uworld NCLEX PREP 2017

The nurse receives report on 4 clients. Which client should the nurse see first?

1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone [21%]
2. Client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently [55%]
3. Client admitted with intestinal obstruction who is reporting abdominal pain and distention and needs nasogastric tube placement [17%]
4. Client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound infection and needs antibiotics and a dressing change [6%]

Although it is not a STAT order, an extra dose of furosemide was prescribed for the client with congestive heart failure. The shortness of breath is most likely due to a change in fluid status, and this client is the priority. Furosemide works immediately and should be given urgently.

(Option 1) Even though this client has asthma exacerbation, steroids (methylprednisolone [Solu-Medrol]) do not show their effect immediately. These drugs control underlying inflammation but take several hours/days to take effect. Bronchodilators such as albuterol or ipratropium work immediately.

Educational objective:
A client who is experiencing symptoms that could compromise airway, breathing, or circulation should be seen first.

What works immediately ASTHMA
work immediately ASTHMABronchodilators such as albuterol or ipratropium

A 59-year-old client comes to the clinic due to a blistering, linear rash on the left chest. The client reports itching and pain around the rash. What is the priority question for the nurse to ask the client?

1. “Did the rash start after taking a new medication?”
2. “Have you been keeping the rash covered?”
3. ”
4. “What have you tried to help the pain?”
Correct Answered correctly

Have you ever had chickenpox?”
{NI}
f this rash is determined to be due to shingles, the affected area should be covered to prevent the spread of infection. Therefore, it is a priority to ask if this client has had chickenpox.
AIRBORN ISOLATION N-95
can occur in clients with a history of chickenpox (varicella-zoster virus exposure). The vesicular rash has a characteristic, linear dermatomal distribution and can present with severe pain. Vaccination prevents shingles.
Herpes zoster (shingles) CDC& Prevention recommends shingle vaccine for use in people 60 years old and older to prevent shingles

Why should nurse anticipate the health care provider transferring to the intensive care unit?

82-year-old with pressure (decubitus) ulcer who has a change in mental status, temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg [69%]

Sepsis
is a potentially life-threatening condition.Physiologic changes related to the aging process, including decreased immune function and inflammatory response (immunosenescence) and altered febrile response to pyrogens, increase the risk for sepsis.

can be the presenting feature of sepsis in elderly clients.
Hypothermia
abnormally high levels of nitrogen-containing compounds
azotemia
60-year-old with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dL (442 µmol/L), and reports nausea and itching [15%]
EXPECTED Hypertension, elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L]), nausea associated with azotemia, and pruritus associated with dry skin are expected for chronic kidney disease clients.
early recognition of sepsis is critical to survival, atypical presentation associated with immunosenescence and absence of fever can delay diagnosis and treatment.
early sepsis
Systemic inflammatory response syndrome
Finding Value
Temperature >100.4 °F or <96.8 °F Heart rate >90/min
Respiratory rate >20/min or PaCO2<32 mmHg (4.3 kPa)
WBC <4000/mm³, >12×109/L (>12,000/mm³), or 10% ban
The influenza virus has an incubation period
of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins
Influenza is transmitted by
inhaling droplets that an infected individual exhales into the air when sneezing, coughing, or speaking
vaccination provides immunity against influenza in about
2 weeks after inoculation, it does not offer complete protection against all virus strains. Therefore, close contact with others should be avoided during the illness stage, especially those with an impaired immune system.
Influenza is a highly contagious respiratory infection transmitted by
airborne droplets and direct contact. It has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins. Vaccination does not offer complete protection against all virus strains.
Femoral-popliteal bypass surgery
involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or vein) graft to restore blood flow.
Femoral-popliteal bypass surgery[NI]
The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and skin temperature, capillary refill, pain, movement) and compares the findings with the preoperative baselinen.
on palpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately!!!!!
the inability of the leg veins to efficiently pump blood back to the heart. It can lead to venous stasis, increased hydrostatic pressure, and venous leg ulcers. Edema and thick skin with brown pigmentation are expected manifestations
Chronic venous insufficiency
Gangrene of the foot is a complication of ________ ________ ______ associated with decreased blood flow to the extremity.
peripheral arterial disease (PAD)
expected manifestations of PAD
Coolness of the skin and shiny, hairless legs, feet, and toes
Intermittent claudication is leg pain caused by decreased blood flow to the muscles that reoccurs during activity such as walking and dissipates with rest. expected
Intermittent claudication
Absent or decreased volume in the peripheral pulses distal to the graft can
indicate compromised circulation or graft occlusion and should be reported to the health care provider immediately!!!!! ABC!
percutaneous endoscopic gastrostomy (PEG) tube
a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper.
The PEG tube’s tract begins to mature It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement
1-2 weeks and is not fully established until 4-6 weeks
IF dislodgement, the nurse should
notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement
DO NOT: Attemptto reinsert a tube through an immature tract can result in improper placement into the peritoneal cavity, leading to peritonitis and sepsis!!!!!!!
The client is exhibiting signs and symptoms OF fever, chills, nausea ,subnormal body temperature instead of fever, hypotension, tachycardia, decreased urine output, and confusion
The client is exhibiting signs and symptoms of septicemia (blood infection)
CVCs are warranted to provide important treatment for many clients, they are often
a source of infection that can lead to sepsis and septic shock
In addition to obtaining blood cultures x 2, it is standard procedure to cut off the tip of the discontinued CVC and send it to the lab to
ensure it is the source of the septicemia
Ondansetron may be administered for
nausea symptoms.
When signs of infection or sepsis occur, the nurse should
obtain cultures prior to antibiotic administration. Identification of the specific pathogen helps the HCP determine the best antibiotic for treatment. If the culture is obtained after antibiotic administration, the culture results will be altered.
Mantoux test,
is administered to screen for tuberculosis (TB). The forearm is injected with 0.1 mL of the PPD, and the client returns in 48-72 hours to have the site assessed for induration (a raised area). Redness alone is not read as a positive response. An area of induration >15 mm is considered a positive response in any client (Option 1). However, a positive PPD test does not mean that the client has active TB infection but rather that the client has been exposed to TB and has developed an immune response.
Positive sputum cultures, chest x-rays, and the presence of symptoms confirm that the client has active disease
TB
Sjögren’s syndrome is an autoimmune condition.
It causes inflammation of the exocrine glands (eg, lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia).
Sjögren’s syndrome NI
Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and air vents can also help
Early-morning low back stiffness is seen
ankylosing spondylitis
Multiple tender points are characteristic
fibromyalgia
Thickening of the skin
scleroderma
Sjögren’s syndrome is an autoimmune condition that can cause dry eyes and mouth
Clients are instructed to use artificial tears and saliva.
Vancomycin is a glycopeptide antibiotic that is excreted by the kidneys. It is used to treat
serious infections with gram-positive microorganisms (Staphylococcus aureus [methicillin-resistant Staphylococcus aureus]) and diarrhea associated with Clostridium difficile.
Serum vancomycin trough level is monitored before the 4th dose (15-20 mg/L [10.4-13.8 µmol/L] is optimal) OF
Vancomycin
Blood urea nitrogen (BUN) and creatinine levels are monitored regularly (usually 2-3 times/week) in clients receiving the drug due to increased risk of nephrotoxicity, and ototoxicity especially in those
with impaired renal function, receiving aminoglycosides, and who are >60 years old
Before administering this VANCOMYCIN, the nurse should The normal range for BUN is 6-20 mg/dL (2.1-7.1 mmol/L) and creatinine is 0.6-1.3 mg/dL (53-115 µmol/L).
notify the HCP that the client’s BUN and creatinine are increased.
A normal hemoglobin level of in adult men;
13.2-17.3 g/dL
A normal hemoglobin level adult women
11.7-15.5 g/dL
magnesium level
1.5-2.5
an overproduction of collagen that causes tightening and hardening of the skin and connective tissue.
Scleroderma
This is a progressive disease without a cure
RN T= treatment is aimed at managing complications in Scleroderma
Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment, this can be fatal.
Raynaud phenomenon can develop secondary to
scleroderma
vasospasm-induced color changes in the fingers, toes, ears, and nose. This requires urgent treatment (eg, immersing hands in warm water) but is not life-threatening.
Raynaud phenomenon

