When administering an otic medication to an adult or child age 3 and older, the pinna is pulled upward and back to straighten the external ear canal (Option 2). For an infant, the pinna is pulled downward and straight back.

(Option 1) The child should be placed in the prone or supine position with the head turned to the appropriate side.

(Option 3) Otic medication should be warmed to room temperature if removed from a refrigerator prior to administration. Holding the bottle in the palm of the hand is an effective method of warming. Instilling cold drops into the ear can cause a vestibular reaction, resulting in dizziness and vomiting.

(Option 4) The medication dropper should be held near the entrance to the ear canal without touching it. This technique allows the drops to fall against the wall of the canal, reducing discomfort while avoiding contamination of the dropper. After instilling the drops, the child should remain with the affected ear up for several minutes to allow full coverage of the medication.

A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Clients with a descending or sigmoid colostomy drain stool that is more formed and similar to a normal bowel movement. Although less common, some clients choose to irrigate their colostomy in order to create a bowel regimen that allows them to wear a smaller pouch or a dressing over the stoma. When irrigated daily, the client gains increased control over the passage of stool. The procedure for bowel irrigation is as follows: Fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang the container on a hook or intravenous pole (Option 2) Instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the irrigation container approximately 18-24 inches above the stoma (Option 3) Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes Clamp the tubing if cramping occurs, until it subsides (Option 4) Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the toilet (Option 1) A cone-tip applicator is used to instill the irrigation solution into the stoma. An enema set should never be used to irrigate a colostomy. A cone-tip applicator is specifically made to avoid damage to the sensitive colostomy opening.

A flaccid extremity and change in verbal ability are symptoms of a stroke, which is considered an emergency. Clients with stroke symptoms are immediately triaged using a special team and set of tools to determine the correct course of action with the goal of preventing further brain damage. In any emergency, the first priority nursing action is to maintain a patent airway (Option 3).

Depending on the mechanism of injury, the symptoms may include changes in airway clearance, which is a priority. The nurse, or another member of the emergency department or stroke alert team, will prepare the client for an immediate head CT scan to rule out a hemorrhagic stroke and determine the location and extent of the injury (Option 4).

This person will also ensure that the client has 2 large-bore IV lines for rapid infusion of fluids or medications as needed (Option 2).

(Option 1) It is vital to determine the onset of symptoms as thrombolytic medications are used in a short time frame (typically within 4.5 hours of onset). Thrombolytic medications are used only in ischemic strokes, so the head CT must be completed to confirm the type of stroke (ischemic versus hemorrhagic). With all of these interventions, the priority nursing actions remain the same: ABC – airway, breathing, and circulation.

Educational objective: In any emergency, the primary nursing interventions are the ABCs. A patent airway should be maintained while other care is provided and throughout the emergency treatment process.

Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds.

(Option 1) A normal hematocrit for a female is 35%-47% (0.35-0.47). In a client with a history of chronic anemia, a hematocrit of 30% (0.30) may be an expected finding.

(Option 3) A normal platelet count is 150,000-400,000/mm³ (150-400 x 109/L). In a client with a history of liver cirrhosis, a platelet count of 80,000/mm³ (80 x 109/L) would be anticipated. An episode of bleeding rarely occurs with a platelet count >50,000 mm³ (50 x 109/L).

(Option 4) A normal prothrombin time is 11-16 seconds, and so a level of 11 seconds would not be concerning.

A low tidal volume alarm indicates that the volume of air the ventilator is delivering is lower than the set volume. This is most often due to a disconnection, loose connection, or leak in the circuit. The nurse should troubleshoot the most common causes of the alarm, but if the client’s condition is deteriorating clinically (eg, decreasing oxygen saturation), then the nurse should disconnect the ventilator and manually ventilate the client’s lungs with a resuscitation bag device at 10-15 L/min oxygen until the ventilator alarm state can be resolved.

(Option 1) Respiratory therapists have specialized training in mechanical ventilators. They should be called to the bedside but only after the nurse has begun to stabilize the client’s condition using manual ventilation.

(Option 2) Since the client is intubated, air cannot pass from the nares and oropharynx into the lungs, and ventilation can be achieved only via the endotracheal tube.

(Option 3) The client would benefit from a higher oxygen level, but the ventilator is unable to deliver the programmed volume to the client, even with an increased oxygen level. The client’s lungs must be manually ventilated with a resuscitation bag.

Educational objective: Ventilators may sound an alarm when set parameters are not being met (eg, low tidal volumes, high peak pressures). These alarms may indicate a client condition or ventilator malfunction. If a ventilator alarm cannot be readily resolved, the nurse should manually ventilate the client’s lungs with a resuscitation bag device.

Hyperphosphatemia can lead to muscle cramps and tetany due to its effect on calcium levels.

The traditional and rigid gender roles described by the client are examples of role stereotyping. Impermeable boundaries, unbalanced power ratio, and dysfunctional feeling tone are also common in abusive families.
CN: Safety and infection control; CL: Analyze

The best option is room 4 as the client with the upper gastrointestinal bleed does not put the immunocompromised client with AIDS at increased risk for infection.

(Options 1, 2, and 3) These room options put the client with AIDS at increased risk for infection because:

Room 1-C difficile is a highly contagious bacterial infection transmitted through stool and requires contact precautions

Room 2 – fever of unknown origin is often a symptom of an undiagnosed viral or bacterial infection

Room 3-pneumonia is an infectious respiratory disease

IV fluids help flush out the released intracellular contents, such as uric acid and electrolytes, through the kidneys, reducing the risk of renal damage.

Close monitoring of electrolyte levels is crucial for detecting and managing the imbalances associated with TLS.

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.

Heat Exhaustion 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).

(Option 1) If the client’s temperature continues to rise after moving to cooler temperatures, ice packs placed on the axilla and groin may help to dissipate heat; further medical help may be necessary.

(Option 2) The client should not leave until the symptoms subside, especially if driving. It is not necessary to have the client visit a health care provider if symptoms resolve.

(Option 3) Assessment can be continued once the client has been moved to a cooler environment and provided with hydration. Alcohol consumption may compound heat exhaustion but does not change initial management of the client.

Educational objective: Initial management of heat exhaustion includes moving the client from the heat to a cooler area and providing a cool, electrolyte-containing sports drink or water. Early intervention in heat exhaustion can prevent the development of heat stroke, a potentially fatal condition leading to brain and additional organ damage.

