Potentiation is a type of drug interaction. Potentiation occurs when two drugs are taken together and the action of one drug increases the action of the other, causing the pharmacologic response to be greater for one of the drugs.

One of the most common side effects of propantheline is a dry mouth, so good oral hygiene is important. Because propantheline reduces stomach acid, it has a "drying" effect that can also result in constipation and urinary retention. The client should be instructed to report side effects. Fluids are not restricted and there is no special diet. Laxatives may be appropriate.

Total parenteral nutrition (TPN) can cause hyperglycemia, so blood glucose levels should be closely monitored. Because of the hypertonicity of the TPN solution, it must be administered via a central venous catheter. The high concentrations of glucose and lipids make TPN an excellent medium for bacterial growth. Therefore, administration sets should be changed every 24 hours if the TPN contains lipids.

Standards of safe medication administration require obtaining two patient identifiers before proceeding. For a child, a parent can give the child's name. Many young children do not know their full name or are accustomed to being called by a nickname. Adults can be asked the child's name and birth date. Room numbers are not a reliable means of verifying identification.

Corticosteroids are often recommended to treat inflammatory conditions such as pneumonitis. The other options are not appropriate. Chest tubes are used for drainage. Albuterol is a drug for rapid bronchodilation. A thoracotomy is a surgical procedure in which a cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax.

The nurse should hold the penicillin and contact the provider who ordered the medication. Even a mild reaction in the past puts the client at risk for an anaphylactic reaction, which typically occurs within an hour of administration. Common adverse effects of penicillin include rash; hives; itching; and swelling of the face, lips, and tongue.

NPH insulin is an intermediate-acting insulin, usually given once or twice a day. The peak effect of NPH insulin occurs 4-12 hours after administration, so the nurse should start to monitor for signs of hypoglycemia at 10:00 a.m. Hypoglycemia (blood glucose below 70 mg/dl) can have a rapid onset. Signs include shakiness, dizziness, anxiety, confusion, sweating, chills, and clammy skin. The patient's pulse may increase. The patient may complain of blurred vision, headache, fatigue, hunger, or nausea.

1mcg = 0.001mg To convert 25 mcg, set up a proportion: 1/0.001 = 25 / x Cross-multiply (0.001 * 25 = 0.025mg) and then multiply by 52kg = 1.3mg per minute. In one hour (60 min × 1.3 mg), the client should receive 78 mg.

Aluminum hydroxide is an antacid that quickly neutralizes gastric acid. It is used to treat heartburn, acid indigestion, and upset stomach. It can also reduce phosphate levels in certain kidney conditions. Constipation is the main side effect, which can lead to worsening hemorrhoids or bowel obstruction. Other side effects include loss of appetite, pain on urination, drowsiness, and muscle weakness. The other options are not related to the use of aluminum hydroxide.

Because thiazide diuretics produce an increase in urine output, the patient should avoid taking the medication in the evening so that sleep is not interrupted. Potassium is lost in the urine along with sodium and chloride, so the patient should be instructed to include potassium-rich foods in the diet to avoid hypokalemia. Examples of potassium-rich foods include avocados, spinach, sweet potatoes, yogurt, and bananas

A teratogen is an agent that can disturb the development of the embryo or fetus. Taking isotretinoin (Accutane) during pregnancy can cause birth defects of the brain and heart as well as facial deformities. Before providing the client any instructions on taking this medication, the nurse should determine whether the client might be pregnant. The client should have a reliable birth control method. The capsules are swallowed whole with a full glass of water. Unusual weight gain or weight loss are listed as rare or unknown adverse reactions.

Hypovolemia is corrected by expanding the intravascular compartment. An isotonic IV solution will expand the intravascular compartment without affecting cells and tissues of other fluid compartments. Hypertonic and colloid solutions would pull fluid into the intravascular space but at the expense of other fluid compartments.

Breathing in slowly and deeply and then holding one's breath allows for the medication to move farther down the patient's airway. If possible, the patient should count to ten before exhaling. Spacers are typically suggested because they prevent the medication from collecting on the tongue and the back of the throat. Because inhalers leave a residue in the mouth, they can increase the risk of developing Candida infections. The patient should always rinse their mouth after use.