Pulmonary fibrosis is a progressive complication of

that is defined as scarring of lung tissue, which then causes reduced function, dry cough, and dyspnea. Some clients may be placed on oxygen. This is not immediately life-threatening.

scleroderma
Heartburn and dysphagia (difficulty swallowing) are common symptoms associated with
scleroderma
is caused by collagen overproduction; it is a lifelong disease without a cure. Treatment is aimed at controlling symptoms and preventing further complications. Renal crisis is life-threatening and should be recognized and treated immediately.
Scleroderma
Acute cholecystitis
Expected S/S
NI The client is scheduled for surgery and is likely on antibiotics. Even if the client is not on antibiotics, neutropenia is a priority over acute cholecystitis

inflammation of the gallbladder

s/s upper quadrant pain that can radiate to the right shoulder, nausea, vomiting, fever, and leukocytosis
NI:The client is scheduled for surgery and is likely on antibiotics

is a malignant cancer of the lymphatic system?

Expected Early S/S

Hodgkin lymphoma
S/S: include painless enlarged lymph nodes, fatigue, fever, weight loss, and drenching night sweats.

is a toxin-producing bacterium that proliferates in the lower gastrointestinal tract.

Expected s/s include diarrhea, fever, and leukocytosis.

First-line treatment metronidazole (Flagyl) and oral vancomycin.

Clostridium difficile

s/s include diarrhea, fever, and leukocytosis.

TX: metronidazole (Flagyl) and oral vancomycin contact isolation Use soap and H2o

Common adverse effects of chemotherapy are bone marrow suppression (eg, anemia, leukopenia, thrombocytopenia) and immunosuppression.
Even a low-grade fever should be taken seriously in clients who are immunosuppressed or have neutropenia
Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer’s) have the same osmolality as plasma and are administered
to expand intravascular fluid volume.
TX: vomiting and diarrhea, burns, and traumatic injury.
Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. TX?
Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer’s)
hyperglycemia / diabetic ketoacidosis results in osmotic diuresis and dehydration. TX:
immediate initial treatment is IV fluid resuscitation with isotonic 0.9% sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy.
Should you use hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses ?
NO! I will make fluid volume deficit worse.
TX: Isotonic 0.9 sc LR
A client with head trauma is at risk
for increased intracranial pressure due to inflammation and cerebral edema
IV mannitol is an
osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature
Priapism The nurse should return this call first as the condition is a
prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis.
The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use).
Priapism
EMERGENCY that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency department.
PRIAPISM >2HRS
streptococcal pharyngitis complication
2-3 weeks after.
RF (rheumatic fever) is an acute inflammatory disease of the heart
The nurse should ask about a streptococcal throat infection when collecting health history information
in a client suspected of having RF.
descending flaccid paralysis (starting from the face), dysphagia, and constipation (smooth muscle paralysis).
Botulism
(The main source is improperly canned or stored food)
Children under age 1 year should not be given honey b/c
their immature gut system makes them prone to developing infant botulism.
an autoimmune disorder in which an abnormal immune response leads to chronic inflammation of different parts of the body.
Ranges in severity from mild: eg, affecting skin, muscles, joints
to severe: eg, affecting kidneys, heart, lung, blood vessels, central nervous system) disease.I

Systemic lupus erythematosus (SLE)
creatinine normal
0.6-1.3 mg/dL
blood urea nitrogen normal 6-20 mg/dL
6-20 mg/dL
potentially serious complication of SLE
lupus nephritis (occurring in 50%)
NI: Early recognition and aggressive immunosuppressive treatment are essential to preserve renal function and prevent irreversible kidney damage
diagnosed with SLE
positive antinuclear antibody (ANA) titer (>1:40) indicates the presence of ANAs, which the body produces against it own DNA and nuclear material
often present in SLE
Anemia, mild leukopenia (white blood cell count <4,000/mm3 [4.0×109/L]), and thrombocytopenia (platelet count <150,000/mm3 [150×109/L])
A pt with SLE has Anemia, mild leukopenia, thrombocytopenia, Lupus nephritis, which is the GREATEST CONCERN?
Increased serum creatinine >1.3 mg/dL, increased blood urea nitrogen >20 mg/dL, and an abnormal urinalysis can indicate the presence of
LUPUS NEPHRITIS
potentially serious complication of SLE in which inflammation of the kidney can lead to renal injury. Early recognition and treatment are essential to preserve renal function and prevent irreversible kidney damage.
Tuberculosis is an infection caused by the
the Mycobacterium tuberculosis microorganism
A client with active, primary TB disease has a positive
tuberculin skin test (TST), usually feels sick, has symptoms, and can spread the disease to others if not treated with medications.
A client with a LATENT TB infection (LTBI) has a positive TST, negative chest x-ray, is asymptomatic, CANNOT
transmit the disease to others, and can complete a full course of treatment to prevent activation of the disease.
A pt. who has Malignancy, immunosuppressant medications, including chemotherapy, and prolonged debilitating disease (eg, HIV), is at RISK convert LATENT TB infection
to active disease
A client with LTBI who begins treatment with a corticosteroid (Prednisone) is at increased risk for conversion to active TB disease. Therefore, the nurse should recognize this and:
notify the HCP.
is a proton pump inhibitor used to treat ulcer disease, erosive esophagitis, and gastroesophageal reflux disease.
Lansoprazole (Prevacid)
is an antimicrobial medication used to treat IBD and does not convert LTBI to active disease.
Metronidazole (Flagyl)
is a gastrointestinal anti-inflammatory medication used to treat IBD
Sulfasalazine (Azulfidine)
West Nile virus is transmitted by an infected mosquito bite. RN TEACH:
avoiding mosquitoes
USE a mosquito repellent. Prevention also includes keeping arms and legs covered with light-colored clothing and avoiding outdoor activities at dawn and dusk.
Sodium polystyrene sulfonate (Kayexalate) is used to treat
mild to moderate hyperkalemia.
Potassium is exchanged for sodium in the intestines and excreted in the stool, thereby lowering the serum potassium.
During sodium polystyrene sulfonate therapy, severe hypokalemia (palpitations, lethargy, cramping) can develop. RN will need to MONITOR Frequent
electrolyte status
Because potassium exchanges with sodium content of the resin, excess sodium absorption could put clients at risk of developing volume overload (water follows sodium).fluid overload
(eg, crackles, jugular venous distension, edema) and have daily weights and intake and output assessment