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).

Educational objective: 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.

The client’s safety, including the need to stay alive, is crucial. Therefore, helping the client develop a safety plan is most important to include in the plan of care  to ensure the client’s safety. Being empathetic, teaching about abuse, and explaining the person’s rights are also important after safety is ensured.
CN: Psychosocial integrity; CL: Synthesize

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.

A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. Clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain.

(Option 2) It can take 24-48 hours for peristalsis to return after bowel surgery due to manipulation of the bowels and anesthesia. This client should be monitored for return of bowel function and should be assessed last.

(Option 3) Clients with atrial fibrillation may experience tachycardia and irregular heart rhythm even with treatment. This client should be assessed after the client with an endarterectomy.

(Option 4) Total parenteral nutrition (TPN) should never be discontinued abruptly (due to the risk for hypoglycemia). This client should be seen third so that TPN is not interrupted

Insulin with dextrose is used to shift potassium from the bloodstream into the cells, temporarily reducing serum potassium levels.

Major side effects of angiotensin-converting enzyme (ACE) inhibitors include:

• Symptomatic hypotension
• Intractable cough
• Hyperkalemia
• Angioedema (allergic reaction involving edema of the face and airways)
• Temporary increase in serum creatinine

For clients unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) such as valsartan or losartan are recommended. ARBs prevent the vasoconstrictor and aldosterone-secreting effects of angiotensin II by binding to the angiotensin II receptor sites.

(Option 1) Alprazolam is an anxiolytic. It is not used in the treatment of heart failure.

(Option 2) Dextromethorphan is a cough suppressant. A cough caused by an ACE inhibitor will not be improved by a cough suppressant.

(Option 3) Lisinopril is an ACE inhibitor. This client has been unable to tolerate this class of drug.

Educational objective: ARBs are recommended for clients unable to tolerate ACE inhibitors.

TLS often leads to hyperkalemia due to the release of potassium from lysed tumor cells.

Parental use of nonviolent discipline, the child’s talk about what the family is doing and the easing of the parent’s negativity toward the school nurse are all signs of progress. Avoidance and wearing clothes inappropriate for the weather implies that the child has something to hide, likely signs of physical abuse.
CN: Psychosocial integrity; CL: Analyze

Postpartum hemorrhage can occur immediately after birth of the placenta or in the hours and days following birth. Risk factors include grand multiparity (ie, >= 5 births), intrauterine infection, prolonged labor, use of oxytocin during labor, and coagulopathy. A perineal pad that is saturated in <= 1 hour indicates heavy/excessive bleeding, which may lead to hemodynamic compromise if not recognized and corrected with interventions (eg, fundal massage, uterotonics). A client with a high parity who saturated a pad every hour for the past two hours is experiencing excessive bleeding, potentially due to uterine atony. The nurse should immediately assess the client’s fundal tone, lochia amount, and vital signs and notify the health care provider (Option 4).

(Option 1) Foul-smelling lochia is a sign of endometritis, a diagnosis that requires further evaluation and antibiotic treatment but is not a priority over hemorrhage.

(Option 2) Venous stasis and hypercoagulability play a role in the development of postpartum deep venous thrombosis (DVT). For clients with a DVT, anticoagulants such as enoxaparin (Lovenox) help prevent pulmonary embolism (PE). Should symptoms of PE (eg, dyspnea, chest pain) occur, immediate assessment is required.

(Option 3) Fever and a red, swollen breast are symptoms of mastitis, a diagnosis that requires antibiotics and breastfeeding support but is not life-threatening.

Educational objective: The nurse should prioritize assessment of clients with signs of immediately life-threatening postpartum complications (eg, hemorrhage, pulmonary embolism). A perineal pad that is saturated in <= 1 hour indicates excessive bleeding and requires immediate assessment to prevent hemodynamic compromise.

Elevated serum creatinine indicates renal impairment, which is a common complication of TLS due to the precipitation of uric acid in the kidneys.

On the first postoperative day, the nurse assists the client with

• Ambulation to evaluate alertness,
• Pain level,
• Signs of orthostatic hypotension,
• Problems with gait or mobility, and
• Ability to ambulate safely.

The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse’s elbow. The nurse should describe the environment while ambulating the client.

(Option 1) The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely.

(Option 2) After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit.

(Option 3) Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely.

Educational objective: When ambulating a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead with the client holding the nurse’s elbow.

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.

Educational objective: 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

Endotracheal (ET) suctioning improves ventilation in mechanically ventilated clients by removing mucus and secretions from the ET tube. Suctioning is performed based on clinical findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or signs of acute respiratory distress. Frequent suctioning increases the risk of tracheal and bronchial trauma, bleeding, and hypoxia. Suctioning should be performed only when needed to reduce the risk for injury (Option 2).

(Option 1) Auscultating the neck to monitor for an ET tube cuff leak is a standard component of respiratory assessment in mechanically ventilated clients. The presence of a cuff leak increases the risk of accidental estuation, impairs ventilation, and allows aspiration of secretions from the mouth and throat.

(Option 3) Oral care with oral suctioning is performed every 2 hours to prevent ventilator- associated pneumonia (VAP). Secretions in the mouth and throat often contain bacteria that can cause pneumonia.

(Option 4) Repositioning clients at least every 2 hours reduces the occurrence of VAP. Turning clients side-to-side promotes mobilization of secretions and prevents secretions from pooling in dependent areas of the lungs.

Educational objective: Endotracheal suctioning in mechanically ventilated clients should be performed based on assessment findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or acute respiratory distress. Suctioning should be performed only when needed to reduce the risk of lung trauma and hypoxia.

This client’s spouse has experienced a traumatic or crisis event (also referred to as “a critical incident”).

When faced with a traumatic situation, clients are often overwhelmed and respond with a wide range of emotions and thoughts, including shock, denial, anger, helplessness, numbness, disbelief, and confusion.

Clients may also experience physical symptoms, such as hyperventilation, abdominal pain, and dizziness.

Priority nursing actions need to be directed at the here and now, providing therapeutic interventions aimed at alleviating the immediate emotional impact of this disruptive crisis event.

Acknowledging the severity of the event validates and normalizes the spouse’s reaction.

Assisting the spouse in identifying feelings and giving the spouse opportunity to ventilate will help reduce immediate emotional stress.