Circulatory overload occurs when blood or plasma enters the blood stream too quickly. It is evidenced by respiratory distress, tachycardia, hypertension, and the presence of pulmonary edema (crackles). The client may also display neck vein distention. Pulmonary embolism signs also include respiratory distress, tachycardia and hypertension, as well as hemoptysis, fever, chest pain, diaphoresis, and fainting. The most common signs of a transfusion reaction are chills, back pain, fever, itching, hives, and shortness of breath. Signs of a myocardial infarction include pressure or tightness in the chest; pain in the chest, jaw, and upper body; shortness of breath; diaphoresis; nausea; vomiting; and anxiety.

Pressing the gauze pad against the skin while removing the needle reduces the discomfort of the pulling sensation. Once the medication has been completely injected, remove the needle using a smooth, steady motion. Remove the needle at the same angle at which it was inserted.

Metronidazole is a broad-spectrum antibiotic that is used to treat a variety of infections, including bacterial vaginosis. If a dose is missed, the client should NOT take a double dose. The client should take the medication at prescribed intervals with a meal or a full glass of water or milk. The client should avoid alcohol while taking metronidazole and for 72 hours after finishing all doses. Drinking can cause nausea, abdominal cramps, vomiting, and headaches. Loss of appetite and a metallic taste in the mouth are possible side-effects that go away when the medication is finished.

The percentage of the drug that is NOT protein bound is the amount of the drug that is free to work as expected. In this case, 50% of the drug is unable to be effective because it is protein-bound. Protein binding has nothing to do with drug excretion, protein in the diet, or the destruction of protein.

The nurse should maintain the current heparin infusion rate. The reference range of aPTT is 30-40 seconds. To obtain an aPTT result, an activator is added that speeds up the clotting time and results in a narrower reference range. The aPTT is considered a more sensitive version of the PTT and is used to monitor the patient's response to heparin therapy. Decreasing or increasing the infusion rate is not appropriate. Protamine sulfate is a heparin antagonist, used to immediately reverse the action of heparin. It is not indicated for this situation.

D5NS infusion is hypertonic, so it will draw fluid into the circulation. Trendelenburg position could compromise the airway in a patient who has had head or neck surgery. Atropine could cause hyponatremia and further hypotension. It is not necessary to move the emergency cart to the patient's bedside at this time.

Corticosteroids and other anti-inflammatory drugs work by reducing inflammation, swelling, and mucus production in the airways of a person with asthma. As a result, the airways are less inflamed and less likely to react to asthma triggers. Inhaled corticosteroids are the primary treatment for asthma.

Most chemotherapeutic agents have a high potential for causing nausea and vomiting. Up to 80% of patients experience chemotherapy-induced nausea and vomiting, which occur when the vomiting center in the brain is stimulated during the chemotherapy infusion. Administering an antiemetic prior to starting the infusion can prevent or minimize nausea and vomiting.

Heparin and low-molecular-weight heparins are normally held 12 hours before surgery because of the increased risk of perioperative bleeding. Patients with a history of atrial fibrillation are often on anticoagulation therapy to prevent the formation of blood clots. The health professional should contact the appropriate physician to clarify whether the heparin should be administered.

The nurse will draw up and administer 2.0 mL. To calculate: 1. Convert mg to mcg: 9.5mg * 1000 = 500mcg 2. Known: 5mL = 500mcg 3. 1 mL = 100 mcg. 0.2mL = 200mcg 5. You. can also set up an equation: (5 mL x 200mcg / 500 * mcg = 2mL Flumazenil, a specific benzodiazepine antagonist, is used as an antidote for intentional benzodiazepine overdose, as well as reversing the sedation and respiratory depression from anesthesia.

Phenazopyridine does not treat the cause of the urinary irritation, but it can help relieve the symptoms while other treatments take effect. Phenazopyridine is a dye that works as an analgesic to soothe the lining of the urinary tract, It relieves the itching and burning, as well as urinary urgency and frequency. It is both a prescription and an over-the-counter (OTC) medication.

