurse should encourage the client to:
 Continue breastfeeding frequently (ie, every 2-3 hr) to ensure adequate milk drainage.
 Ensure proper breastfeeding technique (eg, alternate newborn feeding positions, proper latch).
 Apply warm compresses and massage the breast to facilitate complete emptying (Option 1). Cool compresses can also
be used between breastfeeding as needed for comfort.
 Ensure adequate rest, nutrition, and hydration (Option 3).
 Relieve pain and inflammation with analgesics compatible with breastfeeding (eg, acetaminophen, ibuprofen) (Option 4).
 Wash hands before and after feeding.
(Option 2) The milk is safe because the newborn is already colonized with maternal microorganisms. Giving pumped or hand-
expressed breast milk is acceptable, although direct breastfeeding is preferred because milk ducts are most efficiently drained with
this method.
(Option 5) Underwire or tight bras are not recommended because milk flow is impeded, which worsens engorgement. Soft,
supportive bras encourage milk flow.
Treatment for lactational mastitis includes antibiotic therapy, continued breastfeeding, breastfeeding support (eg, proper latch
technique), warm compresses, massage, adequate nutrition and hydration, and appropriate analgesics (eg, ibuprofen,
acetaminophen).
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Drug toxicity is common with digoxin due to its narrow therapeutic range. Many contributing factors (eg, hypokalemia) can cause
toxicity. However, in the absence of other factors, potassium does not need to be increased just because a client is on digoxin. If
the client also takes some other potassium-depleting medications, such as diuretics, potassium supplements may be needed.
Signs and symptoms of digoxin toxicity include the following:
1. Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest
symptoms (Option 2)
2. Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion)
3. Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness
4. Cardiac arrhythmias – most dangerous
(Option 1) Drug levels are frequently monitored until a steady state is achieved and when changes are expected, such as in
clients with chronic kidney disease and electrolyte disturbances (eg, hypokalemia, hypomagnesemia).
(Option 3) Digoxin toxicity can result in bradycardia and heart block. Clients are instructed to check their pulse and report to the
HCP if it is low or has skipped beats.
Drug toxicity is common with digoxin due to its narrow therapeutic range. Drug levels are frequently monitored. Nonspecific
gastrointestinal symptoms similar to gastroenteritis are common and can lead to serious cardiac arrhythmias if not recognized.
Subjective, objective & positive signs of pregnancy
Subjective (presumptive) Objective (probable) Positive (diagnostic)
 Uterine & cervical changes

o Goodell sign
o Chadwick sign
o Hegar sign
o Uterine enlargement
 Amenorrhea
 Braxton Hicks contractions  Fetal heartbeat heard with
 Nausea & vomiting
 Ballottement Doppler device
 Urinary frequency
 Fetal outline palpation  Fetal movement palpated by
 Breast tenderness
 Uterine & funic souffle health care provider or
 Quickening
 Skin pigmentation changes visible fetal movements
 Excessive fatigue
o Chloasma  Visualization of fetus by use
o Linea nigra of ultrasound
o Areola darkening
 Striae gravidarum
 Positive pregnancy tests
Subjective (presumptive) signs of pregnancy are self-reported by a client. This client's symptoms could originate from
pathologic causes (eg, urinary tract infection [UTI], sexually transmitted infection), but collectively these symptoms may be
indicative of early pregnancy. Any client with possible signs/symptoms of early pregnancy should be asked about menstrual
history (Option 3).
(Option 1) Regular breast self-exams are an important part of breast self-awareness and may alert the client to early pathologic
breast changes. However, breast tenderness is a common sign of early pregnancy, which should be ruled out first.
(Option 2) Leukorrhea (ie, whitish, mucoid vaginal discharge) increases during pregnancy in response to rising hormone levels.
The client should be questioned about color, odor, and consistency of discharge to rule out infection, but this response from the
nurse does not address the larger picture.
(Option 4) Increased urinary frequency may result from hyperglycemia, and clients with diabetes are at increased risk for
infections (eg, UTI, yeast infection). Reviewing home blood sugar logs would help the nurse assess the client's level of glycemic
control over time but would not address the complete picture of the client's acute symptoms.
Subjective (self-reported) signs of pregnancy may include leukorrhea, breast tenderness, and urinary frequency. Any client with
possible signs/symptoms of early pregnancy should be asked about menstrual history.
Thiazide diuretics (eg, hydrochlorothiazide, chlorthalidone) are prescribed to treat hypertension and edema. The major side
effects of thiazide diuretics include:
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 Hypokalemia - manifests as muscle cramps (Option 3)
 Hyponatremia - manifests as altered mental status and seizures
 Hyperuricemia - may precipitate or worsen gout attacks
 Hyperglycemia - may require adjustment of diabetic medications
Hypokalemia is the most serious side effect of thiazide diuretics as it can lead to life-threatening cardiac dysrhythmias.
(Option 1) Orthostatic hypotension may be a side effect of any diuretic. The nurse should teach the client to sit for a few minutes
before standing and rise slowly. The nurse should also check that the client's blood pressure is not too low.
(Option 2) Mild to moderate hyperglycemia is common with thiazides and needs to be addressed. However, it is not life-
threatening and therefore not a priority.
(Option 4) Most thiazide diuretics are sulfa derivatives and can therefore cause photosensitivity. The nurse should encourage the
client to use sunscreen and wear protective clothing.
The nurse should suspect hypokalemia in the presence of muscle cramps in a client taking diuretics. Hypokalemia can lead to
dangerous ventricular dysrhythmias.
Individuals with paranoid personality disorder have a pervasive distrust and suspicion of others; they believe that people's
motives are malicious and assume that others are out to exploit, harm, or deceive them.
These thoughts permeate every aspect of their lives and interfere with their relationships. Individuals with paranoid personality
disorder are usually difficult to get along with as they may express their suspicion and hostility by arguing, complaining, making
sarcastic comments, or being stubborn. Because these clients do not trust others, they have a strong need to be self-sufficient and
maintain a high degree of control over their environment.
(Option 1) This statement best describes an individual with antisocial personality disorder.
(Option 3) Clients with paranoid personality disorder do not have psychotic symptoms.
(Option 4) Clients with paranoid personality disorder will usually not be able to control their anger when confronted with a real or
imagined threat.
Paranoid personality disorder is characterized by distrust and suspicion of others. Because these clients do not trust other people,
they have an intense need to control them and their environment.
Trichomoniasis is a sexually transmitted infection caused by Trichomonas vaginalis. Infected clients may be asymptomatic but
usually seek care when a profuse, frothy, yellow-green, malodorous vaginal discharge is noted. Pruritus, dysuria, and dyspareunia
(ie, pain during sex) may also occur. Oral metronidazole (Flagyl) is the most common drug used to treat trichomoniasis. Client
education includes:
 Abstain from sexual intercourse until the infection is cleared (ie, about 1 week after treatment) (Option 1).
 Avoid drinking alcohol while taking metronidazole and for 3 days after completion of therapy because the combination
can cause flushing, nausea/vomiting, and severe abdominal pain (Option 2).
 Have partner(s) treated simultaneously to avoid reinfection. Use condoms to prevent the infection in the future (Option
3).
 Know that potential side effects of metronidazole may include a metallic taste, gastrointestinal upset, or dark-colored
urine (Option 4).
(Option 5) Vaginal douching is not recommended as it gets rid of good bacteria and alters the pH of the vagina, increasing the risk
for infection (eg, bacterial vaginosis). Teach the client to cleanse the exterior vulva using only unscented products, wear
breathable undergarments, and report persisting odors/discharge to the health care provider.
Trichomoniasis is a sexually transmitted infection that may cause a frothy, malodorous, yellow-green vaginal discharge.
Appropriate teaching for clients undergoing treatment with oral metronidazole includes avoidance of alcohol, treatment of sexual
partners, abstinence from sexual activity until the symptoms resolve (ie, about 1 week after treatment), and awareness of possible
side effects (eg, dark-colored urine).
Indications & contraindications for influenza vaccination
Live attenuated Indications

intranasal
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 Healthy individuals age 2-49
Contraindications
 Age <2 or ≥50

 Immunosuppressed patients (eg, HIV with CD4+cell
vaccine count <200/mm3) & close contacts
 Chronic cardiovascular, pulmonary, neurologic,
neuromuscular, or metabolic (eg, diabetes, renal
insufficiency) diseases
 History of Guillain-Barré syndrome following previous
influenza immunization
 Pregnant women
 Children/adolescents on long-term aspirin
 Severe allergy to vaccine or its components
Indications
 Individuals age ≥6 months
Inactivated
vaccine Contraindications
 Severe allergy to vaccine or its components
Influenza (flu) is a viral, respiratory illness common during the winter months. Each year, a new influenza vaccine is created to
help protect against specific viral strains. The Centers for Disease Control and Prevention and the Public Health Agency of
Canada recommend that all clients age ≥6 months receive the influenza vaccine annually.
The influenza vaccine is available as an inactivated vaccine (intramuscular/intradermal injection) or as a live-attenuated influenza
vaccine (LAIV; intranasal spray) that contains a weakened form of the live flu virus. The LAIV is safe and effective for most
healthy individuals age 2-49 years to receive, including breastfeeding women (Options 2 and 3).
(Options 1, 4, and 5) There is a remote chance the LAIV may become infectious; therefore, the LAIV is contraindicated in
susceptible populations (eg, immunocompromised; children age <2) and populations with severe potential complications
(eg, pregnancy). For these individuals, the inactivated vaccine is safest.
The live-attenuated, intranasal influenza vaccine is a safe and effective choice for many healthy clients age 2-49 years but should
not be given to clients who are immunocompromised, pregnant, or age <2 years.
The anticoagulant heparin has to be administered intravenously or subcutaneously. The duration is 2-6 hours intravenously and
8-12 hours subcutaneously. It is measured by the aPTT (activated partial thromboplastin time) laboratory
value. Warfarin (Coumadin) is taken orally, with onset/therapeutic effects reached after 2-7 days. It is measured by prothrombin
time (PT) or International Normalized Ratio (INR).
The therapeutic range for aPTT or PT/INR is generally 1.5-2.0 times the control value (up to 3 times the control value at times).
An aPTT value above the therapeutic range places the client at risk for excess bleeding. The heparin administration would need to
be stopped or decreased.
(Option 1) Clients on warfarin must eat the same amount of dark green leafy vegetables because these foods contain vitamin K
and will alter the effects of warfarin. The PT/INR is at therapeutic level so there is no concern related to this client's diet.
(Option 3) The warfarin dose has achieved the therapeutic range for PT/INR and does not need adjustment.
(Option 4) Vitamin K is the antidote for warfarin; the antidote for heparin is protamine sulfate. However, due to the short
half-life of heparin, usually the dose is just held instead of administering an antidote when the values are too high.
The therapeutic effect from heparin or warfarin (Coumadin) is 1.5-2.0 times the control value. Heparin is measured with aPTT and
warfarin is measured with PT/INR. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.
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Heatstroke occurs when excessive environmental heat exposure and/or overexertion (eg, athletics) cause hyperthermia and
depletion of fluid and electrolytes (sweating, increased respirations), specifically sodium. Eventually, hypothalamic
thermoregulation fails and sweat production stops, causing a rapid elevation of core temperature. Symptoms include:
 Temperature ≥104 F (40 C)
 Hot, dry skin
 Hemodynamic instability (tachycardia, hypotension)
 Altered mental status/neurological symptoms (confusion, lethargy, coma)
Risk for permanent neurological injury or death from heatstroke is related directly to the degree and duration of hyperthermia.
Treatment involves stabilization of ABCs and rapid cooling interventions (eg, cool water immersion, cool IV fluid infusion).
Antipyretics are ineffective as hyperthermia is unrelated to the inflammatory process (infection).
(Option 1) Epinephrine auto-injectors (eg, EpiPen) for emergency treatment of allergic reactions can be accidentally injected,
potentially causing adverse effects related to adrenergic activation (eg, tachycardia and hypertension). This client requires
monitoring and supportive care (eg, antihypertensive medications).
(Option 2) A child with vaginal lacerations requires evaluation for possible sexual abuse (ie, physical examination, evidence
collection, mandatory reporting). This client needs treatment but is not the priority.
(Option 3) An abscess requires treatment with antibiotics and, possibly, surgical intervention. However, this client is presently
stable and not the priority.
Heatstroke is a medical emergency characterized by a body temperature ≥104 F (40 C); hot, dry skin; tachycardia and
hypotension; altered mental status; and neurological dysfunction. Clients require rapid cooling interventions to decrease the risk of
permanent neurological injury or death.
Leakage of more than 500 mL of air into a central venous catheter is potentially fatal. An air embolism in the small pulmonary
capillaries obstructs blood circulation. A central venous catheter leaks air rapidly at 100 mL/sec. This client requires immediate
intervention to prevent further complications (eg, cardiac arrest, death). The nurse should not delay emergency treatment, not
even to stop and contact the HCP or the rapid response team (RRT).
Priority interventions for active or suspected air embolism are as follows:
1. Clamp the catheter to prevent more air from embolizing into the venous circulation.
2. Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the
right atrium.
3. Administer oxygen if necessary to relieve dyspnea.
4. Notify the HCP or call an RRT to provide further resuscitation measures.
5. Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the
bloodstream over the course of a few hours.
Any delay in treatment of an air embolism could prove fatal. There is no time to call the HCP. Seal off the source of the leak, and
ensure stabilization of the air bubble via left lateral positioning.
Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorten the duration and
severity of active lesions. Genital herpes is a sexually transmitted infection caused by a herpes simplex virus and is highly
contagious, especially when lesions are active. It remains dormant in the body even when active lesions are healed. There is no
cure for genital herpes; treatment is aimed at relieving symptoms and preventing the spread of infection. Touching the lesions and
then rubbing or scratching another part of the body can spread the infection. Therefore, gloves should be used when applying
topical antiviral or analgesic (eg, lidocaine) medications.
(Option 1) Herpetic lesions should be kept clean and dry. They can be cleansed with warm water and soap or other solutions.
Bandages are not applied to the lesions.
(Option 2) There is no cure for herpes infection. Genital herpes often leads to local recurrence. Some clients may need long-
term suppressive therapy.
(Option 3) During periods of active lesions, abstinence from sexual intercourse is indicated. Condoms should be used during
periods of dormancy due to viral shedding.
Clients should be taught to use gloves when applying topical medication to herpes lesions to avoid the spread of infection. There
is no cure for genital herpes infection; recurrences are common. Complete abstinence from sexual intercourse is recommended
when active lesions are present as barrier contraception alone is insufficient to prevent the spread of infection.
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Skin cancers are most often caused by damage to the skin's DNA. This damage is typically due to exposure to ultraviolet (UV)
radiation, primarily from the sun but also from other sources (eg, tanning beds, sunlamps). The instructions to prevent sunburn
and other sun-related damage include:
 Avoid the sun, if possible, especially between 10 AM and 4 PM. UV rays are not blocked by cloud coverage and can be
reflected off water, sand, snow, and concrete. As a result, clients can burn in the shade or even during outdoor winter
activities (eg, skiing) (Option 4).
 Wear protective clothing (eg, long sleeves, wide-brimmed hats, umbrellas) when possible.
 Apply sunscreen:
o Use a broad-spectrum sunscreen to block both UVA and UVB rays.
o Choose a sunscreen with SPF ≥15 for daily use or SPF ≥30 for outdoor activities and sun-sensitive
individuals. Sunscreen should be applied 15-30 minutes prior to sun exposure to allow the formation of a
protective film on the skin. Regardless of the type of sunscreen used, it should be reapplied at least every 2
hours, or more often if possible (Options 1 and 2).
o Because sunscreen is washed off with swimming and sweating, it should be reapplied, even for products labeled
"water-resistant" or "very water-resistant" (Option 3).
 Avoid the use of tanning beds as they emit UV radiation (Option 5).
To prevent sunburn, instruct clients to avoid sun exposure from 10 AM to 4 PM, wear protective clothing, use sunscreen properly
(daily application; minimum SPF of 15-30; 15-30 minutes before going outside; reapplication when wet and every 2 hours), and
avoid non-solar exposure to ultraviolet radiation (eg, tanning beds, sunlamps).
The UAP has the skills and knowledge to perform standard procedures to prevent immobility hazards for a client in traction (eg,
pneumonia, pressure ulcers, foot drop, thromboembolism). When providing care for a stable client, the RN can safely delegate
these tasks to the UAP:
 Assist with active and passive ROM exercises after the client has been taught how to perform them by the RN or
physical therapist (Option 1)
 Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity
 Remind the client to use the incentive spirometer after the client has been taught proper use by the RN or respiratory
therapist (Option 4)
 Maintain proper use of pneumatic compression devices (Option 5)
 Remind the client to move frequently using the overhead trapeze
(Option 2) The UAP changes the linens from the top to the bottom of the bed with assistance; clients are instructed to lift
themselves using the overhead trapeze. This approach maintains immobilization of the injured extremity. Logrolling the client will
require multiple staff members, including one person to stabilize weights.
(Option 3) The RN is responsible for peripheral circulation, neurovascular, and skin assessments.
To prevent immobility hazards for a client in skeletal traction, the RN can delegate the following tasks to the UAP:
 Assist with active and passive ROM exercises

 Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity
 Remind the client to use the incentive spirometer
 Maintain proper use of pneumatic compression devices
Many health care professionals react to an emergency situation automatically. However, some states and provinces will
further penalize health care workers with loss of their professional license if they fail to render cardiopulmonary
resuscitation in an emergency situation.
 Health care professionals will not be penalized for an honest mistake. However, resuscitation must end immediately after
they are notified of the error (Option 1).
 (Option 2) Continuing treatment until the code status is verified with the health care provider (HCP) constitutes
malpractice. Before a do not resuscitate prescription can be posted in a client's medical record/chart, the HCP must
provide documentation that the client's code status has been established through consultation with the client or family.
 (Options 3 and 4) Gross negligence of a client's advance directive can result in legal action.
 Educational objective:
Failure to stop an erroneous code on a client with an advance directive in a timely fashion may result in legal action.
Thyroid storm is a serious and potentially life-threatening emergency for clients with Graves disease. This condition occurs
when the thyroid gland releases large amounts of thyroid hormone in response to stress (eg, trauma, surgery, infection).
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Characteristic features include tachycardia, hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up to 104-106 F (40-
41 C). Other findings include severe nausea, vomiting, anxiety, altered mentation, and seizures.
(Option 2) Heat intolerance is an expected symptom in hyperthyroidism, including Graves disease.
(Option 3) Tachycardia and arrhythmias (eg, atrial fibrillation) are commonly seen with hyperthyroidism of any cause, including
Graves disease. These alone cannot differentiate whether the client has simple hyperthyroidism or life-threatening thyroid storm.
(Option 4) Exophthalmos (protruding eyeball) is commonly seen in Graves disease. The eyelids do not close over the eyeballs
properly, leading to excessive dryness and resultant corneal damage (exposure keratitis). Although it is important to treat
exophthalmos, it is not immediately life-threatening.
Thyroid storm is a life-threatening complication of Graves disease. Fever, altered mentation, and excess autonomic activity (eg,
severe hypertension, tachycardia) are common. Early recognition and treatment are crucial.
A gastroduodenostomy (Billroth I) involves removing the distal two-thirds of the stomach with anastomosis of the remaining
stomach to the duodenum. Following partial gastrectomy, clients should remain NPO until bowel sounds return (Option 3). Once
tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome (ie, rapid emptying of
stomach contents into the small intestine).
Postoperative clients are at risk for developing venous thromboembolism (VTE) due to reduced mobility levels and require VTE
prophylaxis (eg, sequential compression devices, compression hose) (Option 1). Clients are also at risk for hypoventilation and
respiratory compromise due to sedation, pain, and immobility. Encourage clients to turn, cough, and deep breathe while splinting
the surgical site to prevent development of atelectasis (Option 2).
(Option 4) In the postoperative period, the nurse should elevate the head of the bed to improve ventilation and reduce the risk of
aspiration. Only clients who experience dumping syndrome should lay supine for a short period after eating.
(Option 5) Clients may have a nasogastric tube postoperatively for gastric decompression. Clogged nasogastric tubes should
be reported to the surgeon. Attempting to manipulate or flush the device may disrupt the surgical site, causing hemorrhage or
gastric perforation.
Postoperative care of a client with gastroduodenostomy includes initiation of thromboembolism prophylaxis; turning, coughing, and
deep breathing; and aspiration precautions (eg, elevating the head of the bed). The nurse should keep clients NPO until bowel
sounds return and should not manipulate clogged nasogastric tubes.
To prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing up and down
any stairs. Clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the
direction. Clients must also keep 2 points of support on the floor at all times (ie, both feet, foot and cane).
When descending stairs, the client should:
1. Lead with the cane

2. Bring the weaker leg down next (in this client, it is the left leg)
3. Finally, step down with the stronger leg (Option 1)
When ascending stairs, the client should:
1. Step up with the stronger leg first