bedside commode frequent stools
watch skin intergerty

Clients receiving sodium polystyrene sulfonate
must have normal bowel function to avoid the risk of intestinal necrosis. The nurse must assess for constipation, signs of impaction, and recent bowel patterns.
ANY Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered level of consciousness (caused by anesthesia)
RN recognizes: ABC
These clients should be placed on their side and should receive antiemetics to prevent potential airway and breathing complications
After transurethral resection of the prostate
RN EXPECTS:
continuous bladder irrigation for 24-36 hours flushes out small clots and prevents obstruction. Reddish-pink drainage is expected in the immediate postoperative period.
Immediate postoperative nursing care focuses on
management of the airway, breathing, circulation, bleeding, and pain.
*******The same frameworks that guide nurses to prioritize nursing care can guide them to prioritize returning client phone calls as well. These include (in order)********
Maslow’s hierarchy of needs; and airway, breathing, cardiac status, circulation, and vital signs (ABC plus V).
EXPECTED common side effects within 24 hours after receiving the influenza vaccine
low-grade temperature, myalgia, headache, congestion, pain, redness, and itching at the injection site are
common expected side effect after use of a short-acting beta-agonist metered-dose inhaler.
Palpitations

Urinary tract infections (UTIs) are

(Options 1 and 2) When the infection ascends to the kidneys (pyelonephritis), clients become very ill. They develop nausea, vomiting, fever with chills, and flank pain. Assessment shows costovertebral angle tenderness. If the infection is not recognized and treated, clients can become septic.

Educational objective:
Cystitis is an infection of the bladder mucosa. Clients develop burning with urination (dysuria), urinary frequency and urgency, hematuria, and suprapubic discomfort. However, if the infection extends to the kidneys (pyelonephritis), clients become seriously ill with nausea, vomiting, fever with chills, and flank pain.

usually bacterial in origin and are most often caused by Escherichia coli
cystitis
is the most common community-acquired UTI. It is an infection of the lower urinary tract and involves inflammation of the bladder mucosa, leading to hyperemia, tissue hemorrhage, and pus formation. This inflammatory process leads to burning with urination (dysuria), urinary frequency and urgency, hematuria, and suprapubic discomfort (
pyelonephritis
bacteria may continue to ascend the urinary tract to the ureters and kidneys, causing inflammation and infection in the kidneys
cystis Expected S/S
hyperemia
tissue hemorrhage
pus formation
This inflammatory process leads to burning with urination (dysuria), urinary frequency and urgency, hematuria, and suprapubic discomfort
When the infection ascends to the kidneys (pyelonephritis), clients become very ill. What are the EXPECTED S/S & HALLMARK SIGN upon ASS:
They develop nausea, vomiting, fever with chills, and flank pain
Assessment shows costovertebral angle tenderness
clients can become septic
Herpes simplex virus type 2
genital herpes
Lesions are painful and appear as multiple small, vesicular lesions.
Herpes simplex virus type 2 (HSV-2)rpes. NI:
Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak .
After the outbreak has resolved, condoms should be used in future sexual encounters as transmission is possible even in the absence of active lesions.Keep the area with lesions clean and dry.

Avoid use of perfumed soaps and bubble baths.

Maintain proper hand hygiene and avoid touching the lesions to prevent spreading.

Use sitz baths and oatmeal baths to provide comfort and relief of itching and burning.

Vesicles contain numerous virus particles, leading to the possibility of self-inoculation. This can be prevented by avoidance of hand contact with lesions during an outbreak.

Use of a hair dryer on a cool setting is an effective means of drying the lesions and promoting client comfort.

Warm water provides symptomatic relief.

Clients experiencing an outbreak of______________ ____________ should abstain from sexual activity when lesions are present and use condoms in future sexual encounters as transmission is possible even in the absence of active lesions.
genital herpes
Herpes simplex virus type 2
When caring for the client on a ventilator, the nurse may consider delegating the following tasks to unlicensed assistive personnel:
vital sign measurement, oral care, personal hygiene, blood glucose testing, passive or active range-of-motion exercises, and measurement of urine output
In the setting of SIADH, the nurse should question a prescription for a
hyPOtonic solution (eg, 0.45% NaCl; or dextrose water) as it would WORSEN the fluid and electrolyte imbalance.
In the setting of SIADH, the nurse should EXPECT:

A prescription for fluid restriction

hypERtonic IV solution (eg, 3% NaCl) administered in small quantities would be appropriate to shift fluid back into the vascular compartment and correct hyponatremia.

A burn injury causes tissue damage and increased capillary permeability; this leads to fluid and electrolyte losses related to evaporation and intravascular fluid shifts into the interstitial tissue, which result in
EXPECTED S/S
TX:

hypovolemia, hemoconcentration (eg, hematocrit >53% [0.53]), and hypotension.

TX: An isotonic solution (eg, lactated Ringer’s) is prescribed to replace fluid and electrolyte losses.

What is associated with hypervolemia and dilutional hyponatremia
and the rn will tx: Fluid restriction and hypertonic IV solutions (eg, 3% saline) are prescribed to correct hyponatremia.
Syndrome of inappropriate antidiuretic hormone secretion
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is characterized by
excessive release of antidiuretic hormone (vasopressin) from the posterior pituitary gland.
The increase in blood volume (hypervolemia) often results in true hyponatremia in which the plasma sodium levels are lowered and total body fluid is increased. Although the sodium level is low, SIADH is brought about by an excess of water rather than a deficit of sodium.
regular, narrow QRS complex tachycardia with a rate of around 150-220/min. The best treatment is vagal maneuvers and adenosine IV push
Supraventricular tachycardia
regular, narrow QRS complex tachycardia with a rate of around 150-220/min
Supraventricular tachycardia
The best treatment is vagal maneuvers (1st) and then adenosine IV push for
SVT
Adenosine is the drug of choice to treat SVT
half-life
has a 5- to 6-second
the time it takes for the drug to be reduced to half of its original concentration
half-life
Placing the IV line as close as possible, not distal, to the heart is essential for the drug to have full effect.
________________
is given rapidly over 1-2 seconds and then followed by
rapid 20-mL normal saline flush.
Expected: Transient asystole is common, and clients often experience flushing and dizziness.
Adenosine
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure in which
an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed.

potentially life-threatening complication after an ERCP.

Signs and symptoms include (Option 3).