Although neomycin is generally prescribed to treat infection, it is also prescribed for patients with liver disease to kill intestinal bacteria. The bacteria produce ammonia when breaking down protein. The diseased liver is unable to clear the ammonia, so serum levels build and lead to hepatic encephalopathy. Neomycin does not affect pH or prevent further liver damage

Beta-1 receptors are found in the cardiac conduction system and myocytes. Beta-1 blockade will slow discharge from the SA node and decrease speed through the AV node, slowing the heart rate. Propranolol (Inderal) decreases the strength of heart contractions as well as the heart rate, resulting in less cardiac oxygen consumption.

5 mL = 1 teaspoon. The parent should give the child 1 teaspoon of amoxicillin every 8 hours. The parent should use a medication spoon or dropper to measure the dose, not a household spoon. The nurse should educate the parent about completing the prescription even if the child starts to feel better. 1 tablespoon = 3 teaspoons (15 mL), which would be a triple dose.

1tsp = 5mL and 4 mg. Multiply 4mg * 2 to reach the ordered dose of 8 mg. It will take 10 mL (2 tsp) to give 8 mg of Zofran.

A hospital provides the safest for an anticipated severe alcohol withdrawal. All clients should be given thiamine 100 mg as soon as possible, and then daily during the withdrawal period. Benzodiazepines (such as diazepam, alprazolam, chlordiazepoxide, or lorazepam) are prescribed to minimize agitation and anxiety, as well as treat possible seizures. Naloxone hydrochloride is used to reverse the effects of an opioid overdose. Disulfiram is taken to support alcohol abuse treatment by producing an acute sensitivity to drinking alcohol. Haloperidol is an anti-psychotic drug, prescribed for schizophrenia and other psychoses.

Grapefruit and its juice contain furanocoumarins, which inhibit the cytochrome P450 enzyme CYP3A4. CYP3A4 is involved in metabolizing many drugs, including calcium channel blockers. Medication blood levels can increase, becoming toxic. The levels of calcium channel blockers are increased when grapefruit or grapefruit juice is consumed, potentially causing hypotension. Grapefruit can interfere with other drugs too, including statins (atorvastatin, lovastatin, simvastatin), some antibiotics, and some cancer drugs.

Marfan syndrome is inherited in an autosomal dominant pattern, meaning that one copy of the mutated FBN1 gene from either parent is sufficient to cause the disorder.

Individuals with Marfan syndrome often have a tall, slender build, with long arms and legs. This is a key clinical feature of the condition.

Marfan syndrome commonly leads to aortic dilation and dissection due to the weakened connective tissue in the aorta, which is a significant cardiovascular risk

Dislocation of the lens, or lens subluxation, is a common eye issue in Marfan syndrome due to weakened connective tissue.

Scoliosis, or an abnormal curvature of the spine, is common in Marfan syndrome and can contribute to the characteristic physical appearance.

The diagnosis of Marfan syndrome is confirmed by identifying mutations in the FBN1 gene, which encodes the protein fibrillin-1.

Lisinopril, an ACE inhibitor, is used to slow aortic dilation and reduce cardiovascular complications in Marfan syndrome.

Losartan is an angiotensin receptor blocker that decreases TGF-β signaling, which can further slow aortic dilation when used in combination with beta blockers.

Surgical repair or replacement of the aorta may be necessary to prevent complications such as aortic dissection or rupture in patients with significant aortic dilation.

Regular eye exams are important for detecting and managing ocular complications, such as lens dislocation, in patients with Marfan syndrome.

The low pH and elevated PaCO2 indicate an accumulation of carbon dioxide due to hypoventilation, which leads to respiratory acidosis.

The high pH and low PaCO2 suggest hyperventilation, leading to respiratory alkalosis.

The low pH and HCO3- indicate a primary metabolic acidosis due to the accumulation of keto acids.

The elevated pH and HCO3- indicate metabolic alkalosis, possibly from vomiting or diuretic use.

The elevated PaCO2 suggests respiratory acidosis, and encouraging deep breathing can help increase ventilation.

The pH is slightly acidic with an elevated PaCO2, indicating the body is attempting to compensate but hasn't fully corrected the acidosis.

A pH above 7.45 indicates alkalosis, whether metabolic or respiratory.

The low PaCO2 and normal pH suggest that the respiratory system has compensated for metabolic acidosis.