2. Move the cane next, while bearing weight on the stronger leg
3. Finally, move the weaker leg
To remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves before the
weaker leg.
(Options 2, 3, and 4) These options do not provide enough support to the weaker leg when descending.
To prevent falls when descending the stairs using a cane, the client should lead with the cane, follow with the weaker leg, and then
step down with the stronger leg.
Chemical restraints are medications (eg, benzodiazepines, psychotropics) used to restrict freedom of movement or to control
socially disruptive behavior in clients who have no medical indications for them.
Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard treatment for
a client with a history of falls who keeps getting out of bed without assistance. The least restrictive method to ensure client safety
(eg, bed alarm, sitter, assistive devices) should be tried first before administering a chemical restraint. Therefore, the nurse
should question the prescription for haloperidol (Haldol) in this client (Option 1).
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(Option 2) Benzodiazepines (eg, lorazepam [Ativan], diazepam, chlordiazepoxide) are considered standard treatment to control
agitation in the client in alcohol withdrawal.
(Option 3) Antipsychotics (eg, olanzapine [Zyprexa], ziprasidone [Geodon], haloperidol) are considered standard treatment to
control violent behavior in the client with schizophrenia.
(Option 4) Propofol (Diprivan) is considered standard treatment to sedate the client receiving mechanical ventilation to provide
ventilator control, prevent accidental extubation, and promote comfort.
Medications that are standard treatments for specific conditions (eg, alcohol withdrawal, schizophrenia, mechanical ventilation) are
not considered chemical restraints. The nurse should question a chemical restraint prescription that may not be medically
necessary for a client's safety.
When administering subcutaneous anticoagulant injections (eg, heparin, enoxaparin), the nurse must select the appropriate
needle length and angle to avoid accidental intramuscular injection, especially in clients with insufficient adipose tissue (eg,
cachexia). Intramuscular injection of heparin would cause rapid absorption, resulting in a hematoma and painful muscle irritation.
The nurse should administer subcutaneous injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped, or at 45
degrees if only 1 in (2.5 cm) can be grasped (Option 2). Anticoagulants are best absorbed if administered in the abdomen at least
2 in (5 cm) away from the umbilicus.
(Option 1) A 15-degree angle is used for intradermal injections and would not deliver medication into the subcutaneous tissue.
(Option 3) A 90-degree injection angle is appropriate for clients with sufficient adipose tissue (ie, at least 2 in [5 cm] can be
grasped).
(Option 4) Needles longer than 5⁄8 in (1.6 cm) are used to administer intramuscular injections.
Anticoagulant injections should be administered in the abdominal subcutaneous tissue at a 45- to 90-degree angle. A 45-degree
angle is used for clients with minimal adipose tissue to avoid accidental intramuscular injection, which would cause rapid
absorption and result in hematoma and painful muscle irritation.
With procedural moderate sedation at the bedside, the nurse takes on the role of an anesthetist. The nurse's role is to monitor the
client's condition while the health care provider focuses on performing the procedure. The nurse should never leave the client
during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of
the client next door.
(Option 1) This action would place the UAP in the role of assessing and prioritizing, which is beyond the scope of the UAP's
practice. In addition, the nurse must stay in the room and cannot meet the other client's need as a result.
(Option 2) Taking on the role of assessing/monitoring (related to anesthesia) and/or administering additional intravenous drugs
during the procedure is beyond the scope of the UAP's practice.
(Option 3) The UAP has already communicated that the client’s need is urgent. The client should not be kept waiting without
further assessment to evaluate the situation.
The nurse takes on the role of anesthetist when assisting with bedside procedural moderate sedation and cannot leave the client
during the procedure.
The preferred site for venipuncture when collecting blood specimens is the antecubital fossa's median cubital vein. The basilic vein
lies close to the brachial nerve and artery. When severe, shooting pain radiates down a client's arm during venipuncture, nerve
injury may be occurring. The client may also report feelings of "pins and needles" or numbness at and/or near the venipuncture
site. If this occurs, the nurse should promptly withdraw the needle, obtain new equipment, and choose a different site for
specimen collection (Option 4).
The presence of pain and feelings of "pins and needles" during venipuncture may indicate nerve pain and require prompt cessation
of the attempt. The nurse should withdraw the needle, obtain new equipment, and choose a different site for the specimen
collection.
When clients must be housed together in less than ideal circumstances, those infected with the same causative pathogens can be
placed together. However, a client who is infectious should not be placed with an immunosuppressed client (eg, on
steroids/chemotherapy, HIV positive, new post-operative, multiple chronic co-morbidities, splenectomy, diabetes, very
young/elderly).
Every client in the hospital is on universal precautions; therefore, there should be no concern about placing a vulnerable post-
operative client in the same room where standard precautions are being taken for another client. In a disaster setting, clients of
different age groups can be placed in the same room together so long as both are stable and noninfectious (even if this is not
socially acceptable).
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(Option 1) Though both clients are on contact isolation, they are infected with different organisms and this places them at risk for
cross-infection.
(Option 3) By around age 4, clients with sickle cell disease have some level of immunosuppression as their spleens are
dysfunctional due to infarctions from the sickling episodes. The spleen then fails to carry out protective phagocytosis, especially to
encapsulated bacteria (eg, streptococcus pneumoniae).
Clients infected with different organisms cannot be placed together in the same room (due to risk of cross-infection). An infectious
client should not be housed with an immunocompromised one.
Developmental dysplasia of the hip (DDH) is instability or dislocation of the hip joint that may be present at birth or develop
during the first few years of life. Nonsurgical treatment methods, such as a harness or cast, are most successful when initiated
during the first 6 months of life. After this time, surgery is frequently required.
A Pavlik harness, the most common tool used in treating early DDH, maintains the infant's hips in a slightly flexed and
abducted position, allowing for proper hip development. Pavlik harnesses are typically worn for about 3-5 months or until the hip
joint is stable. The straps are adjusted periodically by the health care provider to account for infant growth.
Instructions on care for the infant wearing a Pavlik harness are as follows:
 Regularly assess skin for redness or breakdown under the straps

 Dress the child in a shirt and knee socks under the harness to protect the skin (Option 2)
 Avoid lotions and powders to prevent irritation and excess moisture (Option 1)
 Lightly massage the skin under the straps every day to promote circulation (Option 3)
 Only apply 1 diaper at a time as wearing ≥2 diapers (previous treatment practice) increases risk of incorrect hip
placement
 Apply diapers underneath the straps to keep harness clean and dry (Option 4)
(Option 5) The Pavlik harness is usually worn all the time, particularly during the first few weeks of treatment. Some providers
may allow the harness to be removed for a short bath once a day, but it should be left in place for all other care activities, including
diaper changes.
The Pavlik harness maintains the infant's hips in a slightly flexed and abducted position to allow for proper joint development. Care
of the infant with a harness includes dressing the child in a shirt and knee socks, keeping the skin dry, regularly assessing for skin
breakdown, massaging the skin to promote circulation, and applying diapers under the straps.
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is often caused by the ectopic production of ADH by a
malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which
results in dilutional hyponatremia. Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium
drops below 120 mEq/L (120 mmol/L) (normal: 135-145 mEq/L [135-145 mmol/L]). Therefore, hyponatremia is the highest priority
to report as it poses the greatest threat to survival. Hyponatremia requires immediate evaluation and treatment (eg, seizure
precautions, fluid restriction, intravenous hypertonic saline) by the health care provider.
(Option 1) Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a protein formed in the liver. Hepatocytes lose the ability to synthesize
albumin when the cells are diseased. Hypoalbuminemia (<3.5 g/dL [<35 g/L]) should be expected in this client.
(Option 2) B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is a substance secreted from the cardiac ventricles
in response to increases in ventricular pressures and volume. Therefore, BNP is a marker for heart failure and is elevated in
clients with both stable and decompensated heart failure. BNP is an expected finding in this client.
(Option 3) Clients in alcohol withdrawal usually require magnesium supplements. Hypomagnesemia (<1.5 mEq/L [<0.75 mmol/L])
results from poor dietary intake, malnutrition, and increased renal excretion, and is common in clients with chronic alcoholism. This
finding is within normal limits (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]).
Malignant lung tumors are a common cause of syndrome of inappropriate antidiuretic hormone secretion (SIADH). When serum
sodium drops below 120 mEq/L (120 mmol/L), immediate intervention is necessary to prevent severe neurologic dysfunction. Fluid
restriction is recommended for clients with SIADH.
Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition commonly caused by

bleeding gastroesophageal varices or peptic ulcers. Gastroesophageal varices are distended, fragile blood vessels within the
stomach and/or esophagus that frequently occur secondary to cirrhosis. Due to the fragility of these veins, clients are closely
monitored for variceal rupture. Rupture of gastroesophageal varices is an emergency complication that rapidly results
in massive gastrointestinal bleeding, hypovolemic shock, and death.
Variceal rupture commonly occurs due to a sudden increase in portal venous pressure (eg, coughing, straining, vomiting) and
from mechanical injury (eg, chest trauma, consuming sharp/hard foods). In UGIB, nasogastric tube insertion may be prescribed
for gastric decompression or evacuation. However, nasogastric tube insertion without visualization of the esophagus
may traumatize and rupture varices, causing hemorrhage (Option 3).
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(Option 1) Pantoprazole is prescribed for clients with UGIB to reduce gastric acid secretion and help prevent ulceration of the
gastric mucosa.
(Option 2) Octreotide may be used to help control UGIB related to bleeding gastroesophageal varices, as it reduces portal venous
pressure, which reduces bleeding.
(Option 4) NPO status may be prescribed in cases of UGIB to prepare the client for invasive diagnostic or therapeutic procedures
(eg, esophagogastroduodenoscopy, variceal ligation).
Gastroesophageal varix rupture/hemorrhage is a potentially lethal complication of cirrhosis that may occur from increased portal
venous pressure (eg, coughing) and mechanical injury (eg, nasogastric tube insertion). The nurse should question prescriptions
for activities that increase the risk of such rupture.
Warfarin (Coumadin) is an anticoagulant given to clients with a mechanical valve replacement. To determine if the client is
receiving an appropriate dose, the INR needs to be checked regularly. A therapeutic INR for a client with a mechanical heart
valve is 2.5-3.5. The nurse should not administer warfarin without checking the INR first. If the INR is >3.5, the nurse should hold
the dose and contact the health care provider for further direction.
(Option 1) Although the nurse should assess the client's potassium level prior to administering supplemental potassium, this
medication was scheduled at 0900 and is not indicated at this time. There is no pharmacologic interaction between potassium
levels and warfarin.
(Option 3) The client's vital signs should be measured routinely, but administration of warfarin and simvastatin are not contingent
on the results.
(Option 4) Verification of the client's name and date of birth is an important safety measure that should be performed at the
bedside, immediately before medication administration.
The nurse should check the client's most recent INR level prior to administering warfarin. A therapeutic INR is 2.5-3.5 for clients
with mechanical heart valves. The nurse should hold the dose and contact the health care provider if the INR is >3.5.
Negative-pressure wound therapy is the application of negative pressure to a wound to enhance bacteria and exudate removal.
Negative pressure promotes healing by stimulating cell growth and vessel perfusion in the wound bed.
Medications are administered preprocedure to prevent discomfort (Option 1). After wound cleansing, a skin protectant is applied
around the wound to prevent breakdown and promote an air-tight seal (Option 2). A sterile foam dressing is cut to fit the wound
shape and size and is placed in the wound bed. An occlusive dressing large enough to extend 1.2-2 inches (3-5 cm) beyond the
wound edges is applied to create a seal. Then a vacuum-assisted closure unit is connected to create negative pressure. The
foam dressing should compress when the device is turned on, indicating a proper seal and functioning equipment (Option 5).
(Option 3) The foam dressing is placed using sterile, not clean, technique to prevent wound contamination.
(Option 4) The foam dressing is cut to the size of the wound bed but is never cut directly over it because material can fall into the
wound or injure the client.
Negative-pressure wound therapy promotes wound healing, cell growth, and vessel perfusion. This sterile procedure creates
negative pressure through a sealed dressing and vacuum-assisted closure unit. The foam dressing should not be cut directly over
the wound site.
Fetal movement is a sign of fetal health and indicates an intact fetal central nervous system. Fetal movement may occur
numerous times per hour during the last trimester of pregnancy, although the client may not perceive every movement. Multiple
factors (eg, maternal substance abuse, medications, fasting, fetal sleep) can affect fetal movement. However, fetal movements
should not decrease as the fetus increases in size.
Decreased fetal movement is a potential warning sign of fetal compromise (ie, impaired oxygenation), which may precede fetal
death (Option 2). The nurse prioritizes assessment of client reports of decreased fetal movement to evaluate fetal well-being (eg,
nonstress test).
(Option 1) Leg cramps commonly occur in the third trimester, especially at night, due to the weight of the gravid uterus applying
pressure to nerves affecting calf muscles. Home interventions include stretching legs, massaging calves, and increasing fluid
intake.
(Option 3) Dependent edema in the lower extremities is common in the third trimester due to decreased venous return (gravid
uterus pressure on vena cava), especially with prolonged sitting/standing. This is not a priority over decreased fetal movement.
(Option 4) As the uterus rises in the third trimester, the diaphragm is prevented from allowing full lung expansion, causing
dyspnea, especially with exertion.
Fetal movement is a sign of fetal health and represents an intact fetal central nervous system. The nurse should educate clients
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that fetal movements do not decrease in the late third trimester and prioritize assessment of clients reporting decreased fetal
movement.
Polycythemia vera (PV) is a chronic disorder of the bone marrow in which too many red blood cells, white cells, and platelets
are produced. Clients with PV are at risk of developing blood clots due to increased blood volume and viscosity. Clients are
instructed to elevate the legs and feet when sitting, wear support stockings, and report signs of thrombosis (eg, swelling and
tenderness in the legs). Adequate fluid intake during exercise and hot weather is important to reduce fluid loss and decrease
viscosity (Options 1, 3, and 5).
(Option 2) Increasing intake of iron-containing foods and supplements can further increase hemoglobin production and is not
recommended. Clients with PV need periodic phlebotomy to remove excess blood.
(Option 4) Itching is a common and frustrating symptom of PV. Reducing water temperature, using starch baths, and patting the
skin dry rather than rubbing vigorously are beneficial.
Clients with polycythemia vera are at risk of developing thrombosis and should be taught preventive measures (eg, elevating the
legs when sitting) and symptoms to report. They should take measures to prevent dehydration, and avoid iron-rich foods and hot
showers/baths.
The client with atrial fibrillation is at increased risk for the development of atrial thrombi due to blood stasis, which can embolize
and lead to an ischemic brain attack. The INR (normal 0.75-1.25) is a measurement used to assess and monitor coagulation
status in clients receiving anticoagulation therapy. The therapeutic INR level for a client receiving warfarin (Coumadin) to treat
atrial fibrillation is 2-3. The subtherapeutic INR of 1.3 is the most important result to report to the health care provider (HCP) as the
client is at increased risk for a stroke and dose adjustment is needed.
(Option 2) A client with chronic obstructive pulmonary disease and chronic bronchitis has chronic alveolar hypoxia, which
stimulates erythropoiesis (red blood cell production) and leads to polycythemia (hematocrit >53% [0.53] in males, >46% [0.46] in
females; hemoglobin >17.5 g/dL [175 g/L] in males, >16 g/dL [160 g/L] in females). Increased hematocrit and hemoglobin are
expected in this client and are not the most important results to report to the HCP.
(Option 3) Leukocytosis (white blood cells >11,000/mm3 [11 × 109/L]) is expected in a client with C difficile infection and is not the
most important result to report to the HCP.
(Option 4) A client receiving gentamycin, a nephrotoxic drug, has a normal creatinine level (0.6-1.3 mg/dL [53-115 µmol/L), which
is not the most important result to report to the HCP.
The therapeutic INR range is 2-3 for a client receiving warfarin to treat atrial fibrillation. Subtherapeutic INR increases the risk for
atrial thrombus formation, with subsequent embolization and stroke. Excess anticoagulation (INR >3-4) increases the risk for
bleeding.
Cystic fibrosis (CF) is a genetic disorder involving the cells lining the respiratory, gastrointestinal (GI), and reproductive tracts. A
defective protein responsible for transporting sodium and chloride causes secretions in these areas to be thicker and stickier than
normal.
These abnormal secretions plug smaller airway passages and ducts in the GI tract, which can impair digestive enzymes and result
in ineffective absorption of essential nutrients. These sticky respiratory secretions lead to a chronic cough and inability to clear
the airway, eventually causing chronic lung disease (bronchiectasis). As a result of these changes, the client's life span is
shortened; most affected individuals live only into their 30s.
Chest physiotherapy helps remove sticky secretions that cause ineffective airway clearance (Option 2). Aerobic exercise is
beneficial to promote removal of airway secretions, improve muscle strength, and increase lung capacity (Option 1). Financial
needs must be discussed, as clients with CF have a large financial burden due to health care costs, medications, and special
equipment (Option 3).
(Option 4) A diet high in fat and calories is recommended due to defective digestive enzymes and impaired nutrient absorption.
(Option 5) Fluids are not restricted; liberal intake is recommended to assist in thinning respiratory secretions.
Clients with cystic fibrosis should have a diet high in fat and calories to combat nutrient malabsorption. Liberal fluid intake is
encouraged to loosen thick secretions. Chest physiotherapy and aerobic exercise are performed to remove airway secretions.
Financial needs are addressed as clients have a large financial burden.
Rheumatoid arthritis (RA) is a chronic, relapsing autoimmune disorder causing painful inflammation of synovial joints and

fibrosis and stiffening of synovial membranes. Contracture of ligaments and joint remodeling may occur, resulting in weakness
and deformity. Clients with RA require education on prevention of disease progression, including:
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 Joint protection – Fibrosis from RA can shorten tendons and ligaments when joints are flexed for prolonged periods.
Body aligners or immobilizers should be used when resting to keep extremities straight (especially with advanced
disease).
 Medications – RA is often treated using a regimen of disease-modifying antirheumatic drugs (eg, methotrexate), and
clients should take their medication as prescribed regardless of symptoms (Option 3).
(Option 1) Joint deformity can be prevented with appropriate treatment, including use of disease-modifying antirheumatic drugs
and joint protection.
(Option 2) Obesity is a risk factor for osteoarthritis, in which mechanical erosion of joint cartilage occurs. However, obesity is
unrelated to RA, and clients with RA experience chronic fatigue and pain that may limit oral intake and cause weight loss. The
nurse should ensure that clients with RA have access to adequate nutrition.
(Option 4) During painful episodes, periods of rest are encouraged; however, clients should frequently perform range of motion
exercises to prevent loss of function.
Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes pain and joint deformity. Clients with RA should be taught
to remain active to prevent contracture, take immunosuppressant medications consistently, use body aligners to prevent joint
contracture, and eat a balanced diet.
Polycythemia vera (PV) is a chronic myeloproliferative disorder in which the bone marrow produces an abnormally high number
of RBCs. Although PV is an abnormality of the bone marrow, secondary polycythemia can occur in an individual with chronic
hypoxemia, such as chronic obstructive pulmonary disease or chronic lung disease. The danger of PV is seen when the client
develops blood clots—due to the increased viscosity of the blood, which makes the circulation sluggish—and decreased tissue
perfusion.
Treatment of PV usually includes periodic phlebotomy, the removal of 300-500 mL of blood through venipuncture, to reduce the
RBC count and achieve a hematocrit <45%. Initially, clients may require phlebotomy every other day until the goal hematocrit is
reached. Hematocrit is then monitored monthly, and additional blood draws are performed as necessary.
(Option 1) A blood transfusion is contraindicated in a client with PV because this would have the opposite of the desired effect,
further increasing the RBC count and clotting.
(Option 2) Although an IV fluid bolus may be helpful in the short term to reduce blood viscosity, it is not a maintenance treatment
for PV. Instead, the client should be encouraged to drink >3 L of fluid daily and avoid dehydration.
(Option 4) Steroid injections are not typically used to treat PV.
A client with polycythemia vera requires periodic therapeutic phlebotomy treatments to reduce the RBC count and risk of blood
clotting associated with increased blood viscosity.
Anti-embolism stockings are part of venous thromboembolism (VTE) prophylaxis in hospitalized clients. Anti-embolism
stockings improve blood circulation in the leg veins by applying graduated compression. When fitted properly and worn
consistently, the stockings decrease VTE risk. The stockings should not be rolled down, folded down, cut, or altered in any
way. If stockings are not fitted and worn correctly, venous return can actually be impeded.
(Option 1) Anti-embolism stockings should be applied before ambulating while the client is in bed; this maximizes the
compression effects of the stockings and promotes venous return. The UAP has performed this correctly.
(Option 2) Wrinkles should be smoothed out to avoid impeding venous return. The UAP has performed this correctly.
(Option 3) The toe opening should be located on the plantar side of the foot/under the toes. The UAP has performed this
correctly.
Anti-embolism stockings are worn by clients as part of VTE prophylaxis. It is important that the nurse verifies the stockings are
correctly fitted and worn appropriately. Incorrect size and fit or alterations to the stockings can impede venous return.
Sexual counseling is important for cardiac clients, yet can be difficult for clients and HCPs to discuss and is often neglected.
Clients' concern about resumption of sexual activity can prove to be more stressful than would be the activity itself. The nurse
should encourage clients to discuss concerns with the HCP; in general, if a client can walk 1 block or climb 2 flights of
stairs without symptoms, the client can resume sexual activity safely.
(Option 2) The use of erectile agents is contraindicated if the client is consuming any form of nitrates.
(Option 3) Resumption of sexual activity depends on the emotional readiness of the client and the client's partner and on the
HCP's assessment of recovery. In general, it is safe to resume sexual activity 7-10 days after an uncomplicated MI.
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(Option 4) The client may participate in cardiac rehabilitation, but this should not impact the ability to engage in sexual activity,
especially if the client remains asymptomatic.
It is important to educate clients and their partners about sexual activity after an MI. Generally, it is safe for clients to consider
resumption of sexual activity when they can walk 1 block or climb 2 flights of stairs without symptoms.
In a traumatic, or "open," pneumothorax, air rushes in through the wound with each inspiration, creating a sucking sound, and
fills the pleural space. The lungs cannot expand, so the client develops respiratory distress and air hunger. Tachycardia and
hypotension result from impaired venous return, as the heart and great vessels shift with each breath. A tension pneumothorax
may also develop if air cannot escape the pleural space. The priority action in this medical emergency is to apply a sterile
occlusive dressing (eg, petroleum gauze) taped on three sides, preventing inward air flow while allowing air to escape the pleural
space.
(Option 1) This client's tachycardia and hypotension are likely related to pneumothorax and should improve once the
pneumothorax is resolved; administering fluids alone would not help if the pneumothorax continues to worsen. Fluids are given to
treat blood loss hypotension, but this should not be the first step in this case.
(Option 2) Supplemental oxygen should be applied as needed after covering the wound. If possible, correcting the underlying
cause is always a priority over treating manifestations.
(Option 3) After covering the wound, chest tube placement is usually performed to evacuate air and blood from the pleural cavity.
The client may need more than one chest tube to evacuate both air (placed higher) and fluid or blood (placed lower).
A sucking chest wound indicates a traumatic, or "open," pneumothorax and is a medical emergency. Respiratory distress results
from inability to expand the lung. The priority action is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three
sides.
The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to
specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side
and cause lymphedemaor other complications such as infection, venous thromboembolism, or trauma to the affected arm. The
nurse must avoid any needlesticks, IV insertions, or blood pressure measurements in the affected arm (Options 1 and 4).
The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best
because the client had a left-sided mastectomy (Option 3). Other considerations when selecting IV sites include avoidance of
areas that have obstructed blood flow, dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with
skin conditions or signs of infection.
(Option 2) The antecubital space should be avoided when possible (except for emergency insertion) as it inhibits mobility and may
be positional.
The nurse should review the client's medical record and assess for contraindications to IV sites, including impaired lymphatic
drainage (prior mastectomy), arteriovenous fistula or graft (used for hemodialysis), and areas distal to old puncture sites.
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MIDCAB does not involve a sternotomy incision or placement on cardiopulmonary bypass. Several small incisions are made
between the ribs. A thoracotomy scope or robot is used to dissect the internal mammary artery (IMA) that is used as a bypass
graft. Radial artery or saphenous veins may be used if the IMA is not available.
Recovery time is typically shorter with these procedures and clients are able to resume activities sooner than with traditional open
chest coronary artery bypass graft surgery. However, clients may report higher levels of pain with MIDCAB due to the thoracotomy
incisions made between the ribs.
(Option 1) The client may need pain medication, but this response does not answer the initial question. The nurse should first
answer the client's question, then assess if pain medication is necessary.
(Option 2) Before calling the HCP for an increase in dosage, the nurse should assess the client's pain level and if pain medication
has been effective. However, this should be done after answering the client's question.
(Option 3) The client needs to move, cough, breathe deeply, splint the chest, and use the incentive spirometer. However, the
client is asking the nurse a question that should be addressed before reinforcing these teachings.
The nurse should teach the client that incisional pain from thoracotomy incisions between the ribs may be very painful after
MIDCAB surgery. The nurse should encourage the client to take pain medication before the pain is too intense. The client should
also be instructed to cough, breathe deeply while splinting the chest with a pillow, and use the incentive spirometer routinely to
reduce the incidence of postop complications.
The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to
palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a
positive modified Allen's test.
The modified Allen's test includes the following steps:
 Instruct the client to make a tight fist (if possible)