Perforation or irritation of these areas during the procedure can cause acute pancreatitis

S/S acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (eg, amylase, lipase)

normal amylase
0-130
lipase
0-160
What Expected adverse effects can occur after a colonoscopy due to air inflation during the procedure.
Abdominal cramps
barium contrast solution used during the procedure may make the client’s stool white for
up to 3 days
barium contrast solution
T pt.
encourage fluids, if appropriate, to assist in expulsion of the contrast medium.
Copious, bile-colored (greenish-brown) drainage is expected in a client with a
small bowel obstruction.
The nurse should watch for signs and symptoms of electrolyte imbalances (hypokalemia), dehydration, and metabolic alkalosis pt. with
small bowel obstruction.
a potentially life-threatening complication, can occur following an endoscopic retrograde cholangiopancreatography. Manifestations include acute abdominal pain, often radiating to the back, and a rise in pancreatic enzymes (eg, amylase, lipase).
Acute pancreatitis,
when a client dies by suicide, homicide, accident, or within 24 hours of admission to a health care facility.
Consent from the family is not required.
During postmortem care, all tubes and IV lines should be left in place upon
An autopsy is often performed
any client with a history of severe allergic reaction (sudden blotchy skin rash or swelling of the lips and mouth) should always carry an EpiPen. Epinephrine injection is the only option for treating
Anaphylaxis
This is a medical emergency
crushing, substernal type of chest pain. symptoms include atypical pain (jaw or arm), shortness of breath, indigestion, nausea, dizziness, and cold sweats.
Nurse needs immediate evaluation and intervention
cardiac medical emergency (myocardial ischemia or acute myocardial infarction) that requires .
Older individuals, diabetic clients, and women may have atypical angina symptoms rather than the characteristic crushing, substernal type of chest pain
These are
atypical pain (jaw or arm), shortness of breath, indigestion, nausea, dizziness, and cold sweats
Women with myocardial ischemia and acute myocardial infarction (AMI) often have atypical pain and nonspecific symptoms.
NI
Evaluation and treatment for a suspected AMI are critical as it can be life-threatening.
Solifenacin (VESicare) is a cholinergic antagonist prescribed to treat.
Common expected adverse effects include dry mouth and constipation. The nurse should caution the client about safety when performing activities until the response to the medication is determined, as it can also cause dizziness and blurred vision. This is not a medical emergency.Educational objective:

overactive bladder (eg, urge incontinence, frequency).
Solifenacin
Common expected adverse effects
dry mouth and constipation
dizziness and blurred vision
The maximum rate for infusion of IV potassium chloride through a peripheral vein
10 mEq/hr
maximum rate through a central vein /peripheral line is
40 mEq/hr.
A too rapid infusion of potassium chloride can lead to
pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action not in the normal perimeters
Treatment of hypokalemia may require an IV infusion of potassium chloride (KCL).
IV infusion of potassium must be administered via a pump to prevent too rapid infusion b/c
could cause cardiac arrest.
IVPB KCL must be given via an
infusion pump
Constant headache, decreased mental status, and sudden-onset emesis indicate
increased intracranial pressure
a life-threatening situation.
pt. with atrial fibrillation may also be taking anticoagulants (eg, warfarin, rivaroxaban, apixaban, dabigatran), making a life-threatening intracranial bleed even more dangerous.
The nurse should perform a neurologic assessment (eg, level of consciousness, pupil response, vital signs) immediately.
warfarin, rivaroxaban, apixaban, dabigatran
anticoagulants
Pt. on anticoagulant and has a nerurological acciednt Is HIGH RISK
for HEMORRHAGE Emergency!
antiplatelet drugs are different from anticoagulants bc:

inhibit platelet aggregation (clumping together)

and anticoagulants inhibit the coagulation cascade by clotting factors that happens after the initial platelet aggregation

commonly presents with neurologic manifestations such as gait disturbance, slurred speech, and nystagmus. These are expected symptoms of
Phenytoin toxicity
A brain tumor can also cause increased intracranial pressure; clients report morning headache, nausea, and vomiting.
Dexamethasone (Decadron) can be prescribed short-term to decrease the surrounding edema.
A tumor usually grows more slowly than a possible hematoma therefore the priority assessment is
Hematoma
Influenza (flu) is a contagious viral infection that affects the nose, throat, and lungs. Symptoms of flu include
fever and chills, severe muscle aches, headache, cough, sore throat, nasal congestion, and general malaise.
Teach pt with the flu to
rest, adequate hydration, humidified air, and antipyretics and analgesics.
Antiviral medications such as zanamivir (Relenza) and oseltamivir (Tamiflu) are given to clients who are within 48-72 hours of the onset of symptoms. These medications can shorten the duration of the illness by a few days.
Complications from the flu include secondary bacterial infections, particularly
pneumonia
Oseltamivir is an appropriate antiviral medication that is most beneficial if given within
48-72 hours after symptom onset
UAP =
unlicensed assistive personnel.
The fungus causes pearly, “milk-curd” lesions on the oral or laryngeal mucosa that may bleed when removed.
Oropharyngeal candidiasis, or thrush (moniliasis), is an infection of the mucous membranes generally caused by the yeastlike fungus Candida albicans
Immunosuppressed individuals such as those taking corticosteroid medications, clients undergoing chemotherapy or radiation, or clients with immune deficiency states (eg, AIDS) + 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.
Individuals with dentures and infants also commonly experience
Oropharyngeal candidiasis, or thrush (moniliasis)
Treatment is anti fungal medications
(eg, nystatin) and proper oral hygiene.
pt. taking an inhaled corticosteroid (eg, budesonide, fluticasone) are at increased risk for :
TEACH:
oral candidiasis
To reduce this risk, the client should rinse the mouth after each inhaled dose and maintain good oral hygiene.
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.
When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following in detail:

Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8 µmol/L) for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus).

Monitor blood pressure during the infusion. Hypotension is a possible adverse effect

Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities

Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing

Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis or, if extravasation occurs, tissue necrosis.

Administration using a central venous catheter is preferred; however, a peripheral IV may be used for short-term therapy

Therapeutic vancomycin levels range
from 10-20 mg/L
Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus).
Infuse medication over at least
60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications
Nursing care of clients receiving IV vancomycin includes:
drawing prescribed trough levels before drug administration, infusing the drug over at least 60 minutes, monitoring the client during administration (eg, blood pressure, respiratory status, signs of hypersensitivity/anaphylaxis), and assessing the IV site during and after administration
Clients who have had major surgery, prolonged immobilization, or are taking estrogen-containing contraceptive pills are at high risk.
Pulmonary embolism is a life-threatening emergency
Clients who are bedridden, have undergone major surgery (eg, hip or knee replacement), or are taking estrogen-containing contraceptive pills are at high risk of
developing deep venous thrombosis.
This condition can result in subsequent embolus and life-threatening pulmonary embolism. When blood flow is blocked to certain parts of the lung, the area can become infarcted, resulting in chest pain, shortness of breath, and cough.
These clients require immediate anticoagulation to prevent extension of the blood clot
Large pericardial effusion with resultant cardiac tamponade and is
evidenced by jugular venous distension, hypotension, and muffled heart sound
pt. with acute pericarditis have chest pain that is worse with inspiration/coughing TEACH: expected finding
improves with leaning forward= pt.OK.
Peripherally inserted central venous catheters (PICC) Complications related to the PICC are occlusion of the catheter, phlebitis, air embolism, and infection due to bacterial contamination.
are commonly used for long-term antibiotic administration, chemotherapy treatments, and nutritional support with total parenteral nutrition (TPN).
The central line dressing change is performed using a
sterile technique that includes wearing sterile gloves and mask to prevent contamination of the site with microorganisms or respiratory secretions. During injection cap, tubing, and dressing changes, the client is instructed to turn the head away from the peripherally inserted central venous catheter site to prevent site contamination by the client’s respiratory secretions. During cap/tubing changes, the client is instructed to hold the breath (or perform the Valsalva maneuver) to prevent air from entering the line, traveling to the heart, and forming an air embolism.
There is a high incidence of IV iron causing hypersensitivity reactions, including anaphylaxis.
Therefore, a test dose needs to be given first. =pt. considered unstable
Collect an early morning sputum sterile specimen on 3 consecutive days for an .

acid-fast bacilli (AFB) smear and culture.