The elevated HCO3- and pH with an increased PaCO2 suggest compensation for chronic respiratory acidosis

The elevated PaCO2 and low pH suggest respiratory failure, likely due to inadequate ventilation.

The low pH and high PaCO2 indicate respiratory acidosis, commonly seen in COPD patients.

In metabolic acidosis, there is a loss of bicarbonate or an accumulation of acid, leading to decreased HCO3- levels.

The low pH and HCO3- suggest metabolic acidosis, while the low PaCO2 indicates compensation through hyperventilation.

Hyperventilation causes increased elimination of CO2, leading to respiratory alkalosis.

The low pH and HCO3- indicate metabolic acidosis, commonly seen in conditions like renal failure or severe diarrhea.

The low pH and elevated PaCO2 suggest respiratory acidosis, with the HCO3- slightly elevated indicating some compensation.

The low pH and elevated PaCO2 suggest respiratory acidosis, with the HCO3- slightly elevated indicating some compensation.

The elevated HCO3- and pH suggest metabolic alkalosis, commonly caused by vomiting.

The low pH and HCO3- indicate metabolic acidosis, often seen in chronic kidney disease due to the accumulation of acids.

The normal pH range for arterial blood is between 7.35 and 7.45

Hypoventilation results in CO2 retention, leading to respiratory acidosis.

A pH below 7.35 indicates acidosis.

The pH is normal due to compensation; the low HCO3- indicates a prior metabolic disturbance.

The low pH and HCO3- indicate metabolic acidosis without respiratory compensation.

Vomiting causes a loss of gastric acid, leading to a rise in HCO3- and thus metabolic alkalosis.

Tachypnea may lead to hyperventilation, causing a decrease in PaCO2 and an increase in pH (respiratory alkalosis).

The body compensates for metabolic acidosis by increasing the respiratory rate to blow off CO2.

Oxygen therapy can help improve oxygenation and reduce hypoxia associated with respiratory acidosis.

The kidneys retain bicarbonate to help compensate for the acidosis.

Kussmaul respirations are deep, labored breathing patterns often seen in metabolic acidosis as the body attempts to compensate.

The kidneys retain bicarbonate to compensate for the chronic respiratory acidosis.

During an acute asthma attack, hypoventilation occurs, leading to increased CO2 and respiratory acidosis

Renal failure impairs the excretion of acids, leading to metabolic acidosis.

An elevated HCO3- and high pH suggest metabolic alkalosis.

High pH and low PaCO2 indicate respiratory alkalosis due to hyperventilation.

Hyperventilation can occur due to hypoxia from the embolism, leading to respiratory alkalosis.

Vomiting causes a loss of gastric acid and leads to metabolic alkalosis.

The body will attempt to compensate for the metabolic acidosis by hyperventilating to lower CO2 levels.

The elevated pH and HCO3- indicate metabolic alkalosis, which can cause symptoms like muscle cramps.

The low pH and elevated PaCO2 without a change in HCO3- indicate uncompensated respiratory acidosis.

The elevated pH and HCO3- suggest metabolic alkalosis.

Severe dehydration can lead to metabolic alkalosis due to electrolyte imbalances and hypovolemia.

The low pH and HCO3- suggest metabolic acidosis, possibly due to alcoholic ketoacidosis.

The low pH and high PaCO2 indicate acute respiratory acidosis.

The low pH and high PaCO2 without a change in HCO3- suggest uncompensated respiratory acidosis.

The low pH and HCO3- indicate uncompensated metabolic acidosis.

The elevated pH and low PaCO2 indicate respiratory alkalosis, likely due to hyperventilation.

Chronic kidney disease impairs acid excretion, leading to decreased HCO3- and metabolic acidosis.

Hyperventilation during an anxiety attack leads to respiratory alkalosis.

The low pH and HCO3- indicate metabolic acidosis due to ketoacidosis.

Hoarseness often gets worse during treatment with radiation therapy. The nurse should reassure the patient that this usually improves within 6 to 8 weeks after therapy is completed. Strategies that may help during radiation therapy include voice rest with use of alternative means of communication, as well as saline gargles or sucking on ice chips.

Elevating the head of the bed may help with oxygenation but will not help with hoarseness.