 Occlude the radial and ulnar arteries using firm pressure
 Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded
 Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the
hand, indicating patency of the ulnar artery (positive Allen's test)
If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an
alternate site (eg, brachial artery, femoral artery) must be used.
(Option 1) Capillary refill is tested by applying pressure to the fingernail bed to cause blanching. If refill is adequate, the nail bed
should become pink in less than 3 seconds after pressure is released.
(Option 2) The radial artery is palpated with the fingertips to determine the presence of the radial pulse.
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(Option 4) A neurologic deficit is assessed by monitoring color, sensation, and movement of the hand.
The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to
palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by
performing a modified Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas
collection.
Under the Health Insurance Portability and Accountability Act (HIPAA) and the Personal Information Protection and Electronic
Documents Act (PIPEDA), a client's information regarding medical treatment is private and cannot be released without the client's
permission. There must be a reasonable effort to limit the use of, disclosure of, and requests for protected health information (PHI)
to the minimum necessary to accomplish the intended purpose.
The client's PHI should not be shared with a partner or spouse without the client's permission (Option 3).
PHI is shared with an employee on a "need-to-know" basis. A transporting employee does not need to know the client's diagnosis,
only information related to positioning/transferring or personal protective equipment (for infection precautions), if applicable (Option
4).
(Option 1) A client overhearing report through a privacy curtain is inadvertent communication and is not considered a violation.
(Option 2) Calling a client by the first and last names in the waiting room is not a violation as long as no other pertinent
information is given.
(Option 5) Any employee can provide socially acceptable well wishes to a client. This does not involve PHI.
The Health Insurance Portability and Accountability Act and the Personal Information Protection and Electronic Documents Act
requirements related to protected health information include not giving results to a spouse without permission or telling a client
diagnosis to an employee who does not need to know it. It is not a violation to call clients by their names, have information
overheard inadvertently, or indicate well wishes.
Impaired gas exchange is a deficit in oxygenation and/or elimination of carbon dioxide at the alveolar-capillary membrane.
Impaired gas exchange related to a bacterial infectious process as evidenced by shortness of breath and tachypnea is an
appropriate ND for a client with pneumococcal pneumonia.
(Option 2) Impaired spontaneous ventilation is the inability to maintain independent ventilation to support life and requires
mechanical ventilation. Based on this client's assessment data, it is not an appropriate ND.
(Option 3) This client is demonstrating an ineffective breathing pattern; however, this problem is secondary to impaired gas
exchange. An increased respiratory rate is the body's attempt to compensate for hypoxia caused by consolidations and
secretions preventing adequate gas exchange in the lungs. Impaired gas exchange is the primary problem that is causing the
ineffective respirations and is the more appropriate ND for this client.
(Option 4) Risk for infection is the increased risk for invasion of microorganisms. However, this client has an actual, not potential
infection, so this is not an appropriate ND.
Impaired gas exchange related to a bacterial infectious process as evidenced by shortness of breath and tachypnea is an
appropriate nursing diagnosis for a client with pneumonia.
Shaken baby syndrome (SBS) is a type of abusive head injury and is defined by the Centers for Disease Control and Prevention
(CDC) as severe physical child abuse resulting from violent shaking of an infant by the arms, legs, or shoulders. The impact of the
shaking causes bleeding within the brain or the eyes.
It is not uncommon for the diagnosis of SBS to be missed as the clinical findings are often vague and nonspecific—vomiting,
irritability, lethargy, inability to suck or eat, seizures, and inconsolable crying. Usually, there are no external signs of trauma
except for occasional small bruises on the chest or upper arms where the child was held during the shaking episode.
The most common reasons that caregivers seek medical attention for children with SBS are breathing difficulty, apnea, seizures,
and lifelessness. Caregivers typically do not offer a history of trauma nor do they report the episodes of shaking. By contrast,
children who have sustained unintentional head injury are typically brought for treatment out of concern by their caregivers even
when the children are asymptomatic.
(Option 1) Typically, a history of physical trauma is not reported by the parent or caregiver.
(Option 2) Abdominal bruising is not an expected clinical finding of SBS.
(Option 3) External signs of trauma are usually absent on physical examination of an infant with SBS. Minimal bruising on the
extremities or chest may be present.
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Shaken baby syndrome is a form of child physical abuse resulting from violent shaking of an infant by the extremities or shoulder
that causes bleeding within the brain and/or eyes. The clinical findings of shaken baby syndrome are nonspecific and include
lethargy, vomiting, seizures, irritability, inability to eat, and inconsolable crying. Multiple and severe shaking episodes can result in
breathing difficulty and lifelessness. Caregivers typically do not report a history of trauma.
Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact,
droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended
cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door
closed (Option 2).
Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child) (Option 5). For
disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for
symptoms (Option 3). Procedures and use of sharps/needles are limited whenever possible. There are currently no medications
or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial.
(Option 1) In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals
entering the room must don appropriate personal protective equipment (PPE).
(Option 4) The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer
gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent piece of
PPE (eg, respirator, gown) and removed last.
Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions,
including an airborne isolation room, strict personal protective equipment use, restriction of visitors, and a log of individuals who
enter and exit the room.
Celiac disease (celiac sprue) is an autoimmune disorder in which the body is unable to process gluten, a protein found in most
grains. Gluten consumption will damage the villi of the small intestine; this results in malabsorption of fats (steatorrhea, foul-
smelling stools) and other nutrients, which can lead to malnutrition and failure to thrive. The child will need to adhere to a gluten-
free diet for life. Rice, corn, and potatoes are gluten free and are allowed in the diet (Options 2, 3, and 5).
A child with celiac disease cannot eat barley, rye, oats, or wheat (mnemonic - BROW).
(Option 1) A child with celiac disease cannot consume barley or French bread as both contain gluten.
(Option 4) Peanut butter and jelly on rice cakes are permitted but not the oatmeal cookie.
Celiac disease is an autoimmune disorder in which an individual cannot tolerate gluten, a protein found in barley, rye, oats, and
wheat (BROW). Rice, corn, and potatoes are allowed in the diet and can be used as grain substitutes. Affected individuals must
adhere to a gluten-free diet for life.
Teaching about menstrual cycle physiology increases fertility awareness and helps couples optimize their chances of becoming
pregnant sooner. Timing of sexual intercourse near ovulation (ie, "fertile window") is essential to conception because
the ovum and sperm have limited viability in the reproductive tract.
Instructing the client about how to track menstrual cycles (eg, length and regularity of menses) and recognize signs of ovulation
(eg, cyclic changes in cervical mucus) may improve fertility awareness. Urine ovulation predictor kits may also be used to detect
the surge of luteinizing hormone (LH) that precedes ovulation by 12-24 hours. These predictor kits are easily accessed, over-
the-counter tests that can help the client time intercourse during the "fertile window" to improve chances of conceiving (Option 4).
(Option 1) It is best to provide teaching and encouragement rather than alternatives to pregnancy (eg, adoption, surrogacy).
(Option 2) Teaching about fertility-enhancing medications (eg, clomiphene) may be indicated for clients unable to conceive
naturally but is not the best reply to this client at this time.
(Option 3) Infertility is the inability to conceive after 12 months of frequent, unprotected intercourse for clients without medical
complications (eg, advanced maternal age). However, this is not the best response because this teaching does not assist the
client.
Teaching clients about menstrual cycle physiology may increase fertility awareness and improve their chances of achieving
pregnancy sooner. Over-the-counter ovulation predictor kits detect the surge of luteinizing hormone (LH) that precedes ovulation
so that clients can time sexual intercourse during their "fertile window."
Femoral-popliteal bypass surgery involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or
vein) graft to restore blood flow. The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and
skin temperature, capillary refill, pain, movement) and compares the findings with the preoperative baselines. The
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client's nonpalpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can indicate
compromised blood flow or graft occlusion and should be reported to the health care provider immediately.
(Option 2) Chronic venous insufficiency is the inability of the leg veins to efficiently pump blood back to the heart. It can lead to
venous stasis, increased hydrostatic pressure, and venous leg ulcers. Edema and thick skin with brown pigmentation are expected
manifestations, so this is not the priority assessment.
(Option 3) Gangrene of the foot is a complication of peripheral arterial disease (PAD) associated with decreased blood flow to the
extremity. Coolness of the skin and shiny, hairless legs, feet, and toes are expected manifestations of PAD, so the nurse would
not assess this client first.
(Option 4) Intermittent claudication is leg pain caused by decreased blood flow to the muscles that reoccurs during activity such
as walking and dissipates with rest. It is an expected manifestation of PAD of the lower extremities, so the nurse would not assess
this client first.
Absent or decreased volume in the peripheral pulses distal to the graft can indicate compromised circulation or graft occlusion and
should be reported to the health care provider immediately.
Osteoarthritis (OA) is a degenerative disorder of the synovial joints (eg, knee, hip, fingers) that causes progressive erosion of
the articular (joint) cartilage and bone beneath the cartilage. As the degenerative process continues, bone spurs (osteophytes),
calcifications, and ulcerations develop within the joint space, and the "cushion" between the ends of the bones breaks down.
Clinical manifestations of OA of the knee include:
 Pain exacerbated by weight-bearing activities: Results from synovial inflammation, muscle spasm, and nerve
irritation (Option 4)
 Crepitus, a grating noise or sensation with movement that can be heard or palpated: Results from the presence of bone
and cartilage fragments that float in the joint space (Option 1)
 Morning stiffness that subsides within 30 minutes of arising (Option 3)
 Decreased joint mobility and range of motion
 Atrophy of the muscles that support the joint (eg, quadriceps, hamstring) due to disuse
(Option 2) Low-grade fever develops as part of systemic inflammation. OA is typically a noninflammatory, nonsystemic disorder.
Occasional OA inflammation is limited to affected joints.
(Option 5) Serum rheumatoid factor is positive in clients with systemic rheumatoid arthritis. No diagnostic laboratory tests or
biomarkers exist for OA.
Osteoarthritis is a degenerative disorder of the synovial joints that leads to progressive erosion of the articular (joint) cartilage.
Clinical manifestations include pain exacerbated by weight-bearing, crepitus, morning stiffness subsiding within 30 minutes,
decreased joint mobility and range of motion, and atrophy of supporting muscles.
Sexual assault, or the coercing or forcing of sexual encounters (eg, groping, rape, incest, human trafficking), may happen to any
individual regardless of age, gender, ethnicity, or relationship to the perpetrator. Nurses providing emergency care should support
victims' complex physical and psychosocial needs, initiate preventive and therapeutic treatments, and collect and preserve forensic
evidence. Priority nursing actions include:
 Determining whether the client has bathed, showered, or douched, as these actions may compromise
evidence (Option 1)
 Educating the victim that a pelvic examination is recommended to identify injuries and collect evidence (Option 2)
 Obtaining the date of the client's last menstrual period and current method of birth control to identify risk for
pregnancy (Option 3)
 Performing a head-to-toe assessment to identify physical injuries requiring treatment and thoroughly documenting all
injuries on a body map (Option 4)
 Providing prophylactic therapies for sexually transmitted infections and pregnancy (Option 5)
Emergency nursing care of sexual assault victims includes determining whether evidence has been compromised (eg, shower,
bath, douche), date of the last menstrual period, and current method of birth control. The nurse should inform the client about the
pelvic examination, assess and thoroughly document all physical injuries on a body map, and provide prophylactic therapies for
sexually transmitted infections and pregnancy.
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Burn injuries cause tissue damage that leads to increased vascular permeability and fluid shifts (eg, second and third spacing). In
the emergent phase after a burn (first 24-72 hours), fluid, proteins, and intravascular components leak into the surrounding
interstitium, causing decreased intravascular oncotic pressure and decreased intravascular volume, and resulting in fluid shifts
and hypovolemia.
Potassium, the predominant intracellular cation, is released when cellular damage occurs, resulting in hyperkalemia (potassium
>5.0 mEq [5.0 mmol/L]). Clients with hyperkalemia experience muscle weakness, ECG changes (tall, peaked T waves, shortened
QT interval), and cardiac arrhythmias (Option 4).
(Option 1) Hematocrit and hemoglobin values will be elevated due to hypovolemia (hemoconcentration).
(Option 2) The sympathetic nervous system is activated in response to a burn, causing decreased peristalsis. Nausea, vomiting,
gastric distension, and paralytic ileus may occur.
(Option 3) Sodium is the most abundant extracellular cation. Hyponatremia (sodium <135 mEq/L [135 mmol/L]) occurs as
sodium is lost via fluid shifts and insensible losses.
Burn injuries cause cellular destruction, capillary leaking, and fluid shifts. Fluids are lost during the emergent phase (first 24-72
hours), resulting in hypovolemia and hyponatremia. The blood becomes more viscous and increased hematocrit and hemoglobin
values result. Cellular damage releases potassium, which causes hyperkalemia.
Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a very narrow therapeutic serum range of
0.6-1.2 mEq/L (0.6-1.2 mmol/L). Levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity usually occurs with the
following:
1. Dehydration
2. Decreased renal function (eg, elderly clients)
3. Diet low in sodium
4. Drug-drug interactions (nonsteroidal anti-inflammatory drugs [NSAIDs] and thiazide diuretics)
Lithium is cleared renally. Even a mild change in kidney function (as seen in elderly clients) can cause serious lithium toxicity.
Therefore, drugs that decrease renal blood flow (eg, NSAIDs) should be avoided. Acetaminophen would be a better choice for
pain relief (Option 4).
(Options 1 and 3) Sodium, water, and lithium are normally filtered by the kidneys. Restriction of dietary sodium/water or
dehydration signals renal sodium and water reabsorption which will also increase lithium absorption, resulting in toxicity.
Therefore, clients should never restrict their sodium or water intake while taking lithium; instead, they should maintain a consistent
sodium intake.
(Option 2) Blood should be drawn frequently to monitor for therapeutic lithium levels and toxicity.
Dehydration, decreased renal function, diet low in sodium, and drug-drug interactions (eg, NSAIDs and thiazide diuretics) can
cause lithium toxicity.
Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be
auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve
compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly
cause exsanguination and death. This client may need emergency surgery to repair the aneurysm.
(Option 1) Fever, suprapubic pain, and dysuria in a young female client indicate urinary tract infection, a much lower priority than
AAA.
(Option 2) Diffuse pain and a rigid abdomen indicate peritonitis (eg, from ruptured appendicitis or perforated bowel). Peritonitis is
also an emergency but not immediately life-threatening like AAA rupture. This client should be seen next after the client with AAA.
(Option 4) Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis. The client needs bowel
rest, antibiotics, and IV fluids. This is a lower priority than AAA and peritonitis.
Clients with an impending aortic aneurysm rupture present with abdominal/back pain, and a pulsatile abdominal mass. They may
also have a bruit. Rupture of an abdominal aneurysm can lead to exsanguination and death in minutes.
The nurse should select an IV catheter site on an upper extremity, preferably the hand or forearm. To reduce the incidence of
catheter-related infections, the selected site should be cleaned with antiseptic solution using friction (preferably chlorhexidine,
using a back-and-forth motion) and then allowed to air-dry completely (Option 3). Chlorhexidine is preferred as it achieves an
antimicrobial effect within 30 seconds, whereas povidone-iodine takes ≥2 minutes.
After insertion, the catheter hub should be secured with a narrow strip of sterile tape to prevent accidental removal or excessive
back-and-forth motion, which can introduce microorganisms into the vein. In addition, a sterile, transparent,
semipermeable dressing (eg, Tegaderm) should be used to secure the catheter hub to reduce infection risk and allow visualization
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of the site (Option 1). When the catheter is accessed, the needleless port should be cleansed with an alcohol swab to kill
externally colonized microorganisms (Option 2).
(Option 4) Excessive hair may be clipped but never shaved as shaving may cause microabrasions and potential portals of entry
for microorganisms.
(Option 5) Peripheral IV catheters should not be removed or replaced more frequently than every 72-96 hours unless signs of
complications (eg, infiltration, infection, phlebitis) occur.
To reduce catheter-related infections from peripheral IV catheters, the nurse should clean the site with chlorhexidine in a back-and-
forth motion using friction and allow it to dry completely. The catheter hub is secured with a sterile, semipermeable dressing, and
access ports are cleaned with alcohol swabs prior to use.
A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and
stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube
can become dislodged to the lungs, causing aspiration of enteral feedings.
If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg, crackles,
wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure
insertion depth, obtain x-ray, assess aspirate pH) (Option 2). Some facilities use capnography to determine placement; if a sensor
detects exhaled CO2 from the tube, it is in the client's airway and must be removed immediately.
(Option 1) An inhaled bronchodilator may be prescribed to treat aspiration pneumonia, but the priority is to stop the feeding and
check tube placement to prevent additional aspiration.
(Option 3) Crackles may be heard with fluid overload, aspiration, or pneumonia. A diuretic would be appropriate if a client is
experiencing pulmonary edema from fluid overload. If a client receiving enteral feedings develops signs of aspiration, the nurse
should initially hold feedings and assess tube placement.
(Option 4) Incentive spirometry promotes expansion of the lungs and resolves atelectasis; however, the priority for this client is
assessing for and preventing aspiration.
Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped
immediately and tube placement checked if the client develops signs of aspiration.
The nurse has a medical order stating that the client should not be resuscitated. Therefore, the appropriate first action is to assess
the apical pulse. Then the nurse should call the HCP. If the client's family members are present, the nurse should explain what is
happening and make sure that they have support.
(Option 1) Activating the code system is not appropriate as this client has an order to withhold resuscitation.
(Option 2) The nurse should assess the client and then call the HCP. A stat page is not needed when the client is DNR.
(Option 4) Measuring the blood pressure is not appropriate if this client has stopped breathing. Checking an apical or central
pulse would be appropriate after noticing that the client is not breathing.
A DNR order requires the nurse to withhold resuscitation in the event of a cardiac or respiratory arrest. If an event occurs, the
nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the
HCP to confirm the death.
Pulmonic stenosis causes increased pressure in the right side of the heart as the ventricle tries to push blood through the
narrowed pulmonary area to the lungs. In severe pulmonic stenosis, higher pressure in the right side of the heart causes
unoxygenated blood to travel to the left side through the foramen ovale (or other congenital defect) and into the systemic
circulation, leading to chronic hypoxia and cyanosis and requiring repair (interventional catheterization or surgery).
The presence of severe diaper rash should be reported to the health care provider (HCP). This could delay the procedure if the
rash is in the groin area where access is planned for a femorally inserted arterial cannula. Yeast or bacteria may be present on
the rash and could be introduced into the bloodstream with the arterial stick (Option 3).
(Option 1) A loud heart murmur can be an expected finding in a child with pulmonic stenosis.
(Option 2) Children are NPO for 4-6 hours or longer before the procedure. Younger children and infants may have a shorter
period of NPO status and should be fed right up to the time recommended by the HCP.
(Option 4) Cyanosis indicates severe pulmonic stenosis with right-to-left shunt and the need for interventional catheterization or
surgery without delay.
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The nurse should report the presence of severe diaper rash in an infant who has an interventional catheterization procedure
planned. The rash may delay the procedure due to possible contamination at the insertion site.
Major predisposing factors for the development of delirium in hospitalized clients include:
1. Advanced age
2. Underlying neurodegenerative disease (stroke, dementia)
3. Polypharmacy
4. Coexisting medical conditions (eg, infection)
5. Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia)
6. Metabolic and electrolyte disturbances
7. Impaired mobility - early ambulation prevents delirium
8. Surgery (postoperative setting)
9. Untreated pain and inadequate analgesia
Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and
sepsis. This client is at greatest risk for developing delirium.
(Option 1) Although gastroenteritis with possible dehydration and electrolyte imbalances predisposes to delirium, this client is not
at greatest risk.
(Option 2) Although surgery, especially that requiring cardiac bypass, predisposes to delirium, this client is not at greatest
risk. Early ambulation and adequate pain control prevent the development of delirium in the postoperative setting.
(Option 3) Although coexisting medical conditions, such as diabetes mellitus and impaired mobility, predispose to delirium, this
client is not at greatest risk.
Risk factors for hospital-induced delirium include advanced age, underlying neurodegenerative disease, infections, medical illness,
surgery, impaired mobility, and inadequate pain control.
Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP
syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable
and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and/or
maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and
hypertension may or may not be present.
(Option 1) Nausea and vomiting during the first trimester are normal, expected findings. Vomiting that continues past the first
trimester or that is accompanied by fever, pain, or weight loss is considered abnormal and requires intervention.
(Option 2) Although urinary frequency is common in pregnancy, dysuria could indicate a urinary tract infection. This client should
be evaluated but does not take priority over a client with symptoms of HELLP.
(Option 3) Maternal perception of fetal movement can be altered by obesity, maternal position, fetal sleep cycle, fetal position,
anterior placenta, and amniotic fluid volume (increased or decreased). This client should be evaluated to determine the cause of
decreased fetal movement; however, this is not the priority.
HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is a severe form of preeclampsia. Its clinical
presentation can be quite variable and may include nonspecific symptoms such as right upper quadrant/epigastric pain, nausea,
vomiting, and malaise. Complications including placental abruption, stroke, and death may occur if HELLP syndrome is not treated
immediately.
This client with advanced renal failure who decides not to start dialysis treatments may have only a few weeks to live. Toxins will
build up in the body and soon lead to increased weakness and cognitive decline. This client knows there is a limited time left to live
and wants to ensure that possessions will be taken care of appropriately after the client's death (Option 4).
(Option 1) The client has probably been admitted to the facility due to concerns about safe management at home. However, the
statement does not indicate that the client has been admitted against the client's will.
(Option 2) Clients with end-stage renal disease are at risk for delirium due to a buildup of toxins, which may manifest as agitation
and statements about needing to go somewhere. However, the nurse should not automatically assume that the client is delirious.
Instead, it is important to assess the client's concern with an open mind so that appropriate interventions can be planned.
(Option 3) The client's statement about having "so much to do" suggests that this is not the concern prompting the behavior.
The client with a limited life expectancy will have concerns about completing personal business, such as ensuring that possessions
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go to the appropriate people. The nurse should assess the client's needs and ensure that the plan of care will facilitate the client's
life closure activities (eg, legacy building).
Manipulative behaviors, such as attempts at staff splitting, are common in clients with borderline and antisocial personality
disorders, substance abuse problems, somatic symptom disorder, and bipolar disorder (during the manic phase). The
manipulative behavior is aimed at gaining control/power over a person/situation or for material gratification.
Clients manipulate by flattery or by pitting staff members against each other. They may "tell" on a staff member or act in a way to
give the impression of sincerity and caring.
Nursing interventions for manipulative behaviors include:
 Setting limits that are realistic, nonpunitive, and enforceable

 Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors
 Enforcing all unit, hospital, or center rules (Option 4)
 Ensuring consistency from all staff members in enforcing set limits
(Option 1) Telling the client the gift shop is closed does not address the client's manipulative behavior.
(Option 2) Believing the client's statement is not appropriate as it will only reinforce the client's manipulative behavior.
(Option 3) Asking the client the reason for going to the gift shop ignores the fact that the client is trying to break the rules.
Clients who want to gain power or control over a situation or desire material gratification may use manipulative behaviors (eg, staff
splitting). Nursing interventions include setting behavioral limits; using a neutral, matter-of-fact tone when discussing rules and
consequences of unacceptable behavior; and ensuring consistency from staff members in enforcing limits.
Clients with a diagnosis of chronic congestive heart failure experience clinical manifestations of both right-sided (systemic
venous congestion) and left-sided (pulmonary congestion) failure.
Crackles are discontinuous, adventitious lung sounds usually heard on inspiration and indicate the presence of pulmonary
congestion (left-sided failure) in this client. Increased jugular venous distention reflects an increase in pressure and volume in
the systemic circulation, resulting in elevated central venous pressure (CVP) (right-sided failure) in this client. Although dependent
pitting edema of the extremities can be associated with other conditions (eg, hypoproteinemia, venous insufficiency), it is related to
sodium and fluid retention (right-sided failure) in this client.
(Option 2) Dry mucous membranes are associated with dehydration (increased serum sodium level), not fluid overload (heart
failure).
(Option 4) Rhonchi are continuous lung sounds usually heard on expiration that indicate the presence of secretions in the larger
airways. They are not a classic manifestation of chronic heart failure.
(Option 5) Poor skin turgor or "tenting" is associated with skin moisture and elasticity. It is usually associated with dehydration,
not fluid overload.
Clients with chronic heart failure experience clinical manifestations of both right-sided and left-sided failure. Therefore, the nurse
must be able to assess for the clinical manifestations related to systemic volume increases and pulmonary congestion.
Ethical principles guide decision making and appropriate behavior. Justice is treating every client equally regardless of gender,
sexual orientation, religion, ethnicity, disease, or social standing (Option 4). Accountability refers to accepting responsibility for
one's actions and admitting errors (Option 1).
Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due to their
physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with
dementia (Option 5).
(Option 2) Autonomy is freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree
(eg, informed consent, advanced directive). The nurse can provide information and should respect the client's decisions.
(Option 3) Confidentiality means that information shared with the nurse is kept in confidence unless permission is given to share
or it is required by law to be shared to protect the client and/or community (eg, reportable infectious diseases). If a client discusses
suicidal ideation with the nurse, it must be appropriately reported to protect the client from self-harm.
Accountability is accepting responsibility for one's actions. Autonomy is making an informed decision about treatment for oneself.
Confidentiality is not sharing information unless permission is given or required by law. Justice is treating every client equally.
Nonmaleficence is doing no harm.
A client who is quadriplegic will have limited to no functional mobility in his arms and hands and will therefore be unable to use any
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device that requires pushing a small button (Options 1, 2, and 4). Instead, the nurse should provide a call device that requires
application of a small amount of pressure over a large area, as the client will probably need to use the head to activate the
signal (Option 3). Other call devices that this client would probably be able to activate include those activated by blowing through
a tube or moving the eyes.
A key element of promoting safety when the client is in an acute care setting is to ensure that there is a method of signaling the
staff for assistance at all times. The nurse should ensure that the type of call device fits the client's capabilities, that the client is
able to use it, and that it is always placed where the client can activate it before the nurse leaves the room.
The initial nursing action for a client experiencing cyanosis and excess oral secretions is suctioning the mouth (ie, oropharynx)
to clear the airway (Option 4). Excessive frothy mucus and cyanosis in a newborn could be due to esophageal atresia
(EA) and tracheoesophageal fistula (TEF). If EA/TEF is suspected, the infant should be kept supine with the head elevated at
least 30 degrees to prevent aspiration. A nasogastric tube should be inserted and connected to continuous or intermittent suction
until surgical repair.
(Option 1) Oxygen cannot be delivered to the lungs if secretions obstruct the airway. Therefore, suctioning is a priority.
(Option 2) This infant is aspirating and in immediate distress, which should be addressed without delay. After suctioning the
excess saliva and ensuring a clear airway, the nurse may perform further assessments.
(Option 3) This infant's cyanosis is a result of aspirating secretions and does not indicate a circulatory problem. The knee-chest
position is appropriate to increase pulmonary blood flow in infants with a cyanotic heart defect (eg, tetralogy of Fallot).
The initial nursing action for a client experiencing cyanosis and excess oral secretions is oropharyngeal suctioning to ensure airway
patency.
Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that suppress the inflammatory response in
autoimmune diseases such as rheumatoid arthritis, Crohn disease, and psoriasis. Due to the immunosuppressive action of TNF
inhibitors, clients taking these drugs are at increased risk for infection. A client with current, recent, or chronic infection should
not take a TNF inhibitor (Option 1).
(Option 2) The immunosuppressive action of TNF inhibitors can activate latent tuberculosis (TB). Therefore, a tuberculin skin
test (TST) should be administered prior to beginning TNF inhibitor therapy, and clients who test positively for latent TB must also
undergo treatment for TB before starting therapy. Clients should have a TST every year while receiving the drug.
(Option 3) Clients taking immunosuppressive TNF inhibitors (eg, adalimumab) should receive an annual inactivated (injectable)
influenza vaccine to reduce the risk of contracting the flu virus. Clients taking TNF inhibitors or other immunosuppressants are at
risk for infection and therefore should not receive live attenuated vaccines.
(Option 4) Many clients with rheumatoid arthritis use nonsteroidal anti-inflammatory medications (eg, celecoxib, naproxen) in
conjunction with antirheumatic and/or targeted therapies (eg, methotrexate, adalimumab, etanercept) to effectively treat pain and
minimize inflammation.
Clients with infection should not take tumor necrosis factor (TNF) inhibitors (eg, infliximab, adalimumab, etanercept) as these
suppress the immune response. Before starting drug therapy, clients should be tested for tuberculosis and receive the inactivated
(injectable) influenza vaccine. Clients taking TNF inhibitors should avoid live vaccines.
The nurse should discuss the need to perform good oral hygiene with a soft-bristle toothbrush and to visit the dentist regularly
as phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily), especially in
high doses. Folic acid supplementation can also reduce this side effect.
The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone
density (osteoporosis).
Preconception counseling assesses for pregnancy risk factors and implements appropriate interventions to promote a healthy
pregnancy. Some behaviors the client may begin independently include eating a nutritious diet; exercising; abstaining from
alcohol, tobacco, and illicit drugs; and taking folic acid supplements.
Obesity (BMI >30 kg/m2) during pregnancy is associated with an increased risk for fetal/maternal complications (eg, gestational
diabetes, hypertension, cesarean birth). Achieving a normal BMI (18.5-24.9 kg/m2) is optimal (Option 1).
No amount of alcohol is considered safe in pregnancy; complete abstinence from alcohol is recommended to avoid fetal alcohol
syndrome. Smoking cessation is encouraged due to its association with fetal growth restriction; illicit drugs may also cause fetal
harm (Option 2).
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Folic acid supplementation of at least 400 mcg per day for 3 months before pregnancy is recommended to reduce the incidence
of neural tube defects (Option 3). Neural tube development begins around the third week following conception, before a woman
may realize that she is pregnant.
Finally, clients should visit their health care provider to discuss pregnancy's effect on certain health conditions (eg, asthma,
diabetes) and check rubella immunity (Option 4). Rubella vaccination should be given if the client is nonimmune, and pregnancy
should be avoided for at least 4 weeks after vaccination. Regular visits with a dentist can help prevent periodontal disease,
which is associated with poor pregnancy outcomes (eg, preterm birth, low birth weight) (Option 5).
Preconception care improves pregnancy outcomes and includes folic acid supplementation; regular dental care; updated
vaccinations; avoidance of alcohol, smoking, and illicit drugs; and achieving a normal weight.
Trigeminal neuralgia is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral
and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain, or
"cluster attacks" of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth,
yawning, or talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminal neuralgia
is consistent pain control with medications and lifestyle changes. The drug of choice is carbamazepine. It is a seizure
medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia) and
infection risk. Clients should be advised to report any fever or sore throat.
Behavioral interventions include the following:
1. Oral care – use a small, soft-bristled toothbrush or a warm mouth wash

2. Use lukewarm water; avoid beverages or food that are too hot or cold (Option 1)
3. Room should be kept at an even and moderate temperature
4. Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary.
5. Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected side of the
mouth.
Gout is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood.
Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage.
Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor
diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in uric acid control are
often seen when weight lossis accompanied by dietary modifications (Option 1). Suggested modifications include:
 Increasing fluid intake (2 L/day) to help eliminate excess uric acid (Option 3)

 Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood (eg,
sardines, shellfish)
 Limiting alcohol intake, especially beer (Option 5)
 Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates
A neonate born to an opioid-dependent mother (eg, heroin, methadone, hydrocodone) is at high risk for neonatal abstinence
syndrome, in which the newborn experiences opioid withdrawal typically within 24-48 hours after birth. Clinical manifestations of
withdrawal in infants include irritability, jitteriness, high-pitched cry, sneezing, diarrhea, vomiting, and poor feeding.
Hypersensitivity can make feeding difficult; the newborn should be placed in a side-lying position while swaddled to minimize
stimulation and promote nutritive sucking (Option 1). Between feedings, a pacifier may be used to soothe the infant and help
establish an organized sucking pattern.
Excessive movement places the newborn at high risk for skin excoriation; the infant should be tightly swaddled with arms flexed
to minimize irritation and prevent damage to the skin. Hand mittens and barrier skin protection to the knees, elbows, and heels
may also be used.
Scabies is a highly contagious skin infestation of the Sarcoptes scabiei mite. Scabies spreads easily via direct person-to-
person contact (eg, skilled nursing facility, day care, prison). The pregnant female mite burrows into the outer skin layer to lay
eggs and feces, leaving a superficial burrow track. Intense itching, especially at night, occurs due to the body's inflammatory
response to the mite's eggs and feces.
Treatment for scabies typically involves 1 or 2 applications of a scabicide cream (eg, 5% permethrin). For infants and children,
permethrin should be massaged into all skin surfaces from the head to the feet, avoiding contact with the eyes (Option 2). Even
after effective treatment, itching often continues for several weeks. All persons in close contact with the client during the lengthy
30- to 60-day incubation period (time from infestation to symptom onset) should also seek treatment (Option 1).
To prevent reinfection, clothing and linens should be washed and dried on the hottest settings (Option 5).
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Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a
strong, sudden urge to urinate that is followed by urine leakage. UI may occur without cause or may result from spinal cord injury
and impairment of the bladder (eg, interstitial cystitis) or neurological system (eg, Parkinson disease, stroke). Interventions for
clients with UI include:
 Loss of excess weight to reduce pressure on the pelvic floor (Option 1).
 Anticholinergic medications (eg, oxybutynin, tolterodine) to decrease bladder spasms. Dry mouth (xerostomia) is a
frequent adverse effect (Option 2).
 Avoidance of bladder irritants (eg, artificial sweeteners, caffeine, citrus juices, alcohol, carbonated drinks,
nicotine) (Option 3).
 Pelvic floor exercises (eg, Kegel) to strengthen the muscles and help prevent urinary leakage (Option 4).
 Bladder training (eg, voiding every 2 hours while awake) and gradually lengthening intervals between voiding (Option
5).
Selective estrogen receptor modulators (eg, tamoxifen) have differential action in different tissues (mixed agonist/antagonist). In
the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of estrogen-receptive breast cancer
cells.
However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation
(endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in
premenopausal woman or any bleeding in postmenopausal women can be a sign of endometrial cancer (Option 3). Due to its
estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein
thrombosis).
Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. Therefore, monitoring for life-threatening
side effects is very important.
(Options 1 and 4) Because tamoxifen blocks estrogen receptors, it can cause symptoms of menopause. Vaginal dryness, hot
flashes, and decreased libido (sexual dysfunction) are common and would be discussed after addressing more concerning
symptoms.
(Option 2) Tamoxifen is not associated with significant immunosuppression although it may rarely cause leukopenia.
Tamoxifen has mixed agonist and antagonist activity on estrogen receptors in various tissues. It is used for several years in
estrogen-responsive breast cancer. However, it is associated with increased risk of endometrial cancer and venous
thromboembolism. Menopausal symptoms (eg, vaginal dryness, hot flashes) are the most common side effect.
The client with advanced heart failure on hospice is likely to have dyspnea associated with fluid overload. The first intervention
should be to elevate the head of the bed and then assess for fluid overload, which would be treated with IV diuretics. Morphine
can alleviate dyspnea associated with heart failure, but it should be used in combination with other nonpharmacologic and
pharmacologic interventions.
Stimulant medications (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment
of attention-deficit hyperactivity disorder (ADHD). Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily,
usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than
around 6 PM (Option 3). The sustained-release preparation should be given in the morning. The dosage in children is usually
started low and titrated to the desired response.
This client likely has febrile seizures. It is important to never leave seizing clients alone as the goal is to prevent them from
causing self-injury. The nurse should call out for help if needed. The main objective is to ensure that seizing clients maintain their
airway; therefore, it is important to monitor their oxygen saturation levels. If these levels begin to drop or cyanosis occurs, prompt
intervention is needed, which may be as simple as a head tilt or jaw thrust.
Amitriptyline is a tricyclic antidepressant (TCA) that can produce cardiac toxicity and neurological disturbances by altering

cholinergic pathways, sodium channels, and calcium channels, causing symptoms such as atrioventricular block, hypotension,
cardiac arrest, and seizure.
TCAs have a narrow therapeutic index and rapid onset of action, so ingestion of even a small amount may be life-
threatening for a toddler. Symptoms of toxicity are usually evident within hours of ingestion, but cardiac failure can develop days
after. Neurological and hemodynamic assessments, as well as ECG monitoring in an emergency department setting, are
recommended (Option 2).
Postpartum hemorrhage (PPH) due to uterine atony is exacerbated by conditions that cause overdistension of the uterus (eg,
macrosomia, multiple gestation, multiparity). If excessive bleeding persists after initial interventions (eg, firm fundal massage,
oxytocin bolus), second-line uterotonic drugs (eg, carboprost, methylergonovine, misoprostol) may be given.
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Methylergonovine [Methergine] is contraindicated for clients with high blood pressure (eg, preeclampsia, preexisting
hypertension) because the primary mechanism of action is vasoconstriction. If administered to a hypertensive client, it can lead to
further blood pressure elevation, seizure, or stroke (Option 1).
Trazodone (Oleptro), a serotonin modulator, is used to treat major depressive disorders. In addition to affecting serotonin levels,
the drug blocks alpha and histamine (H1) receptors. Blockade of alpha receptors can cause orthostatic hypotension similar to
that from other alpha blockers (eg, terazosin, tamsulosin) used to treat benign prostatic hyperplasia. Blockade of H1
receptors leads to sedation. Therefore, this drug is particularly effective in treating insomnia associated with depression.
However, concurrent intake of other medications or substances that cause sedation can be detrimental; these include
benzodiazepines (eg, alprazolam, lorazepam, diazepam), sedating antihistamines (eg, chlorpheniramine, hydroxyzine), and
alcohol (Option 4).
Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war,
tornado, rape, plane crash).
There are 3 categories of PTSD symptoms:
1. Reexperiencing the traumatic event
Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or
strong physical reactions to event reminders (eg, rapid, pounding heart; gastrointestinal distress; diaphoresis) (Option 4)
2. Avoiding reminders of the trauma
Examples include avoidance of activities, places, thoughts, or other triggers that could serve as reminders; feeling
detached and emotionally numb; loss of interest in life; inability to set goals; and amnesia about important details of the
event (Option 2)
3. Increased anxiety and emotional arousal
Examples include insomnia, irritability, outbursts of rage, persistent anger and/or fear, difficulty concentrating,
hypervigilance, and exaggerated startle response (Options 1 and 5)
Hydrocephalus is an increase in intracranial pressure (ICP) that results from obstruction of cerebrospinal fluid flow. Increased
ICP can progress to brain damage and death. Signs of increased ICP in children include bulging fontanelles, increasing head
circumference, and sunset eyes (or setting-sun sign) (sclera visible above the iris).
Sunset eyes occur when periaqueductal structures are compressed from increased ICP, paralyzing the upward gaze. This is a late
sign of increased ICP that requires timely treatment (eg, shunt placement) and is the priority (Option 2).
(Option 1) Positional plagiocephaly (flat head syndrome) occurs when an infant is placed in the same position (eg, supine) for an
extended period of time and the pliable skull molds to the surface (flattens). Parents can intervene to avoid or correct
plagiocephaly (eg, periodically repositioning the head during sleep, tummy time). Minor skull deformation is not a priority.
(Option 3) Eight wet diapers in 24 hours is within the normal range (6-10 diapers/day or approximately 1 diaper every 4 hours),
indicating that the infant is likely producing >1 mL/kg/hr urine output and is not dehydrated, despite vomiting.
(Option 4) The Babinski reflex (ie, toes fan outward and the big toe dorsiflexes with stimuli) is expected in infants and is a normal
finding up to age 1 year. However, its presence beyond this age can indicate neurologic disease.
The presence of sunset eyes (sclera visible above the iris) is a late sign of increased intracranial pressure and a priority to report to
the health care provider.
A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's
admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more
after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those
with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of
indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common
nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections.
The 74-year-old client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert
for this complication and should follow infection control procedures diligently.
There are 2 forms of heparin-induced thrombocytopenia. The first form (platelets >100,000/mm3 [100 x 109/L]) normalizes within a
few days. The second form (platelets <40,000/mm3 [40 x 109/L]) is a life-threatening autoimmune process that requires immediate
heparin discontinuation.
When in doubt of a clinician's judgment, the nurse should document these objections and report to the nursing supervisor.
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Although it is not a STAT order, an extra dose of furosemide was prescribed for the client with congestive heart failure. The
shortness of breath is most likely due to a change in fluid status, and this client is the priority. Furosemide works immediately and
should be given urgently.
The LPN should be assigned to clients who are medically stable and have expected outcomes; these criteria apply to the client
who had a total hip replacement 2 days ago. LPNs should not be assigned to clients who require complex care and clinical
judgment and have potential negative outcomes. Teaching, assessment, clinical judgment, and evaluation of a client are the
responsibility of the RN and should never be delegated to the LPN.
(Option 1) Client care is complex for those with acute pancreatitis as they can develop several complications (eg, hypocalcemia,
acute respiratory distress syndrome) and need aggressive supportive care (eg, pain management, IV fluids).
(Option 3) Total thyroidectomy can be complicated by bleeding (throat compression) or hypocalcemia (if parathyroids were
removed inadvertently). Care in these clients is complex.
(Option 4) Alcohol withdrawal can develop into delirium tremens or seizures; both are serious conditions. Clients need frequent
doses of benzodiazepines (eg, lorazepam, diazepam) and aggressive supportive care.
Care of stable clients with expected outcomes should be delegated to the LPN. The RN cannot delegate client teaching or care of
those who will require ongoing assessment and clinical judgment.
Repositioning and transferring clients can be delegated to unlicensed assistive personnel (UAP) when it is deemed safe and
appropriate. The nurse must provide UAPs with detailed instructions, including when to move the client, which techniques to
use, and when to use assistive persons or devices. The nurse must also notify UAPs of any client mobility restrictions. Unstable
clients and spinal cord stabilization require the presence of a nurse for repositioning or moving (Option 4).
The client who is 8 hours postoperative total hip replacement requires assessment prior to repositioning as the client is at risk for
hip dislocation. A wedge may be needed to maintain abduction; nursing judgment is required (Option 1).
To reduce the risk of client and staff injury, safe transfers and repositioning are achieved using the following guidelines:
 Use a gait/transfer belt to transfer a partially weight-bearing client to a chair (Option 2).

 Use 2 or more caregivers to reposition clients who are uncooperative or unable to assist (eg, comatose,
medicated) (Option 3).
 Use a full-body sling lift to move/transfer nonparticipating clients.
 Use 2-3 caregivers to move cooperative clients weighing less than 200 lb (91 kg).
 Use 3 or more caregivers to move cooperative clients weighing more than 200 lb (91 kg) (Option 5).
Client repositioning and transferring can be delegated to unlicensed assistive personnel if it is deemed safe and appropriate. The
nurse must provide instructions to maintain client safety and intervene if the task is performed inappropriately or requires nurse
involvement (eg, spinal cord stabilization).
The priority when administering 2 IV medications concurrently is to determine drug compatibility. Incompatible drugs given
through the same IV line will deteriorate or form a precipitate. This change is visualized through either a color change,
a clouding of the solution, or the presence of particles. If 2 or more drugs are not compatible, the nurse may consider inserting a
second IV or consulting the pharmacist and the health care provider to determine the safest and most beneficial plan for the client.
(Option 1) Assessing the IV site for complications (eg, infiltration, phlebitis) should always be performed before giving any IV
medication. This will be completed after determining drug compatibility.
(Option 2) Verification using 2 client identifiers pertains to the "right client" in the "6 rights" of medication administration. Drug
compatibility should be determined prior to entering the client's room and verifying identity.
(Option 4) Hand hygiene is a standard precaution taken before any type of client interaction to prevent contamination and
infection; hand washing will be completed after checking for drug compatibility.
Checking for drug compatibility is a priority before administering 2 IV medications concurrently in the same IV site. Incompatible
drugs will deteriorate or form a precipitate that is visible as a color change, cloudiness, or particulates.
Rooting and sucking are a part of an infant's natural reflexes. Nonnutritive sucking assists in helping the infant to feel secure.
Some parents become very concerned about their infants sucking fingers, thumbs, or a pacifier and try to stop the behavior. As a
rule, if thumb sucking stops before the permanent teeth begin to erupt, misalignment of the teeth and malocclusion can be
avoided. Parents should be taught that teasing and punishing a child for using a pacifier or sucking the thumb is not an effective
method for getting the child to stop. This can increase the child's anxiety and cause the child to increase the behavior.
(Options 1, 2, and 3) These options are incorrect. Use of a pacifier or thumb sucking prior to eruption of the permanent teeth
does not tend to cause dental issues such as teeth misalignment or malocclusion.
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The risk of teeth misalignment and malocclusion occurs when a child uses a pacifier or sucks the thumb after the eruption of the
permanent teeth.
Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for
myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for
bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be
taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenic purpura, so platelets should
be monitored periodically (Option 5).
(Option 3) Monitoring intake and output is indicated while a client is on diuretic medications (eg, furosemide, torsemide,
bumetanide) but not for antiplatelet agents.
(Option 4) Baseline liver enzymes are obtained for clients taking statins (eg, rosuvastatin, atorvastatin) and isoniazid (for
tuberculosis). Elevated liver enzymes are an infrequent side effect of clopidogrel, and regular monitoring is usually not required in
clients without hepatic impairment.
Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) can pose a risk for serious bleeding. Clients should be
monitored for bruising, signs of bleeding (eg, tarry stools, hematuria), and decreased platelet counts.
When a pregnant client arrives and birth is imminent, the nurse should focus on collecting a brief, focused history to elicit key
information relevant to potential neonatal resuscitation. Essential areas of history-taking include:
 Multiple gestation: To prepare for the potential of multiple newborn resuscitations (Option 1)

 Meconium-stained amniotic fluid: To prepare for potential intubation and tracheal suctioning (Option 2)
 Narcotic/illicit drug use (especially within the last 4 hours): To anticipate respiratory depression (Option 3)
 Preterm labor/birth: To anticipate respiratory immaturity and neonatal ventilation (Option 4)
(Option 5) At this point, birth is imminent, and the name of the health care provider is not immediately pertinent. After the client
has given birth, the nurse may attempt to obtain prenatal records from the health care provider, if available.
When a client arrives and birth is imminent, the nurse's priority is collecting a brief history to elicit key information relevant to
potential neonatal resuscitation. Identifying multiple gestation, preterm gestational age, meconium-stained fluid, and recent
narcotic/drug use are essential areas of concern.
During stabilization of a pregnant client after trauma (eg, motor vehicle collision, fall), uterine displacement is the first step
to address supine hypotension (due to aortocaval compression and decreased venous return to the heart) and promote blood
circulation to the fetus. The client should be tilted laterally while strapped on the backboard to promote venous return and
protect the client from further potential spinal injury (Option 4).
Manifestations of aortocaval compression (eg, hypotension, pallor, dizziness) may mimic those of other complications of trauma. It
is therefore critical to reassess blood pressure after uterine displacement to identify persistent hypotension, which may indicate
hemorrhage caused by trauma (eg, placental abruption).
(Option 1) An IV fluid bolus of isotonic fluids (eg, lactated Ringer solution) to correct hypotension is appropriate if position changes
do not relieve symptoms or hemorrhage is suspected. Client positioning should be considered first.
(Option 2) Assessing medical and obstetric history is important when planning care for a pregnant client, but immediate physical
needs are the priority.
(Option 3) The nurse should first reposition the client to address a potential cause of hypotension (aortocaval compression), which
can affect blood flow to the fetus, and then initiate fetal monitoring.
During stabilization of a pregnant client after trauma, uterine displacement is the first step to prevent/correct supine hypotension
and promote blood circulation to the fetus. A lateral tilt of the backboard can correct aortocaval compression while protecting the
client from further spinal injury.
Pap testing allows early detection of cervical dysplasia (ie, abnormal cell growth) that may indicate cervical cancer. Human
papillomavirus (HPV), an extremely common sexually transmitted infection (STI), causes almost all cases of cervical cancer.
However, most women have transient infections that resolve spontaneously. Therefore, cervical cancer screening guidelines
balance the need to screen for persistent (cancer-causing) infection with the knowledge that overtreating (eg, cold knife cone)
may cause more harm than good.
Cervical cancer screening is typically initiated at age ≥21, regardless of age at onset of sexual activity. Women age 21-29
should be screened with Pap testing every 3 years in the United States or every 1-3 years in Canada (Option 2).
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Some children have a mild reaction to the MMRV vaccine within 5-12 days after the first dose. Problems include low-grade fever,
mild rash, swelling and erythema at the injection site, irritability, and restlessness.
Although rare, fever after MMRV vaccination can lead to febrile seizures. Therefore, it is important for the nurse to determine the
child's temperature to evaluate the risk for a febrile convulsion. It would also be important for the nurse to instruct the parent to
monitor the child's temperature and administer acetaminophen for a fever above 102 F (38.9 C).
Children with a history of seizures should be vaccinated with separate MMR and varicella vaccines instead of the combination
MMRV vaccine.
Interventions to promote safety when using crutches in the home include the following:
 Keep the environment free of clutter and remove scatter rugs to reduce fall risk (Options 1 and 3)
 Look forward, not down at the feet, when walking to maintain an upright position, which will help prevent muscle and joint
strain, maintain balance, and reduce fall risk (Option 2)
 Use a small backpack, fanny pack, or shoulder bag to hold small personal items (eg, eyeglasses, cell phone), which will
keep hands free when walking (Option 4)
 Wear rubber- or non-skid-soled slippers or shoes without laces to reduce fall risk (Option 5)
 Rest crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip
hazard
 Keep crutch rubber tips dry. Replace them if worn to prevent slipping.
Interventions to promote safety and reduce the risk of falling when using axillary crutches in the home include looking forward when
walking, maintaining a clutter-free environment, resting crutches upside down on the axilla pads when not in use, using a small bag
to hold personal items, wearing sturdy rubber-soled shoes, and keeping crutches in good repair.
Lithium toxicity
 Acute: Gastrointestinal findings - nausea, vomiting, diarrhea; neurologic findings

occur later
Features  Chronic: Neurologic - ataxia, sluggishness, confusion, agitation, neuromuscular excitability
(coarse tremor)
 Avoid sodium depletion; low sodium intake precipitates lithium toxicity

 Eat regular diet & drink adequate fluids (2-3 L/day)
Prevention  Therapeutic level is 0.6-1.2 mEq/L (0.6-1.2 mmol/L)
 Level >1.5 mEq/L (1.5 mmol/L) is considered toxic
Lithium carbonate is used for the initial and maintenance treatment of bipolar mania. Typical symptoms of mania include extreme
hyperactivity, delusions and hallucinations, grandiosity, elation, poor judgment, aggressiveness, impulsivity, pressure of speech,
insomnia, flight of ideas, and sometimes hostility.
Acute lithium toxicity presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and
diarrhea. Neurologic symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. Severe toxicity
results in seizures and encephalopathy (Option 1).
Serum lithium levels and clinical condition must be monitored before medication administration. Serum levels ≥1.5 mEq/L (1.5
mmol/L) and/or even the mildest symptoms of lithium toxicity must be reported to the health care provider.
Pheochromocytoma is a condition caused by a tumor in the adrenal medulla. This results in excess release
of catecholaminessuch as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis.
Important points to note when caring for these clients include the following:
1. Hypertension is difficult to treat and is often resistant to multiple drugs.