Fluids and/or expectorants can be given at bedtime to help liquefy secretions. It is usually easier for clients to produce a specimen upon awakening as secretions collect in the airways during the night

Nose cultures determine
methicillin-resistant Staphylococcus aureus
a medical emergency requiring immediate, specialized examination to identify and treat any physical injuries and emotional trauma. Delaying a medical-forensic examination can interfere with evidence retrieval and preservation.
Sexual assault
Psoriasis is a chronic autoimmune condition characterized by
exacerbations of silver plaques on reddened skin. Although there is no cure, management includes topical and systemic medications, phototherapy, and avoidance of triggers.
An immunocompromised client should not
be assigned to a room with a client who is contagious or potentially infected as there is an increased risk for infection.
heart rate >90 beats/min,
temperature >100.9 F (38.3 C),
systolic blood pressure <90 mm Hg, altered mental status, hyperglycemia (>140 mg/dL [7.8 mmol/L]) in the absence of diabetes
absent bowel sounds
Rn KNOWS these are:
Manifestations characteristic of sepsis
The assessment findings most important for the nurse to report to the health care provider include the following when pt suspected of shock:
Absent bowel sounds. Paralytic ileus occurs in the presence of sepsis and hypoxia as blood is shunted away from the gastrointestinal tract to the vital organs.
Capillary refill 5 seconds. Prolonged capillary refill (>3-4 seconds in an adult) indicates inadequate blood flow to peripheral tissues.
Serum glucose >140 mg/dL (7.8 mmol/L). Gluconeogenesis occurs in response to the physiologic stress of infection. Insulin resistance is associated with anaerobic metabolism
Sepsis is a complication of pneumonia that can progress to septic shock and/or multisystem organ dysfunction syndrome. To limit progression,
the nurse assesses oxygenation (pulse oximeter, arterial blood gases), airway (patency), breathing (respiratory pattern and rate), circulation (vital signs), tissue perfusion (eg, level of consciousness, capillary refill, skin temperature and color, bowel sounds), and urine output.
Clients with pulmonary embolism or deep venous thrombosis are treated with anticoagulation. Unfractionated heparin is one such agent, and its efficacy is measured through partial thromboplastin time (PTT) levels. The goal during anticoagulation therapy is a PTT 1.5-2 times the normal reference range of 25-35 seconds. A PTT of 127 seconds is much too prolonged, and spontaneous bleeding could occur.
anticoagulation. Unfractionated heparin is one such agent
Unfractionated heparin is one such agent, and its efficacy is measured through
partial thromboplastin time (PTT) levels.
****The goal during anticoagulation therapy is a PTT
1.5-2 times the normal reference range of 25-35 seconds which is 37-70!!!!!
Clients with chronic obstructive pulmonary disease typically have elevated
PaCO2 levels secondary to air trapping.
A PaCO2 of 52 mm Hg (6.9 kPa), although elevated from the normal range of 35-45 mm Hg (4.7-6.0 kPa), is not extreme for this pt. with
COPD
normal white blood cell (WBC) count is:
4,000-11,000/mm3
anaphylaxis is a medical emergency requiring rapid assessment and intervention. Symptoms of an anaphylactic reaction include
signs of respiratory compromise (eg, oral and airway swelling, stridor, wheezing, chest tightness) and shock (eg, dizziness, loss of consciousness).
in a client who is experiencing an anaphylactic reaction to an IV medication, it is imperative to first i
stop the infusion;
ensure airway patency and administer oxygen;
give epinephrine and initiate IV fluids;
administer adjunctive therapies (antihistamines, bronchodilators, corticosteroids)
infective endocarditis (IE) Rn TEACH:
1.to monitor temperature regularly at home. They can be discharged when their (temp is low)
Persistent temperature elevations may mean that the antibiotic therapy is ineffective or complications have developed2.Prophylactic antibiotics for certain high-risk procedures (eg, manipulation of gingival tissue).
3. Slurred speech could indicate that embolization has caused a possible stroke.

(IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur.

4.IE can require IV antibiotics for up to 4-6 weeks
(home health nurse will come to administer the antibiotics through the client’s PICC line.)