• (Option 1) Assessing this family’s support system is important. However, it is not the priority action at this time.
• (Option 2) This statement does not address what this client’s spouse is experiencing at the moment. At a later time, the nurse can explore the client’s history and any events that may have lead to this situation.
• (Option 4) This response does not address the spouse’s concerns. Also, the wording is judgmental and nontherapeutic.

Educational objective:

Initial reactions to a crisis event may include shock, disbelief, denial, helplessness, and confusion. Nursing actions are directed at providing support to the client. Acknowledging the impact of the event and encouraging the client to ventilate are therapeutic interventions.

TLS occurs when a large number of tumor cells are rapidly destroyed by chemotherapy, releasing their intracellular contents into the bloodstream.

FTT, or growth failure, is a state of undernutrition and inadequate growth in infants and young children. Most cases of FTT are related to an inadequate intake of calories, which can be tied to many different etiologies. Physiologic risk factors for FTT include preterm birth, breastfeeding difficulties, gastroesophageal reflux, and cleft palate. Socioeconomic risk factors include: Poverty – most common Social or emotional isolation – parents may lack the support system needed to assist them with the problems of child rearing Cognitive disability or mental health disorder Lack of nutritional education – parents may not have knowledge of proper feeding techniques or appropriate calorie intake based on age and size of the child (Option 1) There is no known relationship between caregivers working outside the home and FTT. Caregivers who are fully employed may be more able to provide adequate food resources.

(Option 5) There is no indication that unmarried parents pose a higher risk for an infant to develop FTT. More important protective factors include having a stable environment and living with 2 parents. Educational objective: FTT is a state of undernutrition and inadequate growth found in infants and young children. Physiologic risk factors for FTT include preterm birth, breastfeeding difficulties, gastroesophageal reflux, and cleft palate. Socioeconomic risk factors include poverty, social or emotional isolation, caregivers with cognitive disabilities or mental health disorders, and lack of nutritional education.

Children age 3-6 (preschool) are in Piaget’s preoperational stage of cognitive development. At age 5, children are not able to fully understand cause and effect and will therefore ascribe inappropriate causes to phenomena (eg, scraped knee was caused by earlier misbehavior). Five-year-olds are developmentally capable of understanding adoption on a basic level; however, it may be difficult for them to understand the concept of having another family. The child might notice that friends are not adopted. Preschool-age children may also believe they are responsible for being adopted and may develop separation issues and fear abandonment.

(Option 2) School-age children may imagine how life would be different if they were with their biological parents. Self-esteem issues begin to develop around this time with the possible sense of loss of the biological family. School-age children may be sensitive to physical differences between themselves and their adoptive family.

(Option 3) Children age 3 and under are unable to understand differences between adoptive and biological parents. The age at which to begin discussions about being adopted is debatable, but use of positive language is always encouraged. The terms “given up” or “put up” for adoption or someone’s “real” parents are inappropriate and should be avoided.

(Option 4) Adolescents have abstract thinking abilities that enable introspection about their adoption. They typically do not like differing from their peers. Open and honest communication is important at this age. Educational objective: Preschool-age children (3-6 years) are in Piaget’s preoperational stage of cognitive development. They become increasingly verbal but are unable to understand cause and effect, often ascribing inappropriate causes to phenomena; therefore, the adopted child may feel responsible for being adopted.

The nurse needs more information about the client’s decision before deciding what intervention is most appropriate. Judgmental responses could make it difficult for the client to return for treatment should she want to do so. Telling the client that this is a bad decision that she will regret is inappropriate  because the nurse is making an assumption. Warning the client that abuse commonly stops when one partner is involved in treatment may be true for some clients. However, until the nurse determines the basis for the client’s decision, this type of response is an assumption and therefore inappropriate. Reminding the client about her duty to protect the children would be appropriate if the client had talked about episodes of current abuse by her partner and the fear that her children might be hurt by him.

CN: Psychosocial integrity; CL: Synthesize

Addison disease (primary adrenocortical insufficiency) is characterized by a deficiency in all three types of adrenal steroids (ie, glucocorticoids, androgens, mineralocorticoids), most commonly caused by an autoimmune response. Corticosteroid therapy (eg, hydrocortisone, dexamethasone, prednisone) is the primary treatment for Addison disease. Long-term use of corticosteroids can cause immunosuppression, and the anti- inflammatory effects may also mask signs of infection (eg, inflammation, redness, tenderness, heat, fever, edema). Signs and symptoms of infection (eg, low-grade fever) should be reported to the health care provider immediately as infection can develop quickly and spread rapidly (Option 2).

In addition, physiological stress such as infection can trigger Addisonian crisis, a life-threatening complication of Addison disease that would require an increase in the corticosteroid dose.

(Options 1, 3, and 4) Side effects of long-term corticosteroid therapy mimic the signs and symptoms of Cushing syndrome, including buffalo hump, moon-shaped face, and hypokalemia. Increased weight, blood pressure, and blood glucose levels can also occur; however, these effects are not as life-threatening as infection.

Client and staff safety is an ongoing concern when working with clients who are confused and agitated. The least restrictive restraint should be used. One-on-one supervision provided by a trained staff member who stays with the client at all times can promote safety while reducing or eliminating the use of restraints on a client who is confused and agitated. Frequent reassurance, touch, and verbal orientation (regarding name, location, time, and the client’s situation) can lessen disruptive behaviors. Placing a large clock and calendar within the client’s visibility would also help.

(Option 1) Ideally, the client will be placed in a room near the nursing station. However, the client with delirium and agitation will also require ongoing supervision to minimize harm to self or others.

(Option 2) Four-point leather restraints are one of the most restrictive restraint options. These are not appropriate as a first-line option for promoting safety.

(Option 3) Reducing environmental stimuli is important for an agitated client, but these alone are not most helpful.

Educational objective: When caring for clients with behavioral issues that may compromise safety, less restrictive restraint and safety options should be implemented before more restrictive restraint options are used.

The nurse assesses the client who reports burning at the PCA IV site first. The analgesia runs through a special PCA administration set that is attached to the PCA pump. It is attached to a running IV line, which is on its own infusion pump, to flush the PCA drug through the IV line each time a dose is administered. If the IV line infiltrates the subcutaneous tissue or the catheter becomes occluded, the PCA drug can back up into the primary tubing each time a dose is administered, resulting in inadequate pain control. In addition, burning can indicate phlebitis, which causes vessel wall injury and can lead to(Option 2) The nurse will perform abdominal and pain assessments and will check the function and patency of the suction. However, this client was admitted yesterday, is stable, and does not need to be assessed first.