2. The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver).
3. Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can
precipitate a hypertensive crisis.
Hypertensive crisis puts the client at risk for stroke and so has the highest priority for treatment. Nitroprusside (Nitropress,
Nipride) is a vasodilator given via infusion and can be titrated to keep the BP within a desired parameter.
Propranolol is a nonselective beta-blocker that inhibits beta1 (heart) and beta2 (bronchial) receptors. It is used for many
indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heart
rate. Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client taking
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propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess for any history of
asthma or respiratory problems with this client and notify the health care provider (HCP).
Rifapentine (Priftin), a derivative of rifampin, is an antitubercular agent used with other drugs (eg, isoniazid) as a combination
therapy in active and latent tuberculosis infections. Both rifampin and rifapentine reduce the efficacy of oral contraceptives by
increasing their metabolism; therefore, this client will need an alternate birth control plan (non-hormonal) to prevent pregnancy
during treatment (Option 1).
A low-residue, high-protein, high-calorie diet, along with daily vitamin and mineral supplements, is encouraged to meet the
nutritional and metabolic needs of the client with ulcerative colitis. The low-residue diet limits trauma to the inflamed colon and
may lessen symptoms. Easily digested foods such as enriched breads, rice, pastas, cooked vegetables, canned fruits, and tender
meats are included in the diet. Raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol are
avoided. The well-balanced diet includes at least 2000-3000 mL/day of fluid to maintain fluid and electrolyte balance and
hydration. The prescribed sulfasalazine should be continued even when symptoms subside to prevent relapse. Because
sulfasalazine hinders the absorption of folate, folic acid supplements are encouraged.
An external fixator is a device used to stabilize broken bones; metal pins are placed through the tissue into the bone and connect
to a frame outside the skin. The nurse should monitor clients with external fixation closely for signs of neurovascular
compromise and pin site infection, which can lead to osteomyelitis. When caring for clients with external fixation, the nurse
can help prevent infection and maintain extremity and device integrity by:
 Assessing the pin sites regularly for new, increased, and/or purulent drainage and checking the skin surrounding the
pins for erythema, warmth, pain, or breakdown (Option 1)
 Assessing for signs of compartment syndrome (eg, decreased pulses, coolness, pain, numbness) (Option 4)
 Performing pin site care with a sterile cleaning solution (eg, chlorhexidine, sterile normal saline) and gauze (Option 5)
 Monitoring pins and device for loosening and reporting to the health care provider (HCP) if they are loose
(Option 2) The nurse should never manipulate loose pins but should instead notify the HCP immediately if loose pins are noted on
assessment.
(Option 3) The nurse should promote early mobilization for clients with external fixation devices. Some clients may begin walking
with physical therapy the day after surgery.
When caring for clients with external fixation, the nurse should assess for signs of infection (eg, pin site drainage), perform pin care
with a sterile cleaning solution, assess for loose pins, monitor for signs of neurovascular impairment (eg, decreased pulses,
coolness), and promote early mobilization.
Knowledge deficit is the lack of adequate information required for health recovery, maintenance, and promotion. The priority ND is
knowledge deficit of the prescribed therapeutic regimen manifested by the client's verbalization of nonadherence to the prescribed
MDR-TB therapy.
Medication to treat MDR-TB usually must be taken for 6 to 9 months. The length of the treatment regiment, the cost and amount
of medications that must be taken, and the unpleasant side effects all contribute to clients becoming nonadherent with treatment.
If clients do not properly complete the entire medication regimen, they risk reactivating the MDR-TB disease, increasing the
bacteria's drug-resistance, and spreading the disease to others. The medications cannot be discontinued until therapy is
complete.
(Option 1) Activity intolerance is an insufficient physiological or psychological energy to complete daily activities. In this client, it is
related to side effects of the medications and a deconditioned state and is manifested as fatigue or weakness. This is appropriate
to include in the care plan but is not the priority ND.
(Option 2) Imbalanced nutrition, less than body requirements, is an insufficient intake of nutrients to meet metabolic needs. In this
client, it is related to inability to ingest foods secondary to nausea, fatigue, and anorexia and is manifested by inadequate caloric
intake and a loss of appetite. This is appropriate to include in the care plan but is not the priority ND.
(Option 4) In this client, nausea is related to medication side effects and is suggested by a verbal report of nausea and loss of
appetite. It is appropriate to include this in the care plan but is not the priority ND.
The ND, knowledge deficit of the prescribed therapeutic regimen, is appropriate in a client with MDR-TB who is nonadherent to the
prescribed medication therapy. Nonadherence increases the risk for recurrence, development of drug-resistant organisms, and
spread of TB disease to others.
Urinary tract infections (UTIs) are usually bacterial in origin and are most often caused by Escherichia coli. The
microorganisms from the perineal area enter the urethra, causing inflammation and infection (urethritis). They ascend to the
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bladder, where they multiply, causing inflammation and infection (cystitis). The bacteria may continue to ascend the urinary tract to
the ureters and kidneys, causing inflammation and infection in the kidneys (pyelonephritis). A UTI is classified as upper or lower
according to its location within the urinary tract.
Cystitis is the most common community-acquired UTI. It is an infection of the lower urinary tract and involves inflammation of the
bladder mucosa, leading to hyperemia, tissue hemorrhage, and pus formation. This inflammatory process leads to burning with
urination (dysuria), urinary frequency and urgency, hematuria, and suprapubic discomfort (Options 3, 4, and 5).
(Options 1 and 2) When the infection ascends to the kidneys (pyelonephritis), clients become very ill. They develop nausea,
vomiting, fever with chills, and flank pain. Assessment shows costovertebral angle tenderness. If the infection is not recognized
and treated, clients can become septic.
Cystitis is an infection of the bladder mucosa. Clients develop burning with urination (dysuria), urinary frequency and urgency,
hematuria, and suprapubic discomfort. However, if the infection extends to the kidneys (pyelonephritis), clients become seriously ill
with nausea, vomiting, fever with chills, and flank pain.
The PMI is also called the apical pulse. It reflects the pulsation of the apex of the heart and should be felt medial to the
midclavicular line at the 4th or 5th intercostal space. When the PMI is below the 5th intercostal space or left of the midclavicular
line, the heart may be enlarged.
During cardiac assessment, the nurse should palpate the PMI medial to the midclavicular line at the 4th or 5th intercostal space.
Palpation of the PMI below the 5th intercostal space or to the left of the midclavicular line may indicate cardiac enlargement.
Alcohol withdrawal syndrome
Onset since last

Manifestations Symptoms/signs
drink (hr)
Anxiety, insomnia, tremors, diaphoresis, palpitations, gastrointestinal upset,

Mild withdrawal 6-24
intact orientation
Seizures Single or multiple generalized tonic-clonic 12-48
Alcoholic
Visual, auditory, or tactile; intact orientation; stable vital signs 12-48
hallucinosis
Confusion, agitation, fever, tachycardia, hypertension, diaphoresis,

Delirium tremens 48-96
hallucinations
One of every 6 clients undergoing an emergency surgical procedure will show some signs of alcohol withdrawal during the hospital
stay. Screening for heavy use of drugs and alcohol should occur at several points during hospitalization to avoid complications of
withdrawal. Delirium tremens and other withdrawal symptoms can be prevented with benzodiazepine administration during
hospitalization. The stages of alcohol withdrawal do not always occur as a progressive sequence.
(Option 1) Decreased respiratory rate is not a sign of alcohol withdrawal. It is more commonly seen in alcohol or opiate overdose.
(Option 4) Clients experiencing alcohol withdrawal symptoms will be agitated and have tremors and hyperreflexia.
Alcohol dependency is frequently missed during the admission process. Clients should always be screened for heavy use of
alcohol or benzodiazepines as withdrawal is potentially life-threatening and avoidable. Signs and symptoms of delirium tremens
include agitation, fever, tachycardia, hypertension, and diaphoresis.
When the client arrives in the post-anesthesia care unit after pacemaker placement, the nurse should attach the cardiac
monitor to assess the function of the pacemaker. If the atrioventricular (dual-chambered) pacemaker is working properly, pacer
spikes should be visible prior to the P waves and QRS complexes (electrical capture). If the pacemaker is not working properly
(eg, failure to capture, failure to sense), the health care provider should be contacted immediately (Option 3).
The nurse should also assess for mechanical capture by palpating the client's pulse rate and comparing it with the electrical rate
displayed on the cardiac monitor, and check the client's vital signs to assess stability following the procedure.
Hyperthyroidism results from excessive secretion of thyroid hormones. Affected clients are at risk for developing thyroid storm,
a life-threatening form of hyperthyroidism. Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial
fibrillation), nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining
hydration, and preventing cardiac compromise (eg, heart failure).
Clients with decreased level of consciousness may not be alert enough to protect their own airways; therefore, a side lying or
lateral position is used to decrease the risk for developing aspiration pneumonia. If vomiting were to occur, this position promotes
drainage of emesis out of the mouth instead of down the pharynx where it can be aspirated into the lungs. Maintaining an upright
position during and after meals will allow remaining food particles to clear from the pharynx.
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SBAR (situation, background, assessment, recommendation/read-back) is an established reporting format used to communicate
with the health care provider (HCP). Use of SBAR ensures that the HCP receives the necessary information to make a clinical
judgment regarding treatment or need for immediate assessment.
In this situation, the client's presentation indicates worsening symptoms that require immediate intervention. The client's lethargy
represents a declining level of consciousness. The client also has significantly abnormal vital signs (normal infant pulse rate is
110-160/min, respirations generally around 40/min). These are ominous signs that should be reported immediately (Option 3).
(Option 1) Although it is helpful to know that the change is fairly recent, it is most important to report the current concerning
change in the client's clinical presentation and vital signs.
(Option 2) Abnormal vital signs with a decreased level of consciousness are not improvements; rather, these findings indicate
deterioration.
(Option 4) It would not be appropriate to assume and treat potential constipation in this client without further assessment and
diagnostic procedures. The nurse needs to assess additional aspects, including bowel sounds, abdominal characteristics, and
temperature. Vital signs this significantly abnormal would not be caused by constipation.
SBAR (situation, background, assessment, recommendation/read-back) is used to transmit complete essential information to the
health care provider. Any abnormal vital signs or current deterioration should be communicated immediately.
Placental abruption is a possible complication of preeclampsia that can be life-threatening to mother and baby. It occurs when
the placenta tears away from the wall of the uterus due to stress, causing significant bleeding to the mother and depriving the baby
of oxygen. Bleeding can be concealed inside the uterus. This may require immediate delivery of the baby.
Dissociative identity disorder is a condition in which 2 or more identities alternately control the client's behavior. The alternate
identities likely develop as a response to abuse or traumatic events and serve to protect the client from stressful memories. The
client may not be aware of the alternate identities and may be confused by "lost time" and gaps in memory. Switching between
identities occurs as a reaction to stress and individual triggers. The goal of treatment is to integrate the identities into one
personality while maintaining safety.
The client should journal about feelings and dissociation triggers and use a grounding technique (eg, deep breathing, rubbing a
stone, counting coins) to counter dissociative episodes (Options 2 and 5). Identities may be volatile and should be monitored for
indications of harm to self or others (Option 4). The nurse should attempt to form trusting, therapeutic relationships with each
identity to explore feelings and facilitate identity integration (Option 1).
When caring for clients with dissociative identity disorder, the nurse should establish relationships with each identity, listen for
expressions of self-harm, allow clients to recall memories at their own pace, encourage journaling about feelings and dissociation
triggers, and teach grounding techniques to counter dissociative episodes.
A demand ventricular electronic pacemaker set at 70/min delivers an impulse (fires) when it senses an intrinsic rate below the
predetermined rate of 70/min. Failure to capture occurs when the pacemaker sends an impulse to the ventricle, but the
myocardium does not depolarize (pacer spike with no QRS complex; no palpable pulse beat); this is usually associated with pacer
lead (wire) displacement or battery failure. The malfunction can result in bradycardia (pulse <60/min) or asystole and decreased
cardiac output; the nurse should perform an assessment and notify the health care provider immediately.
(Option 1) Clients with atrial fibrillation are usually prescribed an anticoagulant, such as rivaroxaban (Xarelto), due to increased
risk for blood clots that can lead to stroke. This client's ventricular rate is controlled, so there is no urgency.
(Option 3) First-degree atrioventricular (AV) block can be associated with beta-adrenergic blocker drugs, such as atenolol
(Tenormin), as they delay conduction at the AV node. This is reflected as prolonged PR interval on ECG. Although first-degree AV
block should be monitored for progression, it is an expected adverse drug effect. Only second- or third-degree heart block should
be the priority.
(Option 4) Dehydration can cause hypotension. Tachycardia is a normal compensatory mechanism to increase the cardiac output
associated with hypotension.
A demand electronic pacemaker should deliver an impulse when it senses an intrinsic pacemaker drop below a predetermined
rate. Bradycardia with failure to capture (pacer spike with no QRS complex) indicates malfunction and requires immediate
notification of the health care provider.
The Institute for Safe Medication Practices has labeled insulin a high-alert medication. These types of medication can be safe and
effective when administered or taken according to recommendations. However, errors in administration may cause death or
serious illness.
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NPH is an intermediate-acting insulin with a duration of 12-18 hours; it is generally prescribed 2 times daily (morning and
evening). Regular insulin and other rapid-acting insulins (lispro, aspart, glulisine) are typically used with a sliding scale for tighter
control of blood glucose throughout the day. These are generally taken before meals and at bedtime.
(Options 1, 2, and 3) These are correct statements and indicate the teaching objective was completed successfully.
NPH is an intermediate-acting insulin with a duration of 12-18 hours and typically prescribed twice a day.
Hypothyroidism during pregnancy places clients at increased risk for other complications of pregnancy (eg, preeclampsia,
placental abruption, preterm labor). Symptoms of hypothyroidism may include fatigue, cold intolerance, constipation, dry skin, and
brittle hair/nails. Levothyroxine (Synthroid) is the first-line medication for treatment of hypothyroidism during pregnancy. The
client may experience some relief of symptoms beginning approximately 3-4 weeks after initiating levothyroxine therapy (Option
4). Hormone levels are usually rechecked every 4-6 weeks until normal thyroid hormone levels are achieved. It may take up to 8
weeks after initiation to see the full therapeutic effect.
(Option 1) Adequate levels of maternal thyroid hormones are important for fetal brain development, particularly during the first
trimester. Levothyroxine should not be stopped during pregnancy, even if symptoms resolve.
(Option 2) Prenatal vitamins containing iron can affect the absorption of levothyroxine and decrease its effectiveness. The nurse
should instruct the client to take levothyroxine in the morning on an empty stomach, at least 4 hours before or after taking a
prenatal vitamin.
(Option 3) As the pregnancy advances, the client's dose of levothyroxine may need to be increased. Thyroid stimulating hormone
(TSH) levels are closely monitored during pregnancy, and the client's dose is modified as needed to maintain normal levels.
Levothyroxine is the first-line treatment for hypothyroidism during pregnancy to maintain adequate levels of maternal thyroid
hormones, which are critical for fetal brain development. Symptoms of hypothyroidism typically begin to improve approximately 3-4
weeks after initiating levothyroxine. Therapy should not be stopped, even if symptoms resolve.
Shoulder dystocia is an obstetrical emergency in which the fetal head emerges but the anterior shoulder remains wedged
behind the maternal symphysis pubis. The nurse may initially observe the fetal head retracting back toward the maternal
perineum after birth of the head (ie, turtle sign). The condition is frequently associated with macrosomia (fetal weight >8 lb 13 oz
[4000 g]) secondary to gestational diabetes mellitus. However, the occurrence of shoulder dystocia is unpredictable and may be
related to maternal factors, such as suboptimal pelvic shape, obesity, or short stature, rather than fetal size.
The nurse's primary responsibilities during shoulder dystocia include performing the McRoberts maneuver (ie, sharp flexion of
maternal thighs toward abdomen to widen space between pubic bone and sacrum) and applying suprapubic pressure (ie,
downward pressure applied to maternal pubic bone to dislodge fetal shoulder) (Option 4).
(Option 1) Administering a tocolytic agent to stop contractions or relax the uterus is not recommended and does not resolve
shoulder dystocia.
(Option 2) Fundal pressure is contraindicated, as it may wedge the fetal shoulder further into the symphysis pubis or cause
uterine rupture.
(Option 3) Application of a vacuum extractor is contraindicated because it may further wedge the fetal shoulder into the symphysis
pubis, increasing the risk for brachial plexus injury.
Shoulder dystocia occurs when the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis
pubis. The nurse should be prepared to perform McRoberts maneuver and apply suprapubic pressure.
Sudden infant death syndrome (SIDS) is the leading cause of death among infants age 1 month to 1 year. Nurses should inform
caregivers about childcare practices that reduce the risk of SIDS, including:
 Place infant on the back to sleep on a firm surface every time. Infants should not share a bed with anyone.
 Avoid soft objects (eg, stuffed animals, pillows) in the infant's bed. Nothing in the bed with the infant is safest.
 Avoid bumper pads for the crib. Newer cribs do not require bumper pads because improved side rails prevent the
infant's head from getting stuck between slats (Option 4).
 Maintain a smoke-free environment.
 Avoid overheating. Infants do not require more than one extra layer than adults require to be comfortable.
 Breastfeed and ensure immunizations are updated.
(Option 1) Using a pacifier during sleep is appropriate and has been associated with a reduced incidence of SIDS. Pacifiers
should be delayed until after breastfeeding is well established.
(Option 2) A sleeper ("onesie") or a sleeping sack and a comfortable room temperature reduce the need for a blanket, which
could obstruct the infant's mouth and/or nose.
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(Option 3) Infants should sleep on a firm surface or mattress that fits the crib and is covered with a fitted sheet.
To reduce the risk of sudden infant death syndrome, infants should always be placed in their own bed, on their backs, and on a
firm surface without loose bedding or toys. Prevention also includes a smoke-free environment, breastfeeding, pacifiers,
avoidance of overheating, and immunizations.
The transmission of hepatitis A occurs most commonly through the fecal-oral route through poor hand hygiene and improper
food handling by infected persons. It is seen primarily in developing countries. After infection, the hepatitis A virus reproduces in
the liver and is secreted in bile. Therefore, hand hygiene (especially after toileting and before meals) is the most important
intervention to reduce the occurrence of hepatitis A infection (Option 4).
Vaccination against hepatitis A is recommended for all children at age 1 and for adults at risk of contracting the virus (health care
workers, men who have sex with men, drug users, those who travel to areas with a high prevalence, those with clotting disorders,
and those with liver disease).
(Options 1 and 2) Hepatitis A is secreted in bile and is more often transmitted via the fecal-oral route. However, the virus can
also be spread through needle sharing between intravenous drug users and unsafe sexual practices. These practices should be
discouraged and hand hygiene encouraged as the most important intervention for prevention.
(Option 3) Vaccination is an important means of preventing infection. However, hygienic measures (eg, hand washing, sanitation,
cleanliness, avoiding sharing personal items) are readily implemented by all clients regardless of means.
Hepatitis A is spread via the fecal-oral route. Therefore, hygienic practices (eg, hand hygiene, sanitation) are the fastest and most
readily available interventions available to prevent the spread of the hepatitis A virus. Needle sharing and unprotected sex should
be discouraged, and all children age at least 1 year should receive the hepatitis A vaccine.
The majority of cases of epiglottitis are caused by Haemophilus influenza type B (HiB), which is covered under the standard
vaccinations given during the 2- and 4-month visits. Epiglottitis is rarely seen in vaccinated children.
Cases of epiglottitis are preventable, and parents should always be educated on the risks of foregoing vaccinations for their
children.
Pharyngitis caused by group A β-hemolytic Streptococcus is a contagious bacterial throat infection that can lead to renal
(glomerulonephritis) or cardiac complications (rheumatic fever) if not treated.
Children may refuse to eat due to pain. A soft diet and cool liquids (ice chips) should be offered rather than solid foods (Option 2).
It is important to complete the full course of antibiotics to prevent reinfection and complications (Option
1). Toothbrushes should be replaced 24 hours after starting antibiotics; the bristles can harbor the bacteria and reinfection may
occur (Option 4).
Young children may have minor cold symptoms and still be infected. The health care provider should test siblings age <3.
(Option 3) Children with streptococcal pharyngitis may return to school or daycare after they have completed 24 hours of
antibiotics and are afebrile.
(Option 5) Throat lozenges can be given to older children but are a choking hazard in younger children. Acetaminophen or
ibuprofen (liquid preparations) should be given for pain.
Pharyngitis caused by group A β-hemolytic Streptococcus is a bacterial throat infection that can cause renal or cardiac
complications if not treated. It is important to discard the child's toothbrush 24 hours after starting antibiotics, test siblings age <3
years, and complete the full course of prescribed antibiotics.
Most cases of intussusception are successfully treated without surgery using hydrostatic (saline) or pneumatic (air) enema. The
nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the HCP should
be notified immediately to modify the plan of care and stop all plans for surgery.
(Option 2) In intussusception, the stools are mixed with blood and mucus, giving a characteristic "currant jelly" appearance. This
is an expected finding.
(Option 3) Pain in intussusception is typically intermittent. It occurs every 15-20 minutes, along with screaming and drawing up
of the knees. Therefore, if a child stops crying, it may not be due to reduction of intussusception.
(Option 4) Intense pain causes spasms of the pyloric muscle that lead to vomiting after each episode. Vomiting tends to resolve
once the intussusception is reduced.
Reduction of intussusception is often performed with a saline or air enema. The HCP should be notified if there is passage of a
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normal stool as this indicates reduction of the intussusception. All plans for surgery should be stopped and the plan of care should
be modified.
Most cases of intussusception are successfully treated without surgery using hydrostatic (saline) or pneumatic (air) enema. The
nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the HCP should
be notified immediately to modify the plan of care and stop all plans for surgery.
(Option 2) In intussusception, the stools are mixed with blood and mucus, giving a characteristic "currant jelly" appearance. This
is an expected finding.
(Option 3) Pain in intussusception is typically intermittent. It occurs every 15-20 minutes, along with screaming and drawing up
of the knees. Therefore, if a child stops crying, it may not be due to reduction of intussusception.
(Option 4) Intense pain causes spasms of the pyloric muscle that lead to vomiting after each episode. Vomiting tends to resolve
once the intussusception is reduced.
Reduction of intussusception is often performed with a saline or air enema. The HCP should be notified if there is passage of a
normal stool as this indicates reduction of the intussusception. All plans for surgery should be stopped and the plan of care should
be modified.
Cerebral vascular accidents (strokes) can cause visual and perceptual deficits depending on which part of the brain is affected.
Clients with changes in visual field or perception of their body in space can be at risk for safety-related injuries. Homonymous
hemianopsia is a loss in half of the visual field on the same side. For example, the client may lose the left side of the visual field
in both eyes. A client unable to see the left side of the body is at a higher risk for neglecting that side or being unable to eat food
placed on the left side of a plate. These clients are at higher risk for injury because they are unable to incorporate full visual field
input. They are taught to turn the head and scan to the side with the visual field deficit to reduce the risk for injury and self-
neglect.
Obstructive sleep apnea (OSA) is a chronic condition that involves the relaxation of pharyngeal muscles during sleep. The
resulting upper airway obstruction with multiple events of apnea and shallow breathing (hypopnea) leads to hypoxemia and
hypercapnia. CPAP is an effective treatment for OSA; it involves using a nasal or full face mask that delivers positive pressure to
the upper airway to keep it open during sleep.
In this case, the nurse's first action should be to check the tightness of the straps that hold the mask in place. The full face mask
must fit snugly over the client's nose and mouth without air leakage to maintain the positive airway pressure and prevent
obstruction of upper airway airflow. Readjustment of the head straps may be necessary
Heat exhaustion is the result of prolonged exposure to excessive heat. Heat exhaustion manifests with elevated body
temperature (hyperthermia), intravascular volume depletion, and electrolyte imbalance. Manifestations
include dizziness, weakness, fatigue, sweating, flushing, nausea, tachycardia, and muscle cramping.
If heat exhaustion is suspected, the client should be moved to cooler temperatures and provided a cool sports drink, another
electrolyte-containing beverage (eg, Gatorade), or water (Option 4). The priority is to lower the body temperature to prevent heat
stroke, a potentially fatal condition associated with mental status changes (ie, indicating brain damage) and additional organ
damage (eg, kidney injury, rhabdomyolysis).
Topical capsaicin cream (Zostrix) is an over-the-counter analgesic that effectively relieves minor pain (eg, osteoarthritis,
neuralgia). The nurse should instruct the client to wait at least 30 minutes after massaging the cream into the hands before
washing to ensure adequate absorption (Option 2). The client should avoid contact with mucous membranes (eg, nose,
mouth, eyes) or skin that is not intact, as capsaicin is a component of hot peppers and can cause burning. When applying cream
to other areas of the body (eg, knee), the client should wear gloves or wash hands immediately after application.
Certain individuals should receive prophylactic antibiotics prior to dental procedures to prevent infective endocarditis (IE). These
include the following:
 Prosthetic heart valve or prosthetic material used to repair heart valve