Postoperative client care after general anesthesia requires careful monitoring for hypoxia. One of the first nursing interventions
is the head tilt and chin lift to open an occluded airway.
Clients with Sjögren’s syndrome need measures to combat the effects of damaged moisture-producing glands.
These include eye drops, sugar-free candy or artificial saliva, vaginal lubricants, frequent dental examinations, lukewarm showers with mild soap, and avoiding decongestants
TB, regardless of location, commonly presents with constitutional symptoms, including:
Low-grade fever
Night sweats
Anorexia and weight loss
Fatigue
The characteristic signs and symptoms associated with pulmonary TB disease include cardinal
(major) signs (eg, cough, sputum production, dyspnea) and constitutional (minor) signs (eg, anorexia, weight loss, fatigue, fever, night sweats).
The management of anaphylactic shock includes:
Call for help (activate emergency management systems) – first action
Maintain airway and breathing – administer high-flow O2 via non-rebreather mask
Epinephrine, intramuscular – the drug of choice and should be given next. Epinephrine stimulates both alpha- and beta-adrenergic receptors, dilates bronchial smooth muscle (beta 2), and provides vasoconstriction (alpha 1). The IM route is better than the subcutaneous route. The dose should be repeated every 5-15 minutes if there is no response.
Elevate the legs
Volume resuscitation with IV fluids
Bronchodilator such as albuterol is administered to dilate the small airways and reverse bronchoconstriction
Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus
Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction
Diphenhydramine (Benadryl), IM epinephrine, inhaled beta agonists, and methylprednisolone (Solu-Medrol) are administered to treat the manifestations associated with
anaphylactic shock. They modify the histamine response and treat pruritus, reverse bronchoconstriction, and decrease airway inflammation, respectively. IM epinephrine can be repeated for poor response.
Clients should be taught to prevent tick bites by
-using insect repellent with deet
-wearing long pants (light colored easier to see) with closed-toed shoes,
-avoiding tall grass and wooded areas.
-Ticks should be removed with tweezers, keeping them intact.
-Flu-like symptoms and a bull’s-eye rash (erythema migrans) should be reported immediately to the health care provider.
Lyme disease develops after a bite from a tick infected with Borrelia burgdorferi. Initial symptoms are flu-like (eg, headache, fever, myalgia, fatigue). Many clients develop a bull’s-eye rash; however, it is not always present.
How will TX:
doxycycline, amoxicillin
Normal blood gas levels are
PO2 80-100 mm Hg (10.6-13.3 kPa), pCO2 35-45 mm Hg (4.7-6.0 kPa), and pH 7.35-7.45
IV bumetanide (Bumex) or furosemide (Lasix) to promote
diuresis and mobilize excess fluid in the systemic circulation and lungs.
CARDIO:
Murmurs are produced by . They can be characterized as musical, blowing, swooshing, or rasping sounds heard between normal heart sounds. The aortic area is located at the second intercostal space, right sternal border
turbulent blood flow across diseased or malformed cardiac valves
They can be characterized as sounds:
musical, blowing, swooshing, or rasping sounds heard between normal heart sounds
Where would you hear An arterial bruit is a turbulent blood flow sound heard in a peripheral artery
peripheral artery
what is an arterial bruit?
turbulent blood flow sound heard
What Will RN doc:
high-pitched, scratchy sound during S1 or S2 at the apex of the heard heard with the pt. sitting and leaning forward and at the end of expiration.
A pericardial friction rub
It occurs when inflamed surfaces of the heart rub against each other
It is a low-pitched sound heard in early diastole that is similar to the sound of a horse’s gallop.
An S3 gallop is an extra heart sound that occurs closely after S2.
The mitral area is located at the
fifth intercostal space, medial to the mid-clavicular line.
Murmurs indicate turbulent blood flow across diseased or malformed cardiac valves. They are often described as musical, blowing, or swooshing sounds that occur between normal heart sounds. They may be auscultated
at the aortic, pulmonic, tricuspid, or mitral areas.
A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min. Which of the following actions should the nurse take
The client with symptomatic bradycardia should be treated initially with IV atropine. Transcutaneous pacing or infusion of dopamine or epinephrine may be considered if atropine is ineffective
The Trendelenburg position,
not the position,
is used with clients with hypotension.
reverse Trendelenburg
TEACH PT. ON Warfarin
must be taken at the same time daily to reach a therapeutic INR of 2-3.
A diet high in vitamin K may decrease warfarin’s anticoagulant effect.
Most antibiotics will increase INR by causing a vitamin K deficiency.
which classically has moving, “ripping” back pain, is a medical emergency. Hypertension is the most important contributing factor!
An aortic dissection, EMERGENT!!!
In a child with atrial septal defect, the nurse would expect to hear a
heart murmur on auscultation of heart sounds.
Chest pain in an adult, regardless of age,
is a priority
The impaired perfusion from severe atherosclerosis results in
skin atrophy, poor wound healing, and widespread hair follicle death (hair loss).
disorganization of electrical activity in the atria due to multiple ectopic foci
Atrial fibrillation
client at risk for embolic stroke due to thrombi formed in the atria from stasis of blood B/C
client at risk for embolic stroke due to thrombi formed in the atria from stasis of blood
atrial fibrillation, the atrial rate may be increased to
350-600/min
The ventricular response (pulse rate) can vary. The higher the ventricular rate, the more likely the client will have .
decreased cardiac output (ie, hypotension)
What is the is the priority in clients with atrial fibrillation
Ventricular rate control
diltiazem
beta blockers
digoxin
A-Fib Meds TX:
diltiazem (a calcium channel blocker) is the priority as its purpose is to decrease the ventricular response rate to <100/min.
Other medications such as beta blockers (metoprolol) or digoxin may also be used to control the ventricular rate.
Why do pt. with a-fib recieve Calcium channel Blockers, Dig, Beta Blocker?
To slow down the heart rate
Why do pt with A-fib Anticoagulants
(eg, rivaroxaban [Xarelto], dabigatran [Pradaxa], apixaban [Eliquis], and warfarin ?
To decrease the chances of clots PE atrial thrombus and embolic complications
Is giving a pt during A-fib Anticoagulants a priority?
NO, You want to slow the heart rate down 1st.
Then anticoagulants will be given .
NSAIDs may cause
heart attack, stroke, high blood pressure, and possible heart failure after long-term use. NSAIDs decrease the effectiveness of diuretic and blood pressure medications. Long-term use is also associated with chronic kidney disease and peptic ulcers.
Hydrochlorothiazide is a weak
diuretic and is commonly used to treat hypertension.
why is Digoxin (Lanoxin) prescibed?
It is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate).
Digoxin (Lanoxin) action
a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction.
Mointer labs pt on dig?
BUN (7-20) and creatinine .07-1.4 .The drug is excreted almost exclusively by the kidney and is the measurement of how well the kidneys are working.
RN needs to be mindful and cautious if pt. has a chronic disease that effects the kidneys. ie; diabetes
Pt. @ risk for dig Toxicty:
Older pt. w/ decreased GFR; and Chronic Dieases
The early symptoms of dig toxicity are nausea and vomiting. L
nausea and vomiting.
later signs of dig toxicity are
arrhythmias, including heart blocks. Therefore, clients at risk for digoxin toxicity require frequent drug level monitoring and dose adjustment.
Apical heart rate is taken for a full minute prior to administration. It is safe to administer the drug when the apical heart rate is ≥60/min.
Digoxin
MED: hypokalemia can increase the risk of digoxin
toxicity
Fluoxetine (Prozac) is an
antidepressant drug that is a selective serotonin reuptake inhibitor.
Digoxin (Lanoxin) is excreted
almost exclusively by the kidneys. Decreased kidney function usually requires decreased digoxin dosage and frequent drug level monitoring. BUN and creatinine are measurements of kidney function.
MEDS: The client taking a statin such as atorvastatin or rosuvastatin should be taught to call the HCP
if generalized muscle aches develop as this may be a symptom of myopathy, a serious adverse effect of this type of medication.
in CAD FIRST check for the adequacy of blood flow to the lower extremities by palpating for the presence.
of posterior tibial and dorsalis pedis pulses and their quality
Poor circulation to the extremities can place the client at increased risk for
development of arterial ulcers and infection.
What objective assessment can be present in the client with PAD. It is a chronic condition of PAD and is not the priority assessment.
Dry, scaly skin
When the skin on the lower legs becomes thin, shiny, and taut; hairloss to lower legs.
circulation to the extremities is impaired ; This happens over a period of time.
Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance.
Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include
Tachypnea
Tachycardia, even at rest
Diaphoresis during feeding or exertion
Heart murmur or extra heart sounds
Signs of congestive heart failure
Increased metabolic rate with poor weight gain
congenital heart defects (eg, cyanotic defects) impede pulmonary blood flow (eg, tetralogy of Fallot, transposition of the great vessels) and cause cyanosis, which is evident shortly after birth and during periods of physical exertion.
Right-to-left
cardiac shunts (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) result in excess blood flow to the lungs. Manifestations include heart murmur, poor weight gain, diaphoresis with exertion, and signs of heart failure
Left-to-right

Dabigatran

. A study sponsored by the manufacturer found that idarucizumab effectively reversed anticoagulation by dabigatran within minutes.[2]

It is in the class of a direct thrombin inhibitor. It was developed by the pharmaceutical company Boehringer Ingelheim.