(Option 3) An irregular heart rhythm is to be expected in a client with atrial fibrillation, and a heart rate of 94/min is within the normal range (eg, 60-100/min). This client is stable and does not need to be assessed first.

(Option 4) Incontinence of stool in a client with dementia and C difficile is not uncommon. To provide for immediate client comfort, the nurse can delegate the task of bathing the client to the unlicensed assistive personnel. This client does not need to be assessed first. Educational objective: To prioritize care, the nurse first identifies the type of problem, associated complications, and desired outcomes. The nurse then decides which client problems and needs are most urgent and require immediate action and which can be delayed.

The priority for a client with a mandibular fracture whose teeth have been wired together is maintaining a patent airway. If the client begins to choke on oral secretions, the nurse should immediately attempt to clear the airway by suctioning via the oral or nasopharyngeal route. If this intervention is ineffective, cutting the wires may be necessary.

(Option 1) Cutting the wires can cause collapse of the fractured jaw and exacerbate the airway problem. This action is not the first priority unless the situation is an emergency (eg, acute respiratory distress, cardiopulmonary arrest requiring intubation). A wire cutter must be taped to the head of the client’s bed at all times, including during travel.

(Option 2) Elevating the head of the bed is a preventive measure. Because the client is choking, the priority is suctioning secretions to clear the airway. The nurse should also turn the client to the side if the client has excessive oral secretions or begins to vomit to decrease the risk of aspiration.

(Option 3) The nurse should intervene to maintain the airway before calling the health care provider. A prescription for nasogastric suction to decompress the stomach may be indicated to reduce the risk of vomiting.

Educational objective: Maintaining a patent airway is the priority for clients with mandibular fractures who are unable to open their mouths. If choking occurs, the immediate intervention is to suction the mouth and oropharynx. If this is ineffective, cutting the wires may be necessary.

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.

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.

The experience of rape is a crisis. Crisis intervention services, especially with a rape crisis nurse, are essential to help the client begin dealing with the aftermath of a rape. Legal assistance may be recommended if the client decides to report the rape and only after crisis intervention services have been provided. A rape support group can be helpful later in the recovery process. Medications for sleep disturbance, especially benzodiazepines, should be avoided if possible. Benzodiazepines are potentially addictive and can be used in suicide attempts, especially when consumed with alcohol.
CN: Psychosocial integrity; CL: Synthesize

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.

(Option 3) Infants should sleep on a firm surface or mattress that fits the crib and is covered with a fitted sheet.

Educational objective: 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.

Common side effects of immunizations include a mild fever and soreness and redness at the injection site. Caregivers should be instructed to apply a warm compress to the injection site and taught how to correctly calculate the dose of acetaminophen or ibuprofen needed for these symptoms.

• (Option 1) The health care provider should be notified if the child’s temperature is higher than 100.4 F (38 C).
• (Option 2) Children may have increased fussiness and anorexia following immunizations. These symptoms should not last more than 24 hours.
• (Option 4) A child’s activity level should not be restricted following immunizations. Being active may actually help decrease any soreness if the child moves the injected extremity.

Educational objective:

Common side effects of immunizations include a mild fever and soreness and redness at the injection site. Anorexia and fussiness can be present for the first 24 hours.

Oropharyngeal candidiasis, or thrush (moniliasis), is an infection of the mucous membranes generally caused by the yeast like 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.

Educational objective: 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.

Clients may feel overwhelmed when managing chronic illnesses. The nurse should assist them in processing difficult news or events through discussion of thoughts and feelings, which also fosters rapport. Reflecting, or referring the statement back to the client, is a therapeutic communication technique that promotes open dialogue and encourages the client to recognize feelings (Option 3). Acknowledging feelings is an important step in successfully navigating difficult circumstances.

(Option 1) Encouraging the client to cry if needed conveys concern but does not encourage further discussion of feelings.

(Option 2) Giving false reassurance is an example of a nontherapeutic communication technique that may seem supportive; however, it inappropriately offers hope for an outcome that the nurse cannot guarantee. False reassurance also invalidates and hinders discussion of the client’s feelings.

(Option 4) Making cliché statements or automatic responses (eg, “you have a lot to live for”) or shifting the focus to others’ feelings (eg, “think about your family”) invalidates the client’s feelings and impedes open communication.

Educational objective: Nurses should assist clients in processing difficult news or events through discussion of thoughts and feelings. Reflecting is an appropriate technique that promotes open communication and encourages the client to recognize feelings.

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. Educational objective: When the nurse receives report of a change in client condition from the UAP, the nurse should reassess the client before completing other interventions.

In a pregnant client, a serum sample is collected at the first prenatal visit to determine immunity to the rubella virus. A positive immune response indicates immunity to the rubella virus, attributed to either past infection or vaccination. A negative, or nonimmune, response indicates that the client is susceptible to rubella disease and requires vaccination. An equivocal response indicates partial immunity to rubella and is treated clinically the same as nonimmune status. Measles-mumps-rubella (MMR) is a live attenuated vaccine. Live vaccines are contraindicated in pregnancy due to the theoretical risk of contracting the disease from the vaccine. Maternal rubella infection can be teratogenic for the fetus. The fetal effects of congenital rubella syndrome include congenital cataracts, deafness, heart defects (patent ductus arteriosus), and cerebral palsy. The best time to administer an MMR vaccine to a nonimmune client is in the postpartum period just prior to discharge (Option 2).

The MMR vaccine can safely be administered to breastfeeding clients.

(Options 1 and 3) MMR vaccine is contraindicated in pregnancy. Also, pregnancy should be avoided for at least 1-3 months after the immunization is given.

(Option 4) This client is rubella nonimmune and is susceptible to rubella if exposed. The vaccine should be offered in the postpartum period.

Clients with an allergy to penicillin antibiotics (eg, amoxicillin, ampicillin) can possibly experience a cross-sensitivity reaction to cephalosporin antibiotics (eg, cefazolin, cephalexin, ceftriaxone), because the drug molecules are structurally similar. The nurse should obtain more information about this client’s reported allergies, as reactions range from mild to severe. In particular, the nurse must first assess the type of reaction the client had to amoxicillin (Option 3).