 Previous history of IE
 Some forms of congenital heart disease
o Unrepaired cyanotic congenital defect
o Repaired congenital defect with prosthetic material or device for 6 months after procedure
o Repaired congenital defect with residual defects at the site or adjacent to the site of a prosthetic patch or device
 Cardiac transplantation recipients who develop heart valve disease
Neurologic injury is the most common cause of mortality in clients who have had cardiac arrest, particularly ventricular
fibrillation or pulseless ventricular tachycardia. Inducing therapeutic hypothermia in these clients within 6 hours of arrest and
maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes. It is indicated in all
clients who are comatose or do not follow commands after resuscitation.
The client is cooled to 89.6-93.2 F (32-34 C) for 24 hours before rewarming. Cooling is accomplished by cooling blankets; ice
placed in the groin, axillae, and sides of the neck; and cold IV fluids. The nurse must closely assess the cardiac monitor
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(bradycardia is common), core body temperature, blood pressure (mean arterial pressure to be kept >80 mm Hg), and skin for
thermal injury. The nurse must also apply neuroprotective strategies such as keeping the head of the bed elevated to 30 degrees.
After 24 hours, the client is slowly rewarmed
Oxybutynin (Ditropan) is an anticholinergic medication that is frequently used to treat overactive bladder. Common side effects
include:
 New-onset constipation
 Dry mouth
 Flushing
 Heat intolerance
 Blurred vision
 Drowsiness
Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and
during physical activity (Option 1).
Anticholinergic medications are commonly associated with constipation, urinary retention, flushing, dry mouth, and heat
intolerance. Clients should be taught to prevent these side effects by increasing intake of fluids and bulk-forming foods (prevents
dry mouth and constipation) and by avoiding locations or activities that may lead to hyperthermia.
Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction,
reduced blood flow, vascular stasis, and cell damage. Superficial frostbite can manifest as mottled, blue, or waxy yellow skin.
Deeper frostbite may cause skin to appear white and hard and unable to sense touch. This can eventually progress to gangrene.
Treatment of frostbite should include the following:
 Remove clothing and jewelry to prevent constriction.

 Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged (Option 3).
 Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do
not significantly decrease rewarming time but can intensify pain (Option 5).
 Avoid heavy blankets or clothing to prevent tissue sloughing.
 Provide analgesia as the rewarming procedure is extremely painful (Option 4).
 As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to
reduce edema (Option 2).
 Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose,
nonadherent, sterile dressings (Option 1).
 Monitor for signs of compartment syndrome.
Care of the client with frostbite focuses on preventing further injury and reducing pain. This includes removing items that can
cause constriction or sloughing; no massaging or rubbing of the injured area; providing warm water soaks and analgesia; elevating
injured areas; applying loose, nonadherent, sterile dressings; and monitoring for compartment syndrome.
Herbal supplement Uses Side effects
 Memory enhancement  Increased bleeding risk

Ginkgo biloba
 Improved mental performance  Increased bleeding risk

Ginseng
 Mild stomach discomfort

 Benign prostatic hyperplasia
Saw palmetto  Increased bleeding risk
 Postmenopausal symptoms (hot

 Hepatic injury
Black cohosh flashes & vaginal dryness)
St John's wort  Depression  Drug interactions: Antidepressants (serotonin

 Insomnia syndrome), OCs, anticoagulants (↓ INR), digoxin
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 Hypertensive crisis
 Anxiety
 Severe liver damage
Kava  Insomnia
 Stomach ulcers
 Hypertension
Licorice  Hypokalemia
 Bronchitis/viral infections
 Treatment & prevention of cold &

 Anaphylaxis (more likely in asthmatics)
Echinacea flu
 Hypertension
 Treatment of cold & flu
 Arrhythmia/MI/sudden death
 Stroke
Ephedra  Weight loss & improved athletic
performance
 Seizure
MI = myocardial infarction; OCs = oral contraceptives.

St John's wort is an herbal supplement commonly used to treat depression and anxiety. Some clients with mild or moderate
depression claim that its antidepressant effect is comparable to that of prescription medications. The herbal supplement mimics
the action of selective serotonin reuptake inhibitors (SSRIs) by increasing available serotonin in the brain. Taken in combination
with an SSRI (eg, sertraline, fluoxetine, citalopram, paroxetine), St John's wort may cause an excess of serotonin, resulting
in serotonin syndrome, which is characterized by mental status changes, autonomic dysregulation, and neuromuscular
hyperactivity.
The client with a newly diagnosed depressive disorder will likely be prescribed an antidepressant. The nurse should teach the
client not to take St John's wort concurrently with SSRIs to prevent serotonin syndrome (Option 4).
(Option 1) Echinacea is commonly used to prevent or treat the common cold/flu, although there is no evidence of its efficacy. It is
thought to work by stimulating the immune system. Worsening asthma and anaphylaxis have been reported.
(Option 2) Garlic is used to improve cholesterol and lower blood pressure. Ginkgo, garlic, and ginseng (the 3 Gs) increase
bleeding risk when taken with anticoagulants or thrombolytics.
(Option 3) Glucosamine is used to improve joint function. Hypoglycemia may result when it is taken with antidiabetic drugs.
Selective serotonin reuptake inhibitors and St John's wort increase serotonin levels in the brain. Clients taking both products
concurrently are at risk for potentially life-threatening serotonin syndrome (agitation, confusion, tachycardia, diaphoresis, tremors,
hyperreflexia).
A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic
purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is
drawn. The nurse's role when assisting with a lumbar puncture includes the following:
1. Verify informed consent

2. Gather the lumbar puncture tray and needed supplies
3. Explain the procedure to older child and adult
4. Have client empty the bladder
5. Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward
over a bedside table)
6. Assist the client in maintaining the proper position (hold the client if necessary)
7. Provide a distraction and reassure the client throughout the procedure
8. Label specimen containers as they are collected
9. Apply a bandage to the insertion site
10. Deliver specimens to the laboratory
When assisting with a lumbar puncture, the nurse verifies informed consent, gathers supplies, explains the procedure, has the
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client void, and then assists the client into position. During the procedure, the nurse provides a distraction, helps the client stay in
position (if needed), and labels specimens as they are collected. Afterward, the nurse applies a bandage and ensures that the
specimens are delivered to the laboratory.
When a terminally ill person refuses food, family members often become upset and frustrated in their roles of nurturers and
caregivers; they may feel personally rejected. Refusal of food is associated with "giving up" and is a reminder that their loved one
is dying. It is not uncommon for family members to believe that a client would get stronger by eating instead of refusing food.
The registered nurse needs to explore family members' concerns and fears and listen as they express their feelings. The nurse
can help them identify other ways to express how they care. The nurse should also provide education about the effects of food
and water during all stages of the illness.
It is very common for family members to become distressed when a terminally ill loved one refuses food. The nurse needs to
explore their fears and concerns and help them identify other ways to express how they care.
Sepsis neonatorum is a medical emergency. Newborns may not exhibit obvious signs of infection but instead may have elevated
temperature or be hypothermic. Subtle changes such as irritability, increased sleepiness, and poor feeding should be
considered red flags. Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum antibiotics
started.
Sepsis in a newborn is life-threatening. Newborns with fever, lethargy, and refusal to feed require a full septic workup. Broad-
spectrum antibiotics should be started immediately after obtaining blood, urine, and cerebrospinal fluid cultures.
Green amniotic fluid indicates that the fetus has passed its first stool (meconium) in utero. Meconium-stained amniotic fluid places
the newborn at risk for meconium aspiration syndrome, a type of aspiration pneumonia. A skilled neonatal resuscitation team
should be present at the birth of any newborn with meconium-stained fluid for immediate evaluation and stabilization (Option 4).
Previously, endotracheal (ET) suctioning was recommended for nonvigorous newborns (eg, depressed respirations, decreased
muscle tone, heart rate <100/min) born with meconium-stained fluid; however, recent guidelines indicate that routine ET suctioning
is no longer necessary.
(Option 1) Neonates born to mothers with gestational diabetes are at risk for hypoglycemia after birth and should be monitored
closely during the first 6 hours of life. The risk of newborn hypoglycemia is lower if the mother's diabetes is well-controlled and not
insulin-dependent.
(Option 2) Clients with severe preeclampsia may need magnesium sulfate therapy for seizure prevention. Maternal magnesium
therapy can cause newborn respiratory depression at birth. However, this client's mild preeclampsia does not require magnesium
therapy.
(Option 3) Premature rupture of membranes (PROM) refers to the rupture of membranes prior to the onset of labor at term
gestation (≥37wk 0d). PROM on its own does not harm the fetus. However, if labor does not begin after PROM, induction of labor
may be necessary to decrease the risk for infection (eg, chorioamnionitis).
Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome. A skilled neonatal resuscitation
team should be present at birth for immediate newborn evaluation and stabilization.
The SBAR (Situation-Background-Assessment-Recommendation) provides a framework for communicating information about a

change in client status to the health care provider (HCP). It includes the following information:
1. S = Situation – what prompted the communication

2. B = Background – pertinent information, relevant history, vital signs
3. A = Assessment – the nurse's assessment of the situation
4. R = Recommendation – request for prescription or action from the HCP
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The report given by the nurse in Option 3 contains the most appropriate and complete information. The nurse includes pertinent
data related to history, admission, and present treatment (background); indicates when and what changes occurred (situation,
assessment); and requests a prescription from the HCP (recommendation).
(Option 1) This report does not include any information indicating a time frame for admission or when the change in condition
occurred.
(Option 2) This report does not include any information related to the admission time frame, current diagnosis, or pertinent data
assessed by the nurse giving the report.
(Option 4) This report does not include any information related to the admission time frame or pertinent data assessed by the
nurse giving the report.
Nurses commonly use the SBAR framework to report changes in client status to the health care provider, communicating the
current situation, client background, nurse's assessment, and a recommendation for prescription or action.
Patient-controlled analgesia (PCA) delivers a set amount of IV analgesic each time the client presses the administration button.
With many PCA pumps, a continuous IV solution (eg, normal saline) is required to keep the vein open and flush the PCA
medicationthrough the line so that the boluses reach the client. Many facilities have a policy regarding IV fluid for use with PCA;
however, a prescription may be required. To ensure uninterrupted delivery of this client's PCA, the nurse should contact the health
care provider to clarify the prescription to discontinue the normal saline.
(Option 1) A "keep-vein-open" rate (eg, 5-20 mL/hr) may be appropriate; however, a prescription is necessary before the nurse
can implement this.
(Option 3) This client is still receiving PCA, so it is inappropriate to convert the IV to a saline lock. In addition, this does not
address the need to flush the PCA medication through the line.
(Option 4) Continuous IV fluids may be required to deliver the PCA boluses; before discontinuing the normal saline, the nurse
should receive clarification from the health care provider.
Continuous IV fluids are often necessary with use of a patient-controlled analgesia (PCA) pump; the fluids maintain an open vein
and provide a vehicle for PCA delivery.
Leukemia is characterized by unrestricted proliferation of abnormal white blood cells (lymphoblasts), resulting in depression of
normal bone marrow activity. This disorder is the most common form of childhood cancer. Infection is a major concern due
to neutropenia. In addition, anemia occurs due to decreased red blood cell production, and bleeding is common as a result of
decreased platelet production.
It would be appropriate for this client with leukemia to share a room with a client with minimal change nephrotic syndrome
(MCNS). MCNS is a non-infectious condition of the glomeruli and poses no risk to a client with leukemia.
(Option 1) Appendicitis is a result of viral or infectious processes and can lead to rupture of the appendix. A client recovering from
a ruptured appendix poses a threat of infection to the child who has leukemia.
(Option 2) A client with cystic fibrosis has pulmonary complications due to thick mucus that traps bacteria. The tracheobronchial
tree is colonized with bacteria and respiratory infections are a lifelong problem. This client poses a threat of infection to the child
with leukemia.
(Option 4) Rheumatic fever occurs following pharyngitis caused by group A β-hemolytic Streptococcus. A client with this
condition poses a threat of infection to the child with leukemia.
Leukemia is a cancer of the blood and organs involved in hematologic function. Due to myelosuppression, clients are at risk for
problems related to infection, anemia, and bleeding.
When performing the suctioning procedure, the nurse follows institution policy and observes principles of infection control and
client safety. Strict aseptic technique is maintained because suctioning can introduce bacteria into the lower airway and lungs.
1. Place the client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation.
2. Preoxygenate with 100% oxygen (hyper-oxygenate) to prevent hypoxemia and microatelectasis. Alternately, if the client
is breathing room air independently, ask the client to take 3-4 deep breaths.
3. Insert the catheter gently the length of the airway without applying suction to prevent mucosal tissue damage. The
distance can be premeasured (0.4-0.8 in [1-2 cm] past the distal end of the tube).
4. Withdraw the catheter slightly (0.4-0.8 in [1-2 cm]) if resistance is felt at the carina (bifurcation of the left and right
mainstem) to prevent mucosal tissue damage.
5. Apply intermittent suction while rotating the suction catheter during withdrawal to prevent mucosal tissue damage. Limit
suction time to 5-10 seconds with each suction pass to prevent mucosal tissue damage and limit hypoxia.
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Suctioning removes secretions from the airway. The nurse should minimize risks associated with suctioning by using correct
aspiration technique and client positioning. Semi-Fowler's position promotes lung expansion. Preoxygenation and limit of suction
time to 5-10 seconds reduces hypoxia and trauma.
Atopic dermatitis (AD), also known as eczema, is a chronic skin disorder characterized by pruritus, erythema, and dry skin.
The exact cause of AD is unknown, although it may be associated with an impaired skin barrier and resulting immune response to
invading allergens.
The primary goals of management are to alleviate pruritus and keep skin hydrated to reduce scratching. Scratching leads to
formation of new lesions and potential secondary infections.
 Parents should be instructed to give tepid baths using gentle soap; hot water and long bubble baths dry skin and should
be avoided (Option 3)
 Skin should be gently patted dry after bathing, followed by immediate application of an emollient (eg, Eucerin, Cetaphil)
to seal in moisture (Option 1)
 Nails should be trimmed short and kept filed to reduce scratches (Option 4)
 Clothing should be soft (eg, cotton) and climate-appropriate to reduce perspiration, which can intensify pruritus. Long
sleevesshould be worn at night.
 Avoid trigger factors such as heat and low humidity
(Option 2) Wool pajamas and other rough fabrics can cause itching and sweating. Soft cotton fabrics are a better choice.
(Option 5) Rubbing or vigorously drying can damage the skin and lead to exacerbations or infection. Skin should be patted dry
gently.
Atopic dermatitis (eczema) is a chronic skin disorder manifested by pruritus, erythema, and very dry skin. The goal of
management is to reduce scratching with key measures such as giving tepid baths, moisturizing skin with emollients, wearing soft
cotton clothing, and keeping nails trimmed short.
The procedure for safe blood administration includes the following:
1. Obtain a unit of blood from the blood bank and verify the blood product with type and crossmatch results and at least 2
client identifiers with another nurse at the client's bedside. The blood is obtained and infused one unit at a time (Option
2).
2. Assess the client, obtain vital signs for baseline, and teach signs of a transfusion reaction and how to call for help.
3. Use a Y tubing, prime with NS, and then clamp the NS side (Option 6).
4. Spike the blood product, leaving the blood side of the Y tube open while keeping the saline side clamped for
infusion. The saline is only used to prime the tubing and flush after the infusion. It does not infuse
simultaneously.
5. Set the infusion pump to deliver blood over 2–4 hours as prescribed (Option 5). Rapid infusion of the blood puts the
client at greater risk for transfusion reaction and fluid volume overload.
6. Remain with the client for at least the 1st 15 minutes and watch for signs of blood transfusion reaction, including fever,
chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. Stop the transfusion
immediately if a reaction occurs. The first 15 minutes of infusion should be slow to watch for these reactions.
7. Take another set of vital signs 15 minutes after infusion starts and continue in accordance with facility policy. Always
take a final set of vital signs after the infusion is complete.
8. On completion of the blood transfusion, open the saline side clamp of the Y tubing to flush all blood in the tubing through
with NS.
9. Return the blood bag with the attached set-up to the laboratory after completion or dispose of in accordance with hospital
policy. Use new IV Y tubing set-up for the second unit of blood.
Always verify blood products, type and crossmatch results, and client identifiers with another nurse prior to transfusion. Obtain vital
signs before, during, and after blood administration. Use Y tubing primed with NS and an IV pump for administration. Watch for
transfusion reaction and stop the transfusion immediately if a reaction occurs.
Client education on early detection of skin cancer is important as most cases of malignant melanoma are discovered by the client.
A full medical workup of every mole is unnecessary. Routine self-evaluation followed by medical assessment of questionable
growths is sufficient. Clients with advanced age or reduced mobility may need to see a dermatologist for a full-body skin survey.
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Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril, lisinopril, ramipril) and angiotensin II receptor blockers (eg,
losartan, valsartan, telmisartan) should be avoided in clients who are planning to become pregnant. These drugs are teratogenic,
leading to fetal renal and cardiac abnormalities, and are contraindicated in all stages of pregnancy.
(Option 1) Prenatal supplements, especially folic acid and iron, are recommended during pregnancy. Although important, this is
not a priority over discontinuing ACE inhibitors.
(Option 3) Leukorrhea, a whitish vaginal discharge, is common during the prenatal period. The client should be instructed to call
the health care provider if the discharge is accompanied by other signs or symptoms, such as a foul odor, redness, or itching.
(Option 4) As the uterus enlarges, cramping may occur in the lower abdomen and inguinal region. This common finding can be
caused by stretching of the round ligaments, and is usually not concerning in the absence of vaginal bleeding.
Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are teratogenic and need to be discontinued when
planning pregnancy.
The RN can safely delegate the following tasks to the UAP to promote client safety during toileting and ambulating:
 Place the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing
aids, cell phones) as close to the client as possible
 Remind the client of the importance of changing position slowly to minimize orthostatic hypotension
 Report observations of changes in the client's condition (eg, level of consciousness, vital signs, pain level) immediately
 Keep the bed in the lowest position (locked) as it reduces the distance to the floor in the event of a fall
 Provide nonskid footwear for the client before ambulating
 Keep the environment dry and free of clutter and obstacles (eg, intravenous infusion device tubing and poles, electronic
device wires and cords)
Sputum culture and sensitivity testing is used to identify infectious organisms in the respiratory tract and determine which
antimicrobials are most effective at treating the identified organism. Nurses assisting a client to collect sputum should instruct the
client to:
 Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen
contamination by oral flora (Option 1)
 Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of
the skin (Option 2)
 Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and
increases sample volume (Option 3)
 Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during
collection (Option 5)
(Option 4) Sputum specimens should be collected early in the morning after awakening, which improves the quality of the sample
because secretions accumulate overnight due to cough inhibition. A nebulizer treatment may be prescribed to help mobilize thick
secretions.
Collection of a sputum specimen by expectoration is a sterile procedure that requires the client to breathe deeply and cough
effectively. The nurse should instruct the client to rinse the mouth with water, sit upright, inhale deeply several times, and cough
prior to expectorating. The client should avoid touching the inside of the sterile container or lid. Sputum should be collected in the
morning to improve sample quality.
Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the
increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding.
Teaching topics for clients on anticoagulants:
 Take medication at the same time daily