Contents [hide]
1 Medical uses
2 Contraindications
3 Adverse effects
4 Pharmacokinetics
5 History
6 Research
7 References
8 External links
Medical uses[edit]
Dabigatran is used to prevent strokes in those with atrial fibrillation not caused by heart valve issues, as well as deep vein thrombosis and pulmonary embolism in persons who have been treated for 5-10 days with parenteral anticoagulant (usually low molecular weight heparin), and to prevent deep vein thrombosis and pulmonary embolism in some circumstances.[3]

It appears to be as effective as warfarin in preventing nonhemorrhagic strokes and embolic events in those with atrial fibrillation not due to valve problems.[4]

Contraindications[edit]
Dabigatran is contraindicated in patients who have active pathological bleeding, since dabigatran can increase bleeding risk and can also cause serious and potentially life-threatening bleeds.[5] Dabigatran is also contraindicated in patients who have a history of serious hypersensitivity reaction to dabigatran (e.g. anaphylaxis or anaphylactic shock).[5] The use of dabigatran should also be avoided in patients with mechanical prosthetic heart valves due to the increased risk of thromboembolic events (e.g. valve thrombosis, stroke, and myocardial infarction) and major bleeding associated with dabigatran in this population.[5][6][7]

Adverse effects[edit]
The most commonly reported side effect of dabigatran is gastrointestinal upset. When compared to people anticoagulated with warfarin, patients taking dabigatran had fewer life-threatening bleeds, fewer minor and major bleeds, including intracranial bleeds, but the rate of gastrointestinal bleeding was significantly higher. Dabigatran capsules contain tartaric acid, which lowers the gastric pH and is required for adequate absorption. The lower pH has previously been associated with dyspepsia; some hypothesize that this plays a role in the increased risk of gastrointestinal bleeding.[8]

A small but significantly increased risk of myocardial infarctions (heart attacks) has been noted when combining the safety outcome data from multiple trials.[9]

Reduced doses should be used in those with poor kidney function.[10]

Pharmacokinetics[edit]
Dabigatran has a half-life of approximately 12-14 h and exerts a maximum anticoagulation effect within 2-3 h after ingestion.[11] Fatty foods delay the absorption of dabigatran, although the bio-availability of the drug is unaffected.[1] One study showed that absorption may be moderately decreased if taken with a proton pump inhibitor.[12] Drug excretion through P-glycoprotein pumps is slowed in patients taking strong p-glycoprotein pump inhibitors such as quinidine, verapamil, and amiodarone, thus raising plasma levels of dabigatran.[13]

History[edit]

anticoagulant medication taken by mouth

(some cases is an alternative to warfarin, since it does not have to be monitored by blood tests, but offers similar results in terms of efficacy.)

Dabigatran antidote,
In case of major bleeding = idarucizumab
Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk.
of clot formation and stroke in clients with chronic atrial fibrillation
The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush, shaving with an electric razor). Dabigatran capsules
should be kept in their original container or blister pack until time of use to prevent moisture contamination
Thrombin inhibitors such as_________________________ reduce the risk for clots and stroke in clients with chronic atrial fibrillation. The nurse should teach the client to use bleeding precautions and monitor for symptoms of bleeding, swallow capsules whole with a full glass of water, and keep capsules in their original container until time of use.
dabigatran
Discharge education for the client with chronic heart failure should include
daily weights, drug regimens, diet, and exercise plans. The use of any NSAIDS is contraindicated in heart failure as these contribute to sodium retention, and therefore fluid retention. no more than 400mg na+/ meal.
Kawasaki disease (KD), also known as, is characterized by Coronary artery aneurysms are the most serious potential sequelae in untreated clients, leading to complications such as myocardial infarction and death. Echocardiography is used to monitor these cardiovascular complications
mucocutaneous lymph node syndrome
Kawasaki disease (KD), is characterized by
≥5 days of fever, bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash, and extremity swelling.

Kawasaki disease (KD), are the most serious potential :

Echocardiography is used to monitor these cardiovascular complications

Coronary artery aneurysms
sequelae in untreated clients, leading to complications such as myocardial infarction and death.
Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent .
(KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties.)
coronary aneurysms and subsequent occlusion
Tell parents this is being given to prevent heart disease.
Kawasaki disease Treatment: parents should be cautioned about the risk of
Reye syndrome
cardiopulmonary resuscitation should also be taught to parents of children with coronary artery aneurysms.
Is KD contagious?
NO
S/S of KD and NI
expected finding:
Polymorphous rash of the trunk and extremities is an in a child with KD.
Lymphadenopathy (usually a single palpable anterior cervical node >1.5 cm)
splenomegaly
NI:Cool compresses, unscented lotions, and loose-fitting clothing can minimize discomfort. expected finding
Following permanent pacemaker insertion, the nurse should assess for electrical and mechanical capture. e. Mechanical capture is
electrical and mechanical capture
How will RN assess for mechanical capture
verified by palpating the client’s pulse rate and comparing it to the heart rate recorded by the cardiac monitor.
How will RN assess for Electrical capture is verified by a
P wave following an atrial pacemaker spike and/or a widened QRS complex following a ventricular pacemaker spike
The nurse should assess for pacer spikes on the cardiac monitor. For an atrial pacemaker, a pacer spike will precede a P wave. For a ventricular pacemaker, a pacer spike will precede a widened QRS complex. These waveforms indicate electrical capture. The nurse still needs to further assess the client for mechanical capture of the pacemaker. This ensures that the electrical stimulus generates a pulse or heartbeat in the client. To check for mechanical capture, the nurse should palpate the client’s pulse rate and compare it with the electrical rate displayed on the cardiac monitor
To assess the apical heart rate, the nurse needs to place the stethoscope diaphragm on the chest at the
apex/mitral area (fifth intercostal space on the midclavicular line)
Intractable dry cough is a common side effect of ACE inhibitors.
It is thought to be related to the accumulations of kinins (bradykinin).
which ethnic group to be at highest risk for this side effect have a high risk (15%-50%) for ACE inhibitor-related cough
Asians, especially those of Chinese descent,
which ethnic group is at highest risk for this side effect ACE inhibitor-related angioedema
African descent
A major problem with long-term management of hypertension is
poor adherence to the treatment plan. The nurse should teach the client the importance of taking blood pressure medications as prescribed.
Chest tube drainage >3 mL/kg/hr for 3 consecutive hours or 5-10 mL/kg in 1 hour should be reported immediately to the HCP Why?
This could indicate postoperative hemorrhage and needs immediate intervention. Cardiac tamponade can develop rapidly in children and can be life-threatening. This child weighs 4 kg and an output of 30 mL in 1 hour is excessive.
infants age 1-12 months, the normal heart rate is
100-160/min
The nurse should immediately report chest tube drainage >3 mL/kg/hr over 3 consecutive hours or 5-10 mL/kg over 1 hour.
This could indicate postoperative hemorrhage. Cardiac tamponade can occur rapidly in children and can be life-threatening.
Clients with severe aortic stenosis are at risk
for developing syncope and sudden death with exertion. The left ventricle cannot push enough blood into the aorta to meet the body’s demands due to the valve stenosis.
Large amounts of vitamin K-rich foods can decrease the anticoagulant effects of warfarin therapy. Clients are not instructed to remove those foods from their diet but are encouraged to be consistent in the intake of foods high in vitamin K, including

leafy green vegetables, asparagus, broccoli, kale, Brussels sprout, and spinach.