The nurse should then clarify the prescription with the health care provider (HCP) prior to administration. If this client’s reaction to amoxicillin was a rash or other mild reaction that was not life- threatening, the HCP may decide that cephalosporin can be safely administered. However, cephalosporins are contraindicated for a client with a history of anaphylactic reactions to penicillin, and a different antibiotic should be prescribed.

(Option 1) The nurse should hold the medication until more is known about the client’s reaction to amoxicillin.

(Option 2) The nurse must first obtain more information about the reaction so the HCP can make an informed decision about whether the cephalosporin antibiotic can be administered or should be changed.

(Option 4) The nurse must first obtain more information about the type of allergic reaction before notifying the pharmacy

The safety of the client and her children is the most immediate concern.

If there is immediate danger, action must be taken to protect them. The other options can be discussed after the client’s safety is assured.
CN: Psychosocial integrity; CL: Analyze

The off-going nurse must ensure that there is another registered nurse responsible for the care of the clients, if this is not done then abandonment has occurred. A deliberate report must be given using standardized format for continuity of care. During the hand-off, objective data should be provided about the clients’ current status and response to treatment to enable planning care.

The off-going nurse should let the charge nurse know as this individual is responsible for the staffing of the unit and would have the authority to try different options, such as asking another nurse on the unit to stay or notifying the main nursing office to obtain a nurse from another unit. In addition, there is no established time frame for the incoming nurse’s actual arrival; a significant amount of time could pass before this inadequate staffing issue is resolved.

(Option 1) This general vague oversight is an inadequate report and transfer of responsibility to the other nurse.

(Option 2) Tape recording a report is a legitimate method of communication as long as there is an opportunity to ask questions. However, this does not resolve the issue of procuring a nurse to take over responsibility for the clients’ care.

(Option 4) Although this would help transmit essential information, it does not accomplish procurement of another nurse to be responsible for the clients’ current care.

Educational objective: In a facility with 24-hour care, prior to leaving, an off-going nurse must have another nurse take over the responsibility for the clients’ care and give an appropriate report for these clients. Leaving clients without these elements can be deemed to be an act of abandonment.

The mother’s feelings are the priority here. Addressing the mother’s feelings and asking for her view of the situation is most important in building a relationship with the family. Ignoring the mother’s feelings will hinder the relationship. Defending the school nurse and the school puts the client’s mother on the defensive and stifles communication.
CN: Psychosocial integrity; CL: Synthesize

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.

(Option 1) This statement is technically true, but it is not helpful to the parents and misses a critical teaching moment for them.

(Option 3) It is reasonable to attribute the cause of the infant’s epiglottitis to missing the vaccinations for Haemophilus influenza type B.

(Option 4) This statement is both unhelpful and inaccurate as the child is still at risk for further preventable illness.

Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post- anesthesia care unit (PACU). The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1 degree Celsius every 5 minutes and can exceed 105 F (40.6 C). The nurse would notify the health care provider, indicating the need for immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation) (Option 2).

(Options 1 and 3) A client who just arrived in the PACU after general anesthesia would be expected to be difficult to arouse; and to have small pupil size associated with drugs used to induce general anesthesia, sedating drugs, and opioid drugs to control pain.

(Option 4) Hypothermia (<95 F [35 C]) is common in the immediate postoperative period due to anesthetic-induced vasodilation, decreased basal metabolic rate, and a cool environment. This can be managed by the nurse. Hyperthermia (fever) is also common due to the blood products and trauma from surgery.

However, stiffness/rigidity in the presence of elevated temperature is more concerning. Educational objective: Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia

Delirium or acute cognitive dysfunction is a syndrome commonly seen in hospitalized clients; it is reversible but difficult to diagnose.

Clients may manifest delirium states that can be

hypoactive (eg, quiet, disorientation, change in level of consciousness, memory loss),

hyperactive (eg, restlessness, agitation, hallucinations, paranoia), or mixed.

Manifestations of delirium develop acutely and are difficult to differentiate from those associated with pain, anxiety, and medications.

Early diagnosis and treatment are advantageous as delirium is associated with increased mortality (especially in critically ill clients on mechanical ventilation). Delirium is difficult to assess; it is recommended that nurses use a standardized tool (eg, Confusion Assessment Method for the ICU) or checklist (eg, Intensive Care Delirium Screening) for this purpose.

• (Option 1) Amnesia affects short- and long-term memory loss. It can be intentionally induced by drug use or may occur as a result of trauma or underlying physical/psychological disease processes. Amnesia is not the most likely condition manifested by this client.
• (Option 3) In contrast to delirium, dementia is gradual in onset and causes an irreversible and progressive cognitive decline. Remote memory is spared initially and there is no impairment of consciousness until the late stages of the disease.
• (Option 4) Psychosis does not have an acute onset. Clients with this condition are usually oriented but have auditory (not visual) hallucinations. It is not likely in this client.

Educational objective:

New-onset confusion regarding sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy can be manifestations of delirium in a critically ill client who was previously alert and oriented.

Benzodiazepines (eg, alprazolam [Xanax], lorazepam [Ativan], clonazepam, diazepam) are commonly used antianxiety drugs. They work by potentiating endogenous GABA, a neurotransmitter that decreases excitability of nerve cells, particularly in the limbic system of the brain, which controls emotions. Benzodiazepines may cause sedation, which can interfere with daytime activities. Giving the dose at bedtime will help the client sleep.

(Option 1) Eliminating aged cheeses and processed meats, which contain tyramine, is necessary with monoamine oxidase inhibitors (eg, tranylcypromine, phenelzine), which are used for depressive disorders. It is not necessary with benzodiazepines.

(Option 2) A benzodiazepine should never be stopped abruptly. Instead, it should be tapered gradually to prevent rebound anxiety and a withdrawal reaction characterized by increased anxiety, confusion, and more.

(Option 4) Photosensitivity is a problem with most antipsychotics and many antidepressants, but not with benzodiazepines.