Responses 3 and 4 are important but do not speak directly to the patient's concern.

Focus: Prioritization.

Ans: 1, 3, 4, 6 When a patient expresses interest in smoking cessation, this is an important teaching moment for the nurse. However, it is essential to determine the patient's level of nicotine dependence by asking questions such as questions 1, 3, 4, and 6, which will give clues to this important information. While it is important to know about other family smokers and whether the patient smokes inside or outside, this information does not necessarily help with determining nicotine dependence.

Focus: Supervision, Prioritization.

When the need for oxygen is greater in the tissues, there is a curve shift to the right. This means that oxygen is dissociated from hemoglobin faster. Conditions that shift the curve to the right include increased body temperature, increased carbon dioxide concentration, and decreased pH or acidosis. This means that hemoglobin unloads oxygen to the tissues because they need it to support the higher metabolism, and this is a tissue protection that increases oxygen delivery to the tissues that need it the most.

Focus: Prioritization.

The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN.

Focus: Assignment, Supervision.

For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory rate. If the nurse does not intervene, the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chronic emphysema.

Focus: Prioritization;

Test Taking Tip: Immediate or priority concerns are issues that can threaten life or limb. In this case, the nurse should remember the normal drive to breathe and recognize that this patient's drive is different. With a respiratory rate so low, the patient is at risk for a respiratory arrest.

When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

Focus: Prioritization.

Checking vital signs, carrying specimens to the lab, and reminding patients about what has already been taught are actions that are within the scope of practice for UAP. Assessing and teaching patients requires additional knowledge and training that is within the scope of practice for professional nurses.

Focus: Delegation.

When tracheostomy care is performed, a sterile field is set up, and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.

Focus: Delegation, Supervision.

The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed.

Focus: Assignment, Supervision

The UAP can remind patients about actions that have already been taught by the nurse and are part of the patient's plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can administer or assign medication administration to an LPN/LVN.

Focus: Delegation, Supervision.

The new RN is at an early point in orientation. The most appropriate patients to assign to the new RN are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. The newly diagnosed diabetic patient will need much teaching as well as careful monitoring. As the new nurse advances through orientation, the preceptor will want to work with him or her in providing care for patients with more complex needs.

Focus: Assignment, Delegation, Supervision.

Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.

Focus: Prioritization.

Before each use, the cap is removed, and the inhaler is
shaken according to the instructions in the package insert. Next the patient should breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release 1 puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait at least 1 minute between puffs from the inhaler.

Focus: Prioritization.

Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of UAPs. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate to the scope of practice of licensed nurses. Focus: Delegation, Supervision.

Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to UAPs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice.

Focus: Delegation, Supervision.

A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated and should be followed up on but are not a cause for immediate concern.

Focus: Prioritization, Delegation, Supervision.

The UAP's training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the UAP can remind and encourage the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill and are appropriate to the RN's scope of practice. Monitoring the patient's cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN's scope of practice.

Focus: Delegation, Supervision.

Continuous bubbling indicates an air leak that must be identified. With the health care provider's (HCP's) order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require the RN to notify the HCP. If the air bubbling does not stop when the RN applies the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak.

Focus: Delegation, Supervision.

The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations is urgent. In patients with COPD, pulse oximetry oxygen saturations of more than 90% are acceptable.

Focus: Prioritization.

UAPs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic UAP. However, an experienced UAP could assist the patient with positioning after the UAP and the patient had been taught the proper technique. UAPs would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RN.

Focus: Delegation, Supervision.

Patients with COPD often have food intolerance, nausea, early satiety (feeling too "full" to eat), poor appetite, and meal-related dyspnea. The increased work of breathing raises calorie and protein needs, which can lead to protein-calorie malnutrition. Urging the patient to eat high-calorie, high- protein foods can be done by the UAP after the nurse has taught the patient about the importance of this strategy to prevent weight loss. Feeding the patient too rapidly will tire him or her. If early satiety is a problem, avoid fluids before or during the meal or provide smaller, more frequent meals.

Focus: Delegation, Supervision.

Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Also, a fairly new nurse should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

Focus: Assignment.

Patients taking isoniazid must continue taking the drug for 6 months. The other three statements are accurate and indicate an understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing and placing tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB.