 Depending on medication, report for periodic blood tests to assess therapeutic effect
 Avoid any action that may cause trauma/injury and lead to bleeding (eg, contact sports, vigorous teeth brushing, use of a
razor blade) (Option 4)
 Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs)
 Limit alcohol consumption
 Avoid changing eating habits frequently (eg, dramatically increasing intake of foods high in vitamin K such as kale,
spinach, broccoli, greens) (Option 2) and do not take vitamin K supplements
 Consult with health care provider before beginning or discontinuing any medication or dietary/herbal supplement
(eg, Ginkgo biloba and ginseng affect blood clotting and may increase bleeding risk) (Option 1)
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 Wear a medical alert bracelet indicating what anticoagulant is being taken
(Option 3) Early in the recovery period, care of the incision site typically includes washing with soap and water and patting it dry.
Ointments (eg, vitamin E) may be applied after the incision has healed.
Clients who are on anticoagulants should avoid aspirin, NSAIDS, and other over-the-counter or herbal products (eg, Ginkgo biloba)
that can increase bleeding risk. They should also avoid behaviors that increase the risk of clotting (eg, eating excess green leafy
vegetables).
Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction that occurs from relaxation of the
pharyngeal muscles, airway closure, and lack of airflow. This leads to repeated episodes of apnea (≥10 seconds) and hypopnea
(≤50% of normal ventilation), resulting in hypoxemia and hypercapnia.
Administration of general anesthesia or sedating medications (eg, opioids and benzodiazepines) can exacerbate OSA by
decreasing pharyngeal muscle tone and increasing airway closure even further. Therefore, being on continuous positive airway
pressure (CPAP) is very important in these clients, especially during sleep.
The nurse should assess level of consciousness, lung sounds, vital signs, and pulse oximeter readings, and then compare these
with the client's baseline measurements. The nurse should also continue to monitor respiratory status as IV morphine peaks in 20
minutes and has a duration of 3-4 hours.
(Option 1) This 22-year-old with sickle cell crisis will likely need large doses of narcotics due to increased tolerance from prior
use. The nurse needs to assess the pain and any complications from narcotic use. However, this is not the first priority.
(Option 2) This 26-year-old has pneumonia and right side pain on deep inspiration, which indicate pleuritic pain (inflammation of
the 2 layers of pleura). Pleuritic pain is an expected finding associated with pneumonia and is not the priority assessment.
(Option 3) Moderate to severe postoperative pain and lack of audible bowel sounds (due to general anesthesia, bowel
manipulation, and opioid drugs) are expected findings 1 day after major abdominal surgery. This client is not the priority.
Clients with obstructive sleep apnea (OSA) who are receiving sedatives or narcotics require frequent monitoring as these can
exacerbate OSA symptoms. These clients are at increased risk for respiratory complications such as oversedation, respiratory
depression, hypoxia, and hypercapnia.
Sulfasalazine (Azulfidine) is a sulfonamide (salicylate and sulfa antibiotic) and nonbiologic disease-modifying antirheumatic drug
(DMARD) used for mild to moderate chronic inflammatory rheumatoid arthritis (RA) and inflammatory bowel disease (eg, ulcerative
colitis). It inhibits the production of prostaglandin, a mediator in the body's inflammatory response.
Most "sulfa" medications (eg, trimethoprim, sulfamethoxazole) share common side effects, including:
1. Crystalluria causing kidney injury – client should drink 8 glasses of water daily to maintain adequate urine output (eg,
1200-1500 mL/day)
2. Photosensitivity and risk for sunburn – client should avoid sun exposure and apply sunscreen
3. Folic acid deficiency (megaloblastic anemia and stomatitis) – client should eat folate-rich foods and take 1 mg/day folic
acid supplement
4. Rarely life-threatening agranulocytosis (leukopenia) – client should be monitored for complete blood count at the start of
therapy and report fever or sore throat immediately
5. Stevens-Johnson syndrome – client should stop the medicine if rash develops
(Option 2) Ulcerative colitis is characterized by bloody diarrhea, and the medication is taken to reduce this effect.
(Option 3) Urine and skin can turn an orange-yellow color but will return to normal when the drug is discontinued. This is an
expected finding.
Sulfasalazine (Azulfidine) is used for mild to moderate chronic inflammatory RA and inflammatory bowel disease. Important
adverse effects include crystalluria with kidney injury, yellow-orange skin and urine discoloration, folic acid deficiency, and
photosensitivity.
The nurse needs to provide education to the client with a venous leg ulcer who refuses to wear compression
stockings. Compression is essential for the treatment of chronic venous insufficiency, venous ulcer healing, and prevention of
ulcer recurrence. The client will need individual evaluation to determine what level of compression is needed. Assessment of the
ankle-brachial index (ABI) should be performed as well. An ABI of <0.9 suggests concurrent PAD and the need for lower levels of
compression therapy. There are several options that the nurse can explore with the client to decide which compression device will
work best in the situation (custom-fitted elastic compression stockings, elastic tubular support bandages, Velcro wrap, paste
bandage with elastic wrap, or a multilayer bandage system).
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(Option 1) Dangling a limb over the side of the bed is a common practice among PAD clients to relieve pain. There is no need for
this client to discontinue this practice as it allows gravity to maximize blood flow.
(Option 2) Immersing hands in warm water can decrease vasospasm in this client with Raynaud's phenomenon.
(Option 4) This practice should be encouraged by the nurse. It can help prevent venous thromboembolism following surgery.
The nurse needs to educate the client with a venous leg ulcer that wearing some kind of compression stockings is essential for
healing and prevention of ulcer recurrence.
The practices, needs, and experiences of grief vary greatly among individuals. Nurses caring for grieving clients must skillfully use
therapeutic communication techniques to strengthen the nurse-client relationship and support clients in exploring emotions and
experiences.
Reflection (eg, acknowledging client statements) and using open-ended questions or statements assist the client in exploring
emotions and allow for expression of needs (Option 4). Nurses may also suggest strategies and share resources (eg, support
group) to facilitate the client's grieving process (Option 5).
The basic life support sequence is compressions, airway, and breathing (mnemonic - CAB). High-quality CPR is associated with
improved client outcomes and begins with high-quality chest compressions (ie, 100-120/min, 2-2.4 in [5-6 cm] deep). Any
unwitnessed collapse should be treated with 2 minutes of CPR, followed by activating the emergency response system and
obtaining an automated external defibrillator. If no shock is advised, the nurse should resume high-quality chest compressions
immediately (Option 3).
(Option 1) Chest compressions should not be interrupted for more than 10 seconds when assessing for a pulse and chest rise/fall.
(Option 2) Rescue breaths every 5-6 seconds (10-12 breaths/min) are given to clients who have a pulse but are not breathing
normally. For clients with no pulse, the nurse should deliver cycles of 30 compressions followed by 2 rescue breaths.
(Option 4) The jaw-thrust maneuver is used instead of the head-tilt/chin-lift method in clients who may have a head/spinal injury.
Repositioning the jaw forward opens the airway to allow for assessment and delivery of rescue breathing. Assessing the airway is
not indicated at this time.
In basic life support for an unresponsive, pulseless client, the nurse should begin with 2 minutes of CPR in cycles of 30 high-quality
chest compressions to 2 rescue breaths, followed by activating the emergency response system and obtaining an automated
external defibrillator. If no shock is advised, the nurse should resume chest compressions immediately.
Oropharyngeal candidiasis, or thrush (moniliasis), is an infection of the mucous membranes generally caused by the yeastlike
fungus Candida albicans. The fungus causes pearly, "milk-curd" lesions on the oral or laryngeal mucosa that may bleed when
removed.
Immunosuppressed individuals such as those taking corticosteroid medications, clients undergoing chemotherapy or radiation,
or clients with immune deficiency states (eg, AIDS) have an increased incidence. Clients receiving prolonged or high-
dose antibiotic treatment are at increased risk as the normal microbial flora of the mouth is reduced, allowing other opportunistic
infections to arise (Option 2). Individuals with dentures and infants also commonly experience monilial infections. Treatment is
antifungal medications (eg, nystatin) and proper oral hygiene.
(Option 1) Inhaled beta-2 agonists (eg, albuterol) do not increase the risk for fungal infections. However, individuals taking an
inhaled corticosteroid (eg, budesonide, fluticasone) are at increased risk for oral candidiasis. To reduce this risk, the client should
rinse the mouth after each inhaled dose and maintain good oral hygiene.
(Options 3 and 4) Proper oral hygiene and nutrition are important in prevention of oral candidiasis. However, the client with
braces or poor hygiene and inadequate nutrition is at lower risk than one who is immunosuppressed or taking antibiotics.
Immunosuppressed clients (eg, taking steroids, undergoing chemotherapy or radiation, with immunodeficient states) and those
taking prolonged or high-dose antibiotics are at increased risk of oral candidiasis. Elderly clients with dentures are also at high
risk. Infection is treated with antifungals (eg, nystatin) and proper oral hygiene.
If the chest tube is dislodged from the client and the nurse hears air leaking from the site, the nurse's immediate action should be
to apply a sterile occlusive dressing (eg, petroleum jelly dressing) taped on 3 sides. This action permits air to escape on
exhalation and inhibits air intake on inspiration. The nurse would then notify the HCP and arrange for the reinsertion of another
chest tube
The client with chronic heart failure is at risk for exacerbations that may require hospitalization. The priority for the nurse on the
phone is to ascertain if the client is experiencing any physiological symptoms such as shortness of breath, coughing, or
edema (Option 4). These could indicate fluid overload. This information can help the nurse direct the client to come in for further
assessment, follow a protocol to make changes in medications/dosages, or restrict fluids.
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A key feature of attention-deficit hyperactivity disorder (ADHD) is hyperactivity; however, some children with ADHD behave
aggressively and have difficulty controlling anger, especially when frustrated or if unable to meet demands and challenges.
An immediate intervention to help settle an out-of-control child is deep breathing. Taking slow, deep breaths relaxes the body,
slows the heart rate, and distracts the child from inappropriate behaviors. Asking the child to blow up a balloon provides an easy
mode of distraction and engages the child in a deep breathing exercise. After the child is calm, the nurse and the child can further
discuss the disruptive behavior.
Nursing interventions include the following:
 Stay calm and remove the child from the source of frustration/anger
 Assist the child in calming down with deep breathing exercises
 Discuss what precipitated the behavior and why the behavior is wrong
 Discuss acceptable ways of expressing anger and frustration
 Acknowledge that controlling anger is difficult
 Provide rewards for appropriate behavior
 Discuss the consequences of inappropriate behavior
Developmental milestones of infants
Age
Gross motor Fine motor Language Social/cognitive
(months)
 Attempts to hold  Maintains fisted  Cries when  Gazes at parent's

head up when hands upset face when parent
1 prone speaks
 Gains head  Holds rattle  Makes cooing  Smiles in response

control when when placed in sounds to smiling & talking
2-3 held hand  Recognizes familiar
faces
 Rolls front to  Holds objects  Begins to laugh  Becomes calmed

back, then back with palmar  Makes some by parent's voice
to front grasp consonant
4-5  Sits with support  Puts things in sounds
mouth
 Sits without help  Moves objects  Babbles &  May have stranger
 Begins to crawl between hands imitates sounds anxiety
6-9  May pull to a  Uses crude  May say
stand pincer grasp "mama"
 May walk with  Uses 2-finger  Says 3-5 words

 May have
help or take pincer grasp  Uses nonverbal
separation anxiety
independent  Hits 2 objects gestures (eg,
10-12  Searches for
steps together waving
hidden objects
 Crawls up stairs goodbye)
Fine motor skills of infants develop around the ability to grasp and pick up objects. By 3 months, infants will reflexively grasp a
rattle placed in their hand. At 5 months, they are able to voluntarily clasp it with their palm. Around 7 months, infants are able to
transfer an object from one hand to the other. By 8-10 months, infants have replaced the palmar grasp with a crude pincer
grasp (use of thumb, index, and other fingers) to pick up round oat cereal and other finger foods. By 11 months, this develops into
a neat pincer grasp (use of thumb and index finger).
(Options 2 and 4) By 12 months, infants may attempt to turn multiple book pages at once, and they also begin attempts to stack 2
blocks. These skills require finer muscle control than is expected of a 10-month-old.
Fine motor skills of infants develop around the ability to grasp objects. Voluntary grasping with the palm begins around 5 months,
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followed by the ability to transfer an object between hands by 7 months and the development of a crude pincer grasp (using the
thumb, index, and other fingers) around 8-10 months.
The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory
reporting. Signs of abuse may include:
 Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures)

 Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid
 Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4)
 Injuries to genitalia
 Lapsed time between the injury and the time when care is sought
 Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental age,
mechanism of injury)
(Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg, aspiration or poisoning from foreign
objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table). The injuries and caregivers'
explanations are reasonable for these clients. Prior to discharge, the nurse should instruct caregivers on child safety measures
within the home to prevent future injury.
The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of
healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to state
or provincial laws.
Nurses caring for clients who have paranoid delusions must work to build a trusting relationship and ground the client while
ensuring basic needs are met (eg, nutritional intake). When clients believe food is poisoned, the nurse should offer unopened,
individually packaged food to promote adequate intake without reinforcing delusions.
Steps for indwelling urinary catheter insertion for the male client include:
 Perform hand hygiene and open sterile catheterization kit (Option 3).

 Apply sterile gloves and place sterile fenestrated drape with opening centered over penis (Option 2).
 Maintaining sterility of gloves, arrange remaining kit supplies on sterile field. Remove protective covering from catheter,
lubricate catheter tip, and pour antiseptic solution over cotton balls or swab sticks.
 Firmly grasp penis with nondominant hand, retracting foreskin if present. Nondominant hand is now
considered contaminated and remains in this position for duration of procedure (Option 6).
 Use dominant (sterile) hand to cleanse in a circular motion from the meatus to the glans with antiseptic solution using
cotton balls or swab sticks. Use new cotton ball/swab stick with each swipe (Option 4).
 Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5).
 Advance to bifurcation of catheter tubing. Hold in place and inflate balloon (Option 1). Urine return in catheter tubing
may be from urethra and does not indicate that balloon tip is fully inside bladder. Because male urethra varies in length,
balloon should not be inflated until catheter is fully advanced.
During resuscitative efforts and invasive procedures, the nurse should allow family members to be present if they desire.
Allowing family members to be present helps with coping, alleviates fear and anxiety, and facilitates the grieving process in the
case of a poor outcome.
Central venous catheters (CVCs) are used in the treatment of clients who require long-term IV access or are prescribed
hypertonic solutions (eg, total parenteral nutrition) or vesicant medications. CVCs can serve as a portal of entry for bacteria,
which increases the risk of developing serious bloodstream infections. Nurses caring for clients with CVCs should report any
new or worsening signs of infection (eg, fever, chills, erythema at the CVC site) to the health care provider because central line–
related bloodstream infections (CRBSIs) require prompt treatment to prevent possible sepsis.
In response to a possible CRBSI, the CVC should be removed as soon as possible to prevent continued exposure to the infection
source. Blood cultures should be obtained before initiating antibiotic therapy, as antibiotics may contaminate the sample and
prevent identification of the infectious organism
When making room assignments, it is important to remember that a client with an active or suspected infection should not be
paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma exacerbation does
not have an infection and is not at risk for spreading infection to a client who had recent bowel resection surgery
Advance directives outline the client's choices for medical care (eg, cardiopulmonary resuscitation [CPR], mechanical ventilation)
ahead of time. This allows the family and care team to follow the client's wishes at the end of life, when the client may be unable
to make choices known. Clients can sign a do not resuscitate (DNR) directive instructing that CPR and other life-saving
measures be withheld. With an advance directive in place, the client's wishes are followed, even if they conflict with the wishes of
loved ones (Option 3). This is different from a medical power of attorney (health care proxy) in which the client designates a
person to make decisions on their behalf.
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Advance directives outline the client's choices for medical care at the end of life, including resuscitation status. Client's wishes for
medical care are honored over the wishes of family members.
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using
the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during,
and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery. Hypotension, back pain, flank
ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into
the retroperitoneal space and require immediate intervention/evaluation (eg, notify health care provider, serial CBCs, abdominal
CT).
Thromboembolic deterrent stockings (TED hose) are elastic stockings that provide graduated compression to the leg to
promote venous return and reduce risk of venous thromboembolism.
Correct sizing and application of TED hose are essential to effectively promote venous return. Stockings that are too large will
not provide adequate compression, and stockings that are too tight or applied incorrectly may impair perfusion. When applying
TED hose, the nurse should:
 Select a size of knee-length stockings by measuring length from the heel to the popliteal area and circumference at
the widest point of the calf (Option 2).
 Ensure stockings are free of folds, rolls, or wrinkles; these may have a tourniquet-like effect, exacerbating venous stasis
and impairing perfusion (Options 3 and 5).
 Discrete wounds should be covered with occlusive dressings (eg, hydrocolloid) before TED hose application.
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During seizure activity, the priority is client safety. Nursing interventions include:
 Assist seated or standing clients to lie down, while protecting the head, and position on the side to maintain a patent
airwayand prevent aspiration (Option 3).
 Loosen restrictive clothing and clear the area near the client (eg, furniture corners, sharp or hard objects) to prevent
injury.
 Administer oxygen as needed in response to signs of hypoxia (eg, cyanosis, pallor) (Option 1).
 Record and document the time and duration of the seizure (Option 4).
Bruising behind the ear (eg, Battle sign) following head trauma may indicate a basilar skull fracture (Option 3). Because
of their close proximity to the brainstem, basilar skull fractures pose a risk of serious intracranial injury, which is the most
common cause of traumatic death in children. Other signs include blood behind the tympanic membrane, periorbital
hematomas (ie, raccoon eyes), and cerebrospinal fluid leakage from the nose or ears. This client requires cervical spine
immobilization, close neurologic monitoring, and support of airway, breathing, and circulation.
Total parenteral nutrition (TPN) may be prescribed for clients with dysfunction of the gastrointestinal tract (eg, short
bowel). Glucose (dextrose) is a primary component of TPN solutions; therefore, the nurse should monitor blood glucose and
assess for symptoms of hyperglycemia (eg, polydipsia, polyuria, headaches, blurred vision). A urine output of 4,800 mL during a
shift may indicate hyperglycemia (Option 3). Symptomatic clients should be assessed and treated immediately as hyperglycemia
can lead to seizures, coma, or death.
Continuous bladder irrigation is prescribed following surgical transurethral resection of the prostate and prevents obstruction
of urine outflow by removing clotted blood from the bladder. A 3-way catheter is used to continuously infuse solution into the
bladder by gravity. The catheter drains urine, irrigant solution, and blood into a collection bag.
The registered nurse (RN) should consider the five rights of delegation when delegating to unlicensed assistive personnel (UAP):
 Catheter care is a routine, noncomplex task that may be safely delegated to UAP (Option 2).
 Any client reports of pain or bladder spasms to UAP should be immediately conveyed to the RN as these symptoms
may indicate obstruction (Option 3).
 Measuring output is routine data measurement. UAP should report the volume to the RN, who will determine the
adequacy of drainage (Option 5).
Bipolar disorder is characterized by alternating episodes of depression and mania. Manic clients demonstrate hyperactivity and
distractibility and may refuse to sit still long enough to drink or eat, placing them at risk for inadequate nutritional intake.
When caring for a client with mania, the nurse should prioritize physiological needs over psychological or self-fulfillment needs.
The nurse can address imbalanced nutrition in a manic client by providing high-calorie snacks and finger foods that the client can
carry and eat without having to sit down
Electroconvulsive therapy (ECT) is a procedure in which the client receives an electrical current via electrodes placed on the
temples to induce a brief seizure. It can be used to treat clients with mood disorders (eg, major depression, bipolar disorder) or
schizophrenia.
Informed consent is required for ECT. Clients who have mental illness can give or withhold consent unless they have been
deemed incompetent through legal proceedings (Option 2). The client is also deemed incompetent if inebriated, psychotic,
delirious, or under the influence of mind-altering medication. Guidelines for determining competency to give consent apply to all
clients, with or without mental illness.
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Insulin is a medication used to control and lower blood glucose levels in clients with diabetes mellitus. Peak effect times vary
according to insulin type and represent the time of highest risk for hypoglycemic events. Insulin lispro, which is rapid acting,
reaches peak effect 30 minutes to 3 hours after subcutaneous administration
For clients with increased intracranial pressure, the nurse should reduce metabolic demands (eg, treat fever and/or pain), promote
venous blood return (eg, keep the head midline at 30 degrees), maintain a quiet environment, administer stool softeners to prevent
straining, and suction only when needed.
Femoral central venous catheters may be placed in emergency situations but should be removed/replaced as soon as possible due
to the high risk of contamination and infection.
The client's coagulation status is checked before the liver biopsy using PT/INR and PTT. The liver ordinarily produces many
coagulation factors and is a highly vascular organ. Therefore, bleeding risk should be assessed and corrected prior to the
biopsy (Option 2). Blood should be typed and crossmatched in case hemorrhage occurs (Option 3).After the procedure, frequent
vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and respirations, with hypotension occurring
later (Option 1).
Essential nursing actions related to a needle liver biopsy include checking coagulation, blood type, and crossmatch beforehand,
positioning the client on the right side for hours afterward, and monitoring vital signs and for potential signs of shock.
Clients prescribed crutches after a musculoskeletal injury must understand appropriate device use to facilitate independent
ambulation, promote wound healing, and prevent reinjury. When educating a client to rise from sitting, the nurse instructs the client
to hold the hand grips of both crutches in the hand on the affected side, move to the chair's edge, and hold the armrest with the
hand on the unaffected side (Option 1). The client then uses the crutches, armrest, and unaffected leg for support when rising.
When standing or sitting in a chair, clients with crutches should hold both crutches in the hand on the affected side and hold the
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armrest with the other hand for support. Clients should touch the back of the unaffected leg to the chair before sitting, and should
move to the chair edge and rise up with the unaffected leg to stand.
Middle East respiratory syndrome (MERS) is a viral respiratory illness caused by the coronavirus (MERS-CoV). Symptoms
include fever, cough, and shortness of breath that often worsen and cause death in many of those afflicted. The incubation period
is 5-6 days but can range from 2-14 days. How the virus spreads is not fully understood, but it is thought to spread via respiratory
secretions. Because it has easily spread to those who care for infected persons, the Centers for Disease Control and Prevention
recommends the use of standard, contact, and airborne precautions with eye protection when caring for clients with MERS.
Standard, contact, and airborne precautions with eye protection should be used when caring for a client with suspected or
diagnosed Middle East respiratory syndrome.
The correct administration of nasal medication includes pointing the nasal spray tip toward the side and away from the center of the
nose.
Paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection. Pertussis is a highly contagious
disease and requires droplet precautions. It can be deadly if contracted in infancy before vaccination is started. This client should
be placed in isolation immediately to prevent the spread of disease.
(Option 1) Chickenpox is no longer contagious after the lesions have crusted and dried, but this process can take as long as 3
weeks. This client would not require isolation.
(Option 2) Impetigo is no longer contagious after 24 hours of antibiotics. This client would not require isolation.
(Option 3) Poison ivy rash is not considered contagious. A person develops the rash only on contact with the urushiol oil itself.
The pustules do not contain this oil, and therefore the rash cannot be spread via person-to-person contact.
Chickenpox is no longer contagious after the lesions have crusted and dried. Pertussis is a highly contagious disease that requires
droplet precautions.
Reflecting is a therapeutic communication technique that reiterates the feeling, idea, or message conveyed by the
client. Therapeutic communication encourages the client and family to express feelings and thoughts, increases the nurse's
understanding, and conveys support. Emotional expression is an important part of the coping process for the client and family.
The nurse provides support by expressing empathy, actively listening, and encouraging open
communication. Nontherapeutic responses can block communication by shifting the receiver's focus away from the expression of
feelings and thoughts.
When clients and families are faced with significant life changes, the nurse should support the process of coping by encouraging
emotional expression. The nurse provides support by expressing empathy, actively listening, and encouraging therapeutic
communication.
Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly
personal or sensitive (Option 2).
The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the client's
words literally. Communication is with the client, not the interpreter. The nurse should use basic English rather than medical
terms, speak slowly, and pause after 1-2 sentences to allow for translation (Option 3).
105
Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to understand. For
example, the nurse can indicate that there will be surgery and then a follow-up visit as opposed to, "You'll follow up with the health
care provider after your procedure" (Option 5).
When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex individual rather than a family
member or personal friend. The nurse should speak slowly and directly to the client, not the interpreter; provide information in the
sequence it will occur; and obtain feedback of comprehension beyond merely nodding.
Because the nurse is unfamiliar with the client, the prescriptions from the HCP should be reviewed before giving any fluids. It is
common for clients admitted from the emergency department to be designated nothing by mouth (NPO) until appropriate
diagnostics have been completed or in case of possible surgery. Caffeine would be questionable as it can interfere with certain
diagnostic tests, such as nuclear cardiac studies.
Before giving any client oral fluids, the nurse should verify HCP prescriptions related to oral intake and prescribed diagnostics or
procedures.
Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg,
creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a
crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained
from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of
the urine.
Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and
container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after
the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning
voiding and to end it at the same hour the next morning after the morning voiding (Option 2).
(Option 1) Adding 250 mL to the total output when the test is completed is not an appropriate action as the actual urine output
from the 24-hour period is needed for accurate results.
(Option 3) To start the collection period, the nurse asks the client to void and discards this specimen (it is not added to the
collection container). The 24-hour period starts at the time of the client's first voiding.
(Option 4) Relabeling the same container and changing the start time from 6:00 AM to 10:00 AM is not an appropriate action. The
container would include part of the urine produced in a 28-hour period, and the test results would be inaccurate.
It is common practice to start a 24-hour urine collection test at the time of the client's first voiding in the morning. If any urine is
discarded by accident during the test period, the procedure must be restarted. All produced urine should be placed in the same
container and kept cool (on ice).
Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg,
creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a
crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained
from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of
the urine.
Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and
container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after
the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning
voiding and to end it at the same hour the next morning after the morning voiding (Option 2).
It is common practice to start a 24-hour urine collection test at the time of the client's first voiding in the morning. If any urine is
discarded by accident during the test period, the procedure must be restarted. All produced urine should be placed in the same
container and kept cool (on ice).
Signs and symptoms of a blood transfusion reaction typically will occur within the first 15 minutes after initiation of the transfusion.
These include shortness of breath, chest tightness, fever, back pain, anxiety, tachycardia, and hypotension.
When a transfusion reaction is suspected, the first step is to stop the infusion (Option 5). An infusion of normal saline is typically
started. It is important that normal saline be administered through a different port of the CVC using new tubing or at the closest
access point to the client. The HCP must then be notified (Option 3).
Because the client has shortness of breath and chest tightness, an assessment of breath sounds is appropriate. Adventitious
sounds could indicate bronchospasm or excess fluid in the lungs (Option 1).
106
If an adverse blood transfusion reaction is suspected, the first action is to stop the infusion. An infusion of normal saline through a
different port for the CVC is typically started. A client assessment and notification of the HCP are also required.
A feeding tube is marked with indelible ink at the exit site (nare). If the external length of the tube changes, the nurse should
contact the health care provider and request a prescription for a repeat x-ray to determine tube location before resuming
administration of enteral feedings and medications.
Following a needlestick injury, the nurse's immediate actions should be to remove their gloves and thoroughly wash the
affected area with soap and water. Exposure should be reported to the nurse's supervisor and the facility exposure hotline as
soon as possible to facilitate the evaluation process. The nurse should then seek evaluation and treatment from the employee
health clinic or emergency department. Blood should be drawn for baseline testing, and postexposure prophylaxis will be given
based on the risk of exposure. Postexposure prophylaxis for HIV infection is most effective when given within two hours of an
exposure incident.
After a needlestick injury, the nurse should remove gloves, wash the area, report the incident to the facility exposure office, and
proceed to employee health for baseline blood draw and possible postexposure prophylaxis.
Ear irrigation may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure:
1. Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify
that the tympanic membrane is intact and ensure there are no foreign bodies (Option 1).
2. Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth).
3. Place the client in a side-lying or sitting position with the head tilted toward the affected ear (Option 4). Place a towel and
an emesis basin under the ear (Option 3).
4. Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort.
5. Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ≤3 years (Option 5).
6. Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal (Option 2).
Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the
client experiences severe pain, nausea, or dizziness.
7. Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled.
8. Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client
teaching.
To perform ear irrigation, assess for contraindications (fever, ear infection, tympanic membrane injury); tilt the affected ear down;
straighten the ear canal; and use a solution at body temperature to irrigate gently, aiming toward the top of the ear canal until it is
clear.
Enteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the small intestine) to protect the stomach
from irritant effects. Crushing enteric-coated medications (eg, ibuprofen) disrupts the barrier coating and may cause stomach
irritation. In addition, the particles from the coating may clog the NG tube, particularly small-bore NG tubes.
Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly within a specific time frame.
Crushing these medications alters this property and introduces the risk of adverse effects from toxic blood levels due to more rapid
drug absorption. Therefore, the nurse should first contact the PHCP for clarification.
107
(Options 2 and 4) Double- and extra-strength drugs such as sulfamethoxazole and acetaminophen may be crushed and
administered separately through an NG tube as long as they are not enteric-coated. The nurse should flush the tube with water
before and after each drug administration.
Crushing an enteric-coated, slow-release, extended-release, or sustained-release drug disrupts its designed time of release and is
contraindicated. The nurse should contact the PHCP for an alternate prescription if such a drug is prescribed via NG route.
Clients with a health care-associated infection, such as methicillin-resistant Staphylococcus aureus, are placed on contact
precautions to prevent transmission of microorganisms. Contact precautions include standard precaution measures in addition to
use of a gown and gloves and single-client-use equipment (eg, stethoscopes, blood pressure cuffs, thermometers).
Disposable or single-client-use equipment must not be shared between clients or transferred to other care areas. Dedicated
equipment should be kept in the room for client care, and then disinfected or discarded when no longer needed (Option 1).
Nurses should implement contact precautions (eg, gown/gloves, single-client-use equipment) for clients with methicillin-
resistant Staphylococcus aureus to prevent transmission of microorganisms. Single-client-use or disposable equipment should not
be shared between clients. Hand hygiene with alcohol-based hand rubs is appropriate unless visible soiling or exposure
to Clostridium difficileoccurs.
When the urinary catheter balloon occludes the urethra, it should be deflated immediately to prevent further injury or complication.
After balloon deflation, gently and slowly remove the catheter. If there is resistance, notify the urologist.
Routine catheter care to prevent health care catheter-associated UTIs includes routine hand hygiene, cleansing the perineal area
with soap and water routinely, keeping the catheter bag below the bladder and off the ground, keeping the catheter and tubing free
of kinks and facilitating urine into the bag, and using sterile technique when collecting urine specimens.
Prior to discharge, the nurse must evaluate the client's ability to perform home wound care. When performing a simple dry
dressingchange, the client should:
 Don clean gloves and perform hand hygiene before and after removing the old dressing
 Cleanse the wound bed using sterile saline (or a prescribed cleanser) by moving from "clean" to "dirty," or from the
center of the wound outward (Option 3)
 Thoroughly dry the wound and surrounding skin using sterile gauze to prevent maceration (breakdown) of underlying
tissues
 Monitor the site for signs of infection (eg, redness, warmth, purulent drainage) (Option 4)
 Apply dry, sterile gauze over the wound bed
 Cover the gauze with an occlusive sterile dressing to keep gauze in place and maintain asepsis. The covering should
be applied without touching the wound bed (Option 1)
The nurse must evaluate a client's ability to perform home wound care before discharge. Instructions for a dry dressing change
should include performing hand hygiene, properly cleansing the wound bed, drying the wound, monitoring for signs of infection,
and securing a dry, sterile dressing to the wound surface.
The process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should
be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to prevent
hypoxia (Option 1). The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia (Option 4).
In addition, deep rebreathing should be encouraged.
(Option 2) The suction catheter should be no more than half the width of the artificial airway and inserted without suction.
(Option 3) The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set
at medium pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as excess pressure will traumatize the mucosa and
can cause hypoxia.
(Option 5) Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be
advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction.
Proper airway suctioning technique includes preoxygenation, limiting a suction pass to 10 seconds, and allowing 1-2 minutes
between passes to prevent hypoxia. Medium suction pressure should be set at 100-120 mm Hg for adults, with the catheter
inserted without suction.
People with latex allergy usually have a cross-allergy to foods such as bananas, kiwis,

avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food
proteins. Latex sensitivity increases with exposure and should be suspected in the following
situations:
108
1. Allergic contact dermatitis (rash, itching, vesicles) developing 3–4 days after exposure to
a rubber latex product. This is a type IV hypersensitivity reaction (delayed onset).
2. Anaphylaxis - many cases of anaphylaxis have been reported in both medical and non-
medical settings. These represent a type I hypersensitivity reaction and should be treated
with intramuscular epinephrine injections. Some common settings include:
o Glove use
o Procedures involving balloon-tipped catheters (eg, arterial catheterization)
o Blowing up toy balloons
o Use of bottle nipples, pacifiers
o Use of condoms or diaphragms during sex
Clients with severe allergies should wear a Medic Alert bracelet and carry an injectable
epinephrine pen due to cross-sensitivity with many food and industrial products that can be
impossible to avoid.
(Option 1) Foods rich in vitamin K reduce the effects of warfarin (which works by inhibiting
vitamin K-dependent clotting factors). Consumption of these foods decreases the effectiveness of
warfarin; clients must be taught to eat the same amount of or avoid dark, green, leafy vegetables.
(Option 2) Nitroglycerine is a vasodilator and a headache from dilating cerebral vessels is an
expected finding. The side effect is treated with acetaminophen (Tylenol).
(Option 3) Peripherally acting calcium channel blockers (eg, nifedipine, amlodipine, felodipine)
cause vasodilation, and clients may develop peripheral edema. This is an expected, frequent side
effect and is not an allergic reaction. Clients are advised to elevate the legs when lying down and
to use stockings.
Latex allergy is suspected when there is a food allergy to banana, kiwis, or avocados. Peripheral
edema is an expected side effect of peripherally acting calcium channel blockers. Headache is an
expected side effect of nitroglycerine. Clients taking warfarin (Coumadin) should consume the
same amounts of food high in vitamin K.
Parenteral medications are administered via injection into body tissues using aseptic technique
(eg, intradermal, intramuscular, subcutaneous, IV).
Intradermal
109
 Administer injections at a 5- to 15-degree angle to reduce risk of injection into
subcutaneous tissue (Option 2).
 Apply firm pressure to the injection site to reduce bleeding. Massaging the site introduces
medication into deeper tissues and should be avoided (Option 3).
Subcutaneous
 Administer injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped or

at 45 degrees if only 1 in (2.5 cm) can be grasped (Option 1).
Intramuscular
 Acceptable sites include the deltoid, vastus lateralis, and ventrogluteal. The ventrogluteal
is preferred as fewer large blood vessels and nerves are present.
 Position the client supine, prone, or side-lying with the knee and hip flexed when
administering ventrogluteal injections. Flexing the knee and hip reduces muscle tension,
improves access, and promotes client comfort (Option 4).
(Option 5) A filter needle must be used when withdrawing medication from a glass ampule to
prevent aspiration and injection of glass shards. After the medication is withdrawn, the filter
needle is discarded and an injection needle (eg, 20-gauge, 1-in [2.5-cm] needle) is attached to the
syringe.
Use filter needles to withdraw medications from ampules to prevent aspiration and injection of
glass shards. Perform intradermal injections at 5- to 15-degree angles and avoid massaging
injection sites to prevent accidental subcutaneous administration. Administer subcutaneous
injections at 45 or 90 degrees, depending on the volume of subcutaneous tissue.
Establishing the presence of the client's ABCs/physiological stability is first step as the client could
have lost consciousness or had a cardiovascular event that caused the fall. The need for
immediate resuscitation should be assessed first (Option 1).
The presence of gross injuries should be established prior to moving the client so that appropriate
immobilization can be taken. If awake, clients should be asked what body parts were struck, how
they fell, if they hit their head, and what currently hurts. The spine should be immobilized and a
cervical collar used for any neck pain (Option 4).
Additional help should be obtained to move the client to proper position at the site and avoid injury
to the staff. After emergent stabilization, the client should be returned to bed for vital signs and
further assessment (Option 3).
The HCP should be notified of the incident and assessment findings (Option 5).
Documentation should be made in the client's chart and an incident report filed for risk
management (Option 2).
The appropriate order of actions when a client is found on the floor is assessment of stability,
assessment of injuries, moving the client, notifications, and documentation.
Low-molecular-weight heparins (LMWHs) (eg, enoxaparin, dalteparin) are anticoagulants
commonly used for prevention and treatment of deep venous thrombosis and pulmonary
embolism. LMWH is administered subcutaneously and is often available in a prefilled syringe,
which contains an air bubble to ensure delivery of the entire dose. During injection, the air
110
bubble follows the medication out of the syringe, ensuring that no medication is left behind. The
nurse should not expel the air bubble prior to administration as this could result in an incomplete
dose and medication error (Option 2).
(Option 1) After subcutaneous anticoagulant injection, the client should not rub the injection site
as this increases bruising and the risk for hematoma.
(Option 3) A 90-degree angle is appropriate for a subcutaneous injection in an obese client. In
general, subcutaneous injections are administered at a 90-degree angle if 2 in (5 cm) of tissue can
be grasped or a 45-degree angle if only 1 in (2.5 cm) of tissue can be grasped.
(Option 4) Subcutaneous anticoagulants are best absorbed when administered in the lower part
of the right or left lateral abdominal wall (ie, "love handles"), at least 2 in (5 cm) away from the
umbilicus.
Low-molecular-weight heparin is often available in a prefilled syringe, which contains an air bubble
to ensure delivery of the entire dose during injection. The nurse should not expel the air bubble
prior to administration as this could result in some medication being left in the syringe and an
incomplete dose delivery.
With the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L
(6.5 mmol/L) in any client who is walking and talking should raise the suspicion of an erroneously
elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis,
or clotting. A serum potassium level of 7.0 mEq/L (7.0 mmol/L) would normally constitute a life-
threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable
arrhythmias, and eventual cardiac arrest.
An assessment would focus on evaluating cardiac symptoms and muscle strength and be
reported to the health care provider (HCP). In this case, it is likely that a repeat blood draw would
be prescribed.
Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnated
hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching, and use of a
larger gauge needle for the sample.
(Option 1) This blood urea nitrogen (BUN) value is elevated (normal 6-20 mg/dL [2.1-7.1
mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the most
likely erroneous result.
(Option 2) Similar to the BUN level, this creatinine value is significantly elevated (normal 0.6-1.3
mg/dL [53-115 µmol/L]). Further nursing assessment is indicated, with documentation and
involvement of the HCP in evaluating the impact of this kidney damage on the client's health.
(Option 4) This sodium value is high (normal 135-145 mEq/L [135-145 mmol/L]) and requires
further exploration. The nursing assessment should be documented and reported to the HCP.
High serum potassium levels could be due to hemolysis or clotting during the blood draw. If a
clinical assessment does not correlate with the laboratory values, repeat testing is needed.
111
During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic
or therapeutic purposes. Before the procedure, the nurse places the client in an upright
sitting position on the side of the bed, leaning forward over the bedside table, with arms
supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to
the pleural space through the intercostal spaces, and promotes client comfort.
(Option 1) The fetal position is appropriate for a client having a lumbar puncture, not a
thoracentesis.
(Option 2) If unable to sit, the client can be positioned lying on the unaffected, not affected, side.
(Option 3) Prone position is not used for this procedure, is uncomfortable, and would make it
more difficult for a client with dyspnea to breathe.
Before a thoracentesis, the nurse places the client in an upright sitting position on the side of the
bed, leaning forward over the bedside table, with arms supported on pillows. This position
ensures that the diaphragm is dependent, facilitates access to the pleural space through the
intercostal spaces, and promotes client comfort.
Hand hygiene is performed before and after providing client care. HIV is a blood-borne virus, and
standard precautions are sufficient protection against viral transmission. The nurse wears gloves
when anticipating exposure to blood or body fluids. Isolation gowns are applied if the nurse
anticipates splashing of body fluids on clothing. A face shield and goggles are applied if splashing
in the eyes is a possibility. The nurse should always don gloves when starting an intravenous line.
112
(Option 3) This would be an acceptable level of protective equipment if the client undergoes a
non-sterile procedure with significant splash risk, such as vaginal delivery.
(Option 5) Face shields are used when splashing on the face or in the eyes is anticipated. A N95
respirator mask is used when caring for a client with airborne isolation precautions.
The Centers for Disease Control and Prevention recommend the use of standard precautions for
preventing transmission of HIV.
The proper fit and use of crutches are important in preventing injury. They include:
 Proper measurement and fit - There should be a 3-4 finger-width space (1-2 in [2.5-5
cm]) between the axilla and axillary pad (Option 4). Clients are taught to support body
weight on the hands and arms, not the axillae. Handgrip location should allow 20-30
degrees of flexion at the elbow (Option 2).
 Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the
affected extremity. The injured extremity and crutches are moved simultaneously (Option
3). The client who is rehabilitating from an injury of the lower extremity usually progresses
from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait)
to full weight-bearing status (4-point gait).
(Option 1) Wear and tear of the axillary pads raises concern for the incorrect use or fit of
crutches. Excessive and prolonged pressure on the axillae can cause localized damage to
the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis,
or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when
ambulating.
113
Proper crutch fit includes a 3-4 finger-width space between the axillary pad and axilla and a
handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body
weight on the hands and arms, not the axillae. Wear and tear on the crutch pads may indicate
improper use or fit. Clients progress from 3-point gait (no to partial weight-bearing) to 2-point gait
and then 4-point gait as rehabilitation continues.
Acute exacerbation of chronic back pain is usually associated with inflammation triggered by
(strenuous and/or repetitive) activities that stress the previously injured area. Interventions should
be directed toward reducing inflammation. Nonpharmacologicintervention to treat the
inflammation includes rest from pain-aggravating activities which may continue to promote
inflammation and delay healing.
Effective teaching can be accomplished only with effective communication, which can be
compromised by language barriers, cultural differences, and low health literacy. When
an interpreter is necessary, using a translator who is skilled in medical terminology is the best
approach to provide accurate information (Option 4). Hearing instructions and information in
one's primary language decreases the risk of adverse clinical consequences.
When language is a barrier to effective communication and teaching, the nurse should use a
trained medical interpreter for translation purposes.
Shingles (herpes zoster) is a reactivation of the varicella-zoster (chicken pox) virus. It is more
likely to occur when a client's immune system is compromised by disease (eg, HIV infection) or
treatments (eg, chemotherapy).
Shingles lesions that are open may transmit the infection by both air and contact. The client
with disseminated shingles that are not crusted over will require contact precautions, airborne
precautions, and a negative airflow room to prevent transmission of the infection to others in
the hospital. Negative airflow pulls air from the hospital environment into the room, and the air
from the hospital room then goes directly to the outside rather recirculating to the rest of the
hospital. Localized shingles require only standard precautions for clients with intact immune
systems and contained/covered lesions.
The client with open lesions from a herpes virus infection, such as shingles or chicken pox, will
require both contact and airborne precautions and a private room with negative airflow.
Sexual assault is a medical emergency requiring a thorough head-to-toe physical examination by

a specially trained health care provider (eg, sexual assault nurse examiner) to identify and treat
injuries. A student reporting potential sexual assault (eg, waking in a strange room, signs of
physical assault) should be instructed to seek immediate medical attention and not to bathe,
brush teeth, urinate, douche, or change clothes. These activities can delay a medical-forensic
examination and interfere with evidence retrieval and preservation. Many college and university
health centers have providers for this specialized physical and emotional care, but if they do not,
the student should be referred to a local hospital emergency department.
(Option 1) The student should be reassured that although contracting viral meningitis is possible,
it is unlikely as the incubation period is 1 week and typical symptoms include headache, fever,
photophobia, and stiff neck.
(Option 2) The student most likely has a rotator cuff injury and should be instructed to rest, apply
ice and heat, take a nonsteroidal anti-inflammatory drug, and seek medical evaluation.
114
(Option 4) The student's vaginal discharge is most likely related to a candidiasis (ie, yeast) fungal
infection. The student should be instructed to seek medical attention and refrain from sexual
activity until testing for sexually transmitted diseases is completed.
Sexual assault is a medical emergency requiring immediate, specialized examination to identify
and treat any physical injuries and emotional trauma. Delaying a medical-forensic examination
can interfere with evidence retrieval and preservation.
115

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Contact precautions

 MDR organisms (eg, MRSA, VRE)

 Hand hygiene (soap & water for C difficile)

MDR = multidrug-resistant; MRSA = methicillin-resistant Staphylococcus aureus; VRE = vancomycin-resistant Enterococcus.

 Use strict sterile technique throughout suctioning (Option 5)

 Limit suctioning to ≤10 seconds on each suction pass

 Discontinuing uterotonics (eg, oxytocin [Pitocin]) to reduce uterine activity (Option 3)

 Inability to completely close the eye on the affected side

 Pleuritic chest pain (ie, sharp lung pain while inhaling) (Option 2)

 Clinical assessment  Monitoring RN findings  Activities of daily living

LPN = licensed practical nurse; LVN = licensed vocational nurse; RN = registered nurse;

*Limited assessments (eg, lung sounds, bowel sounds, neurovascular checks).

Perinatal mood disorders

Postpartum blues Postpartum depression Postpartum psychosis

Prevalence 40%-80% 8%-15% 0.1%-0.2%

Emotional lability, mild Extreme sadness, irritability,

Older individuals, diabetic clients, and women may have atypical angina symptoms rather than the characteristic crushing,

Common characteristics of anorexia nervosa

 Significantly low body weight

 Limit the child's intake of caffeine and sugar

Sign 0 points 1 point 2 points

Appearance/ Completely Body pink, Completely

P Pulse Absent <100/min >100/min

Grimace/ Grimace/ Cough/

 Implementing pharmacological and nonpharmacological pain management (eg, encouraging caregiver soothing), as

 The abusive partner exhibits intense jealousy and possessiveness (Option 3).

1. The presence of extra inguinal or thigh folds

1. Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority).

1. First shake MDI and attach it to the spacer.

Constipation is a common discomfort of pregnancy and is due to an increase in the hormone progesterone, which causes

Risk factors for esophageal cancer

Squamous cell carcinoma Adenocarcinoma

 Alcohol use  Barrett esophagus

 Making brief, frequent contacts

Sodium polystyrene sulfonate (Kayexalate) is used to treat mild to moderate hyperkalemia. Potassium is exchanged for

 Young parent age

(Option 1) Having siblings is not a risk factor for FTT.

Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients (eg,

1. Oxygen to maintain saturation >90%

 Wear gloves when handling cold objects (Option 5).

 Self-dramatizing, exaggerated or shallow emotional expression

 Clinical assessment  Monitoring RN findings  Activities of daily living

LPN = licensed practical nurse; LVN = licensed vocational nurse; RN = registered nurse;

*Limited assessments (eg, lung sounds, bowel sounds, neurovascular checks).

 Difficulty in making day-to-day decisions

 Implement a fixed voiding schedule (eg, every 2 hours) to prevent bladder overfilling.

 Provide identifying information (eg, client's name and room number).

 Corticosteroids and other immunosuppressants (eg, cyclosporine)

Clinical manifestations  Initially normal at birth

 ↑ TSH & ↓ free T4 levels

FLACC scale (face, legs, activity, cry, consolability)

 Uneasy, restless, tense

 Lying quietly  Squirming, shifting back &  Arching, rigidity, or jerking

 Steady cry, screams, or

Subjective, objective & positive signs of pregnancy

Subjective (presumptive) Objective (probable) Positive (diagnostic)

 Uterine & cervical changes

Indications & contraindications for influenza vaccination