Approach to adult cardiac arrest

Start CPR,

give oxygen

attach monitor/defibrillator VF/pulseless VT PEA/asystole Defibrillation shock •

CPR x2 min

Airway,

IV/IO access Epinephrine every 3-5 min

Pulse & rhythm check every 2 min

Treat reversible causes Shockable rhythm ROSC Non Shockable rhythm

A breast prosthesis is an artificial appliance that is fitted to the external chest wall or inserted into a female client’s undergarments to simulate previous symmetry after a mastectomy or breast trauma. This is an option for clients who are not interested in, or are not candidates for, breast reconstruction surgery. This appliance assists in the promotion of well-being, body image, and sexuality. When evaluating the use of a breast prosthesis, nurses should assess the client for body image disturbance using open-ended questions and therapeutic communication (Option 4).

(Option 1) Sexual activity can be affected by the client’s overall body image but is not a comprehensive evaluation.

(Option 2) How often a prosthesis is used is not an indication of its effect on body image. Not all clients feel the need to wear a prosthesis for a healthy body image.

(Option 3) Although assessing coping techniques and effectiveness is important to the client’s ability to cope with the loss of a body part, this question does not evaluate the prosthesis’ effect on body image. This question also assumes that the client is or should feel self-conscious.

The Boston brace, Wilmington brace, thoracolumbosacral orthosis (TLSO) brace, and Milwaukee brace are used to diminish the progression of deformed spinal curves in scoliosis. Braces do not cure the existing spinal deformities but do prevent further worsening. These braces are also sometimes used for clients who undergo spinal fusion. The braces are molded plastic shells worn around the trunk of the body under the client’s outer clothing. Due to the risk for skin breakdown, clients should wear a cotton t-shirt under the brace to decrease skin irritation and absorb sweat. Compliance is a major problem in most adolescents as they are preoccupied with body image and appearance. Psychosocial issues (eg, body image, sense of control, socialization) are very important to discuss. Many clients may find it helpful to meet other individuals their age who also wear the braces.

(Option 1) The use of lotion or powder can cause skin irritation due to heat buildup beneath the brace.

(Option 2) It is important to build and maintain strength in the spinal muscles to promote stabilization throughout treatment. Most prescribed bracing courses allow brace removal for such exercises.

(Option 3) The exact course of bracing treatment varies based on the type of brace and severity of spinal curvature. Most braces are worn for 18-23 hours per day and removed for bathing and exercise. Clients should never shower while wearing a hard brace as padding will absorb moisture and promote skin breakdown. Educational objective: Clients wearing a brace during treatment for scoliosis must perform proper skin care, wear a cotton t-shirt under the brace, and understand the importance of wearing the brace as prescribed to slow curvature progression. Psychosocial issues (eg, body image, socialization) should also be addressed to promote compliance.

Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside (Option 4).

During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L/min by facemask. Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly during administration (Option 1).

Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately available (Option 2). Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client’s room (Option 5).

(Option 3) Severe preeclampsia is associated with CNS irritability, and excessive stimulation should be avoided. Lights should be lowered to decrease visual stimuli and risk for seizures. Educational objective: Magnesium sulfate is commonly prescribed to clients with severe preeclampsia to prevent seizures and is a central nervous system depressant. Safety measures for preeclampsia include seizure precautions and decreasing environmental stimuli.

Hyperkalemia and other electrolyte imbalances in TLS can lead to dangerous cardiac arrhythmias.

Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client’s vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the health care provider (HCP). (Option 1) The client with atrial fibrillation (AF) should be seen after the MI client. Vital signs are stable, but the International Normalized Ratio (INR) should be lower (therapeutic range of 2.0-3.0 for AF). The nurse should assess for signs of bleeding and notify the HCP; the scheduled dose of warfarin should likely be held. (Option 2) A temperature of 99 F (37.2 C) is not uncommon in the days immediately following surgery. The nurse should assess surgical incisions and respiratory status and give the scheduled antibiotic. (Option 4) After NPO status is discontinued, the client should be offered fluids. This task can be delegated to unlicensed assistive personnel and is not the priority

Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in the release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites.

TLS may result in the following life-threatening conditions:

• Hyperkalemia (>5.0 mEq/L [5.0 mmol/L]) that can cause lethal dysrhythmias

• Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) that can overwhelm the kidneys and cause hyperuricemia and acute kidney injury (AKI) from uric acid crystal formation

• Hyperphosphatemia (>4.4 mg/dL [1.42 mmol/L]) that can cause AKI and dysrhythmias

• Hypocalcemia (<8.6 mg/dL [2.15 mmol/L]) that can cause tetany and cardiac dysrhythmias Potassium-sparing medications (eg, spironolactone) can worsen hyperkalemia (Option 4). Loop or osmotic diuretics may be prescribed to increase urine output and lower serum potassium. Sodium polystyrene sulfonate (Kayexalate) also helps to reduce potassium.

(Options 1 and 2) Hypouricemic agents (eg, allopurinol) prevent the formation of uric acid, and aggressive fluid hydration (eg, IV normal saline) flushes out the kidneys to avoid the accumulation of toxins. Hydration therapy also dilutes serum potassium, lowering the risk for lethal dysrhythmias.

(Option 3) Health care providers often prescribe mealtime phosphate binders (eg, sevelamer, lanthanum carbonate, calcium acetate) to prevent absorption of additional nutritional phosphorus.

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).

(Option 2) Rifapentine should be taken with meals for best absorption and to prevent stomach upset.

(Option 3) Hepatotoxicity may occur; therefore, liver function tests are required at least every month. Signs and symptoms of hepatitis include jaundice of the eyes and skin, fatigue, weakness, nausea, and anorexia.

(Option 4) Rifapentine may cause red-orange-colored body secretions, which is an expected finding. Dentures and contact lenses may be permanently stained.

Educational objective: Clients taking rifampin or rifapentine (Priftin) as part of antitubercular combination therapy should be taught to prevent pregnancy with non-hormonal contraceptives, notify the health care provider of any signs or symptoms of hepatotoxicity (eg, jaundice, fatigue, weakness, nausea, anorexia), and expect red-orange-colored body secretions.

Neurogenic shock belongs to the group of distributive (vasodilatory) shock. Parasympathetic nervous system (PNS) activity, which is directed from the brain through the vagus nerve (cranial nerve X), includes relaxing smooth muscle tone (eg, blood vessels) and decreasing heart rate and contractility. Sympathetic nervous system (SNS) activity, which normally balances the PNS, is communicated from the spinal cord. In neurogenic shock, a cervical or thoracic injury (or spinal anesthesia) disrupts the SNS, leading to bradycardia (eg, apical heart rate 48/min), massive vasodilation, and pooling of blood in the venous circulation (Option 1).