Focus: Prioritization.

Patients who have recently experienced trauma are at risk for deep vein thrombosis (DVT) and pulmonary embolus (PE). None of the other findings are risk factors for PE. Prolonged immobilization is also a risk factor for DVT and PE, but this period of bed rest was very short.

Focus: Prioritization.

An LPN/LVN who has been trained to auscultate lung sounds can gather data by routine assessment and observation under the supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN.

Focus: Assignment, Supervision.

While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). Assessment of patients is within the scope of practice for professional nurses. All of the other instructions are appropriate for the UAP when caring for a patient receiving anticoagulants.

Focus: Delegation, Supervision.

Patients with COPD often have chronic fatigue. Teach them to not rush through activities but to pace activities with periods of rest. Encourage patients to avoid working with their arms raised. Activities involving the arms decrease exercise tolerance because the accessory muscles are used to stabilize the arms and shoulders rather than to assist breathing. Smaller more frequent meals may be less tiring. Teach the patient to avoid breath-holding while performing any activity because this interferes with gas exchange.

Focus: Prioritization.

A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing.

Focus: Prioritization.

The ET should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after ET placement. The priority at this time is to verify that the tube has been correctly placed. Use of an end-tidal carbon dioxide detector is the gold standard for evaluating and confirming ET position in patients who have adequate tissue perfusion.

Focus: Delegation, Supervision, Prioritization.

2 The UAP's educational preparation includes measuring vital signs, and an experienced UAP would have been taught and know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN.

Focus: Delegation, Supervision.

Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system. The other vital signs are important and should be followed up on but are not of as urgent concern. Focus: Prioritization.

Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the health care provider needs to be called.

Focus: Prioritization.

Manual ventilation of the patient will allow the nurse to deliver an Fio, of 100% to the patient while attempting to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, or insertion of an oral airway, but the first step should be assessing the reason for the high-pressure alarm and resolving the hypoxemia.

Focus: Prioritization

he patient's history and symptoms suggest the development of acute respiratory distress syndrome (ARDS), which will require intubation and mechanical ventilation to maintain oxygenation and gas exchange. The HCP must be notified so that appropriate interventions can be taken. Application of a nonrebreather mask can improve oxygenation up to 95 to 100%. The maximum oxygen delivery with a nasal cannula is an Fio₂ of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.

Focus: Prioritization.

Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure.

Focus: Prioritization.

Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP. Focus: Prioritization; Test Taking Tip: Prevention of VAP has been a subject of research; as a result, a ventilator bundle order set has been developed to apply to patients placed on ventilators with the goal of prevention of VAP.

Older patients, especially those who have smoked or who have chronic lung problems such as COPD, are at risk for ventilator dependence and failure to wean. Age-related changes, such as chest wall stiffness, reduced ventilatory muscle strength, and decreased lung elasticity, reduce the likelihood of weaning. Younger patients without respiratory illnesses are likely to wean from the ventilator without difficulty.

Focus: Prioritization.

Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. It is a symptom that the patient may need to be reintubated. When stridor or other symptoms of obstruction occur after extubation, respond by immediately calling the Rapid Response Team before the airway becomes completely obstructed. It is common for patients to be hoarse and have a sore throat for a few days after extubation. A respiratory rate of 25 breaths/min should be rechecked but is not an immediate danger, and an oxygen saturation of 93% is low normal.

Focus: Prioritization.

The standard size catheter for an adult is a no. 12 or 14 French. Infection is possible because each catheter pass can introduce bacteria into the trachea. In the hospital, use sterile technique for suctioning and for all suctioning equipment (e.g., suction catheters, gloves, saline or water). Apply suction only during catheter withdrawal and use a twirling motion to prevent the catheter from grabbing tracheal mucosa and leading to damage to tracheal tissue. Apply suction for no more than 10 seconds to minimize hypoxemia during suctioning.

Focus: Prioritization.

Teach the UAP that compared with light-skinned adults, adults with dark skin usually show a lower oxygen saturation (3% to 5% lower) as measured by pulse oximetry; this results from deeper coloration of the nail bed and does not reflect true oxygen status. None of the other responses are correct. Focus: Supervision.