(Option 2) Massive vasodilation from neurogenic shock causes hypotension, not hypertension.

(Option 3) In neurogenic shock, vasodilation in the skin brings blood closer to the surface, causing the skin to be warm and dry initially. Cool, clammy skin is characteristic of other types of shock that involve impaired perfusion in the skin (eg, cardiogenic, hypovolemic).

(Option 4) Neurogenic shock can cause impaired thermoregulation (poikilothermia), but this takes time to manifest. As heat from vasodilation in the skin is lost to the environment, the client’s temperature begins to reflect the ambient temperature. Low-grade fever (eg, 100 F [37.8 C]) is not a characteristic manifestation.

Educational objective: Neurogenic shock (a form of distributive [vasodilatory] shock) causes a disruption in the function of the sympathetic, but not parasympathetic, nervous system. Bradycardia is a characteristic manifestation of neurogenic shock that occurs because parasympathetic activity causes a decrease in heart rate.

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.

Educational objective: 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.

Guilt and self-blame are common feelings that need to be addressed directly and frequently. The client needs to be reminded periodically that she did not deserve and did not cause the rape. Continually encouraging the client to report the rape pressures the client and is not helpful. In most cases, resuming sexual relations is a difficult process that is not likely to occur quickly. It is not necessarily true that the
rapist will be caught, tried, and jailed. Most rapists are not caught or convicted.
CN: Psychosocial integrity; CL: Apply

INH interferes with the action of vitamin B6 (pyridoxine), resulting in peripheral neuropathy; it manifests as ataxia and paresthesia. Individuals who are most predisposed to becoming neurotoxic from taking INH include older adults, those who are malnourished, diabetic clients, pregnant or breastfeeding clients, alcoholics, children, those with liver or renal disease, and HIV-positive individuals. To prevent these complications, a vitamin B, supplement at a dose of 25-50 mg/day is recommended for those at high risk.

(Option 1) Folic acid deficiency does not cause peripheral neuropathy. It is associated with macrocytic anemia and neural tube defects in children.

(Option 3) Vitamin B12 deficiency can cause peripheral neuropathy; however, it is not seen with INH therapy.

(Option 4) Vitamin D deficiency causes osteomalacia but not peripheral neuropathy.

Educational objective: High-risk clients on isoniazid therapy for treatment of tuberculosis may experience neurological side effects due to a decrease in the body’s ability to utilize vitamin B6 (pyridoxine). A vitamin B supplement will prevent these effects.

Allopurinol is commonly used to prevent and treat hyperuricemia in patients with TLS by inhibiting the formation of uric acid.

Trousseau’s sign is a clinical indication of hypocalcemia, which is a common electrolyte disturbance in TLS.

Long-term therapy with a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption of calcium and promote osteoporosis. A bone density test can assess if the client already has osteoporosis. Hospitalized clients also have an increased risk of diarrhea caused by Clostridium difficile. PPIs cause suppression of acid that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias.

(Option 1) Drinking extra water and being upright for 30 minutes after taking bisphosphonates (eg, risedronate, alendronate) is necessary to prevent esophagitis. However, this is not necessary with PPI use.

(Option 2) The medication should be taken prior to meals.

(Option 4) PPIs do not affect blood pressure. Educational objective: Long-term use of PPIs (eg, omeprazole, pantoprazole, esomeprazole) is associated with osteoporosis, C difficile infection, and pneumonias. Clients should be encouraged to increase calcium and vitamin D intake to help prevent osteoporosis.

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.

(Option 2) A high-fiber diet is not required for a client with trigeminal neuralgia, and the additional chewing with higher-fiber foods may serve as a pain trigger.

(Option 3) Clients with trigeminal neuralgia are encouraged not to massage the face as this can trigger pain .

Metabolic syndrome is the presence of >= 3 metabolic health factors that increase a client’s risk for stroke, diabetes mellitus, and cardiovascular disease.

Criteria include:

1. Abdominal obesity: Waist circumference (240 inches [102 cm) in men, >= 35 | inches [89 cm] in women)
2. High serum triglycerides > 150mg / d * L 1.7 mmol/L) or hypertriglyceridemia drug treatment
3. Low levels of high-density lipoprotein (HDL) cholesterol (< 40mg / d * L | 1.0 mmol/L] in men, < 50mg / d * L [1.3 mmol] in women)
4. Hypertension >= 130/85 mm Hg or hypertension drug treatment
5. Fasting blood glucose >= 100mg / d * L 5.6 mmol/L) or hyperglycemia drug treatment

The 55-year-old woman (waist circumference 37 inches [94 cm), triglycerides 190 mg/dL [2.2 mmol/L], fasting blood glucose 120 mg/dL [6.7 mmol/L]) is at highest risk for metabolic syndrome with 3 of 5 criteria (obesity, high triglycerides, hyperglycemia) (Option 3).

(Option 1) The 27-year-old woman (triglycerides 210 mg/dL [2.4 mmol/L]) has only 1 metabolic syndrome-associated condition (hypertriglyceridemia). (Option 2) The 45-year-old man (fasting blood glucose 118 mg/dL [6.6 mmol/L]) has only 1 metabolic syndrome-associated condition (hyperglycemia).

(Option 4) The 82-year-old man (blood pressure 148/88 mm Hg, fasting blood glucose 104 mg/dL [5.8 mmol/L]) has only 2 metabolic syndrome-associated conditions (hypertension, hyperglycemia). His HDL is within normal limits.

Educational objective: Clients with metabolic syndrome are at increased risk for stroke, diabetes mellitus, and cardiovascular disease. Criteria for metabolic syndrome include at least 3 of 5 conditions: abdominal obesity, hyperglycemia, low levels of high-density lipoprotein, high serum triglycerides, and hypertension.

• The complete blood count (hemoglobin, hematocrit, platelet count) should be assessed periodically with the administration of enoxaparin, an anticoagulant that can cause bleeding and thrombocytopenia (Option 4).
• Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL) (Option 1).
• Potassium levels should also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity (Option 5). Prednisone is a glucocorticoid that can cause hyperglycemia. Glucose levels should be monitored periodically in clients receiving this medication (Option 2).

(Option 3) Low-molecular-weight heparins (eg, enoxaparin, dalteparin) produce a stable response at recommended dosages and negate the need for monitoring of activated partial thromboplastin time (aPTT) or international normalized ratio (INR) levels. aPTT is monitored when administering unfractionated heparin. INR is monitored in clients receiving warfarin (Coumadin).

Educational objective: The nurse should routinely monitor laboratory values prior to administering medications. A complete blood count should be assessed periodically in clients receiving enoxaparin to monitor for bleeding and thrombocytopenia. Digoxin and potassium levels should be assessed with the administration of digoxin. Glucose levels should be monitored in the client receiving glucocorticoids.

Early recognition and treatment of heart attack are critical. Women, the elderly, and clients with a history of diabetes may not have the classic heart attack symptoms of dull chest pain with radiation down the left arm. Instead, they can present with “atypical” symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue.

(Option 1) Taking a careful history and evaluating for any sick contacts would be helpful in identifying food poisoning, but a more important initial step is to assess for a heart attack.

(Option 2) A viral infection is a possibility, but fever and myalgia are usually present during an episode of influenza.

(Option 4) Early intervention in stroke is also critical, and a neurologic assessment would take place after the acute coronary syndrome algorithm, especially with negative electrocardiography and serum heart enzyme levels.

The nurse should check on the assigned clients in the following order:

1. Client with the gastrointestinal bleed receiving packed red blood cells (PRBCs) – the nurse should: Check the infusion device; flow rate; and IV site, tubing, and filter Collect baseline physical assessment data against which to compare subsequent assessments • Assess for complications associated with the administration of PRBCs, which include fluid overload and an acute transfusion reaction; these can occur at any time during the transfusion (Option 1)

2. Client with chronic kidney disease scheduled for dialysis in 30 minutes – the nurse should perform a baseline assessment before dialysis is initiated. The nurse should then prepare the client by making sure the client eats breakfast, administering prescribed morning medications that are not dialyzed out, and holding those that are dialyzed out. Elevated creatinine level (eg, normal 0.6-1.3 mg/dL [53-115 µmol/L]) is an expected finding. (Option 4)

3. Client with ulcerative colitis (UC) with elevated temperature and abdominal pain – UC is an inflammatory bowel disease; fever and lower-quadrant abdominal cramping are expected findings. After assessing the client, the nurse will administer an analgesic and an antipyretic as prescribed. (Option 2)

4. Client with history of atrial fibrillation, prescribed warfarin (Coumadin) – the client is on telemetry; in most facilities, if dysrhythmias occur, the monitor technician/nurse will notify the primary care nurse immediately. The goal INR is 2.0 to 3.0 for atrial fibrillation. An INR of 3.2 is expected when adjusting the warfarin dose. (Option 3)

When a medication error occurs, client safety is the nurse’s first priority. The nurse should assess the client immediately for any adverse effects and inform the healthcare provider (HCP) (Option 3).

Before taking any other actions, the nurse must ensure that the client is stable. Following client stabilization, the error should be reported to the appropriate nursing authority (eg, supervisor, manager), and an incident or occurrence report should be filed within 24 hours.

(Option 1) Prior to administering the correct medication, the HCP should be informed to ensure that the original medication is appropriate in light of the medication error. Additional medications or therapies may be necessary to reverse the effects of the medication given in error.

(Option 2) Although it is important that the graduate nurse has a chance to learn from the mistake, ensuring client safety is the first priority. An incident report can be filed after the client is stable.

(Option 4) Discontinuing dopamine without providing another medication for hemodynamic stabilization may harm the client. The nursing supervisor should be informed after client stabilization.

Educational objective: Client safety is the first priority when a medication error occurs. The nurse should assess the client and inform the HCP about the error before reporting to nursing management and completing an incident report.

Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. The procedure for measurement of pulsus paradoxus is as follows:

1. Place client in semirecumbent position

2. Have client breathe normally

3. Determine the SBP using a manual BP cuff

4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP

5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure

6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure

7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox

8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.

(Option 1) Variation in QRS amplitude is termed electrical alternans. It could be present in cardiac tamponade, but it is not how pulsus paradoxus is determined. Electrical alternans is due to the swinging motion of the heart in a fluid-filled pericardial sac.

(Option 2) An apical/radial pulse deficit may be present during certain dysrhythmias, but this is not the procedure for measuring pulsus paradoxus. (Option 4) This is the formula for calculating mean arterial pressure.

Educational objective: The nurse should assess the client for pulsus paradoxus when cardiac tamponade is suspected. The amount of paradox is the difference between the pressure heard at the first Korotkoff sound during expiration and the Korotkoff sounds heard throughout inspiration and expiration. A difference of <10 mm Hg is normal, but if it is >10 mm Hg, this may indicate cardiac tamponade.

Ultimately, a victim of a crime needs to move from being a victim to being a survivor. A reasonable sense of safety and security is key to this transition. Getting through the shock and confusion, carrying out home and work routines, and resolving grief over any losses represent steps along the way to becoming a survivor.
CN: Psychosocial integrity; CL: Synthesize

Proper care of the umbilical cord stump facilitates healing and reduces infection and bleeding risks. The primary goal of cord care is to keep the cord stump clean and dry, which reduces infection risk. Additional teaching points regarding cord care include: Keep the cord stump open to air when possible to allow for adequate drying. Do not apply antiseptics (eg, alcohol, triple dye, chlorhexidine) to the cord stump (previously common practice); current recommendations are to avoid such solutions due to the potential for skin irritation (Option 3).

Report any signs of infection (eg, redness, purulent drainage, swelling) to the health care provider.

(Option 1) The umbilical cord is usually clamped and cut a few minutes after birth. The clamp is left in place until the cord begins to dry, usually around 24 hours after birth. The remaining cord stump begins to shrivel and turn black in 2-3 days.

(Option 2) The cord usually separates spontaneously from the umbilicus 1-2 weeks after birth. Parents should be instructed not to pull on the cord stump or attempt to hasten cord separation, which could result in bleeding or other complications.

(Option 4) The diaper should be folded below the cord to keep the cord dry and prevent contamination with urine or feces. Educational objective: The primary goal of cord care is to keep the cord stump clean and dry. Parents should keep the umbilical area dry, not apply antiseptics to the stump, and report any signs of infection.