Several beverages also affect warfarin therapy. Green tea, grapefruit juice, and cranberry juice may alter its anticoagulant effects.

The nurse should teach the client receiving warfarin therapy to be consistent with intake of foods high in vitamin K. Clients do not need to restrict vitamin K-rich foods completely. are the most important to teach.
Leafy green vegetables and grapefruit juice
**Drugs commonly associated with orthostatic hypotension include:

1.)Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha blockers (eg, terazosin)

2.) Antipsychotic medications (eg, olanzapine, risperidone) and

3.)antidepressants (eg, selective serotonin reuptake inhibitors)

4.)Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide)

5.)Vasodilator medications (eg, nitroglycerine, hydralazine)
Narcotics (eg, morphine)

SAFETY: Teach pt. at risk for developing orthostatic hypotension to:
Take medications at bedtime, if approved by the health care provider
Rise slowly from a supine to standing position, in stages (especially in the morning)
Avoid activities that reduce venous return and worsen orthostatic hypotension (eg, straining, coughing, walking in hot weather)
Maintain adequate hydration
Muscle cramps and liver injury, are the major adverse effects of
statin medications (eg, atorvastatin).
Major side effects of metformin are
lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea).
lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea) are associated with?
metformin
Proton pump inhibitors (eg, omeprazole) are associated with increased risk of
pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis)
Nausea, vomiting, or slow pulse rate can indicate .
digoxin toxicity
General guidelines are to hold digoxin in infants and young children
pulse <90-110/min
General guidelines are to hold digoxin in young children
<70/min in older children
Why is dig given to kids?
heart failure
It is given to increase myocardial contraction, which increases cardiac output and improves circulation and tissue perfusion.
Digoxin is a potentially dangerous drug due to its
narrow margin of safety in dosage
Parent teaching for administration of digoxin includes the following:
1.Inform parents of the pulse rate at which to hold the medication based on HCP prescription. In general, digoxin is held if pulse <90-110/min for infants and young children or <70/min for an older child.
2.Administer oral liquid in the side and back of the mouth
3.Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication
4.If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule.
5.If more than 2 doses are missed, notify the HCP
If the child vomits, do not give a second dose 6.Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP .
7.Give water or brush the client’s teeth after administration to remove the sweetened liquid.
why do we give dig to adults
a-fib / CHF
Digoxin (Lanoxin) is excreted almost exclusively by the kidney, what should RN monitor?
BUN and creatinine levels are measurements of kidney function. The normal range for creatinine is 0.6-1.3 mg/dL
Caution the use of Digoxin (Lanoxin) in elderly and diabetics b/c ?
Elderly clients tend to develop age-related decrease in glomerular filtration rate (GFR). These clients and those with obvious kidney injury (possibly due to diabetes in this client) can accumulate digoxin.
What are the early signs of Digoxin (Lanoxin) toxicity?
nausea and vomiting
What are the late signs of Digoxin (Lanoxin) toxicity?
Later signs of toxicity are arrhythmias, including heart blocks
What must the RN do when a pt is on Digoxin?
Monitor heart rate
apical heart rate for full minute prior to administration. It is safe to administer the drug when the apical heart rate is ≥60/min
Watch for dig toxicity s/s
mointor Creatine and BUN
Moiniter dig levels and make dose adjustments as needed.
Monitor for HypOK
The nurse needs to educate the client with a venous leg ulcer that wearing some kind of compression stockings is
essential for healing and prevention of ulcer recurrence
The nurse should teach the client with MVP to stay hydrated, avoid caffeine and alcohol, exercise regularly, reduce stress, and take beta blockers as prescribed for palpitations and chest pain. Nitrates are usually not effective for chest pain from MVP
Client teaching for MVP includes the following:
-Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms
-Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms
-Reduce stress and avoid alcohol use
-begin or maintain an exercise program, preferably aerobic exercise
A serious complication associated with statin medication is
rhabdomyolysis
Rhabdomyolysis ( ass. with statin meds)
is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood
These substances can be harmful to the kidney and often cause kidney damage. The client should immediately report any signs of muscle aches or weakness to the HCP. These could be early signs of rhabdomyolysis, which can be fatal.
.The nurse should teach all clients taking statin drugs (eg, atorvastatin, rosuvastatin) to immediately report any
muscle aches or weakness, as these can lead to rhabdomyolysis, a muscle disintegration that can cause serious kidney injury.

A client in the emergency department has an acute myocardial infarction (MI). The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP?

1. Client is currently menstruating [14%]
2. Client rates chest pain at a 8 out of 10 on pain scale [5%]
3. Client reports a history of cerebral aneurysm at age 20 [63%]
4. Current blood pressure is 170/96 mm Hg, heart rate is 110/min [15%]
Correct Answered correctly
63% Time: 69 seconds
Updated: 04/26/2017
Explanation:

Thrombolytic therapy is aimed at stopping the infarction process, dissolving the thrombus in the coronary artery, and reperfusion of the myocardium. This treatment is used in facilities without an interventional cardiac catheterization laboratory or when one is too far away to transfer the client safely. Client selection is important because all thrombolytics lyse the pathologic clot and may lyse other clots (eg, postoperative site). Minor or major bleeding can be a complication of therapy.

Inclusion criteria for thrombolytic therapy are chest pain typical of acute MI 6 hours or less in duration, 12-lead electrocardiogram findings consistent with acute MI, and no absolute contraindications.

(Option 1) Menstruating is not considered a contraindication.

(Option 2) The presence of chest pain is part of the inclusion criteria for thrombolytic therapy.

(Option 4) The client’s blood pressure is high, but not >180/110 mm Hg, a relative contraindication.

Educational objective:
The client being considered for thrombolytic therapy should be screened for absolute and relative contraindications. The nurse should immediately notify the HCP if the client reports a history of cerebral aneurysm as it is an absolute contraindication to the use of thrombolytics.

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Block Time Remaining: 01:28:10
TIMEDTUTOR
Test Id: 80207062
QId: 31863 (921666)
21 of 75
A A A
The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention does the nurse anticipate?1. Administering PRN antiemetic prior to the infusion [2%]
2. Administering via an infusion pump over at least 30 minutes [20%]
3. Drawing a trough level just prior to administration of the vancomycin [71%]
4. Starting a new IV line before administration [5%]
Correct Answered correctly
71% Time: 31 seconds
Updated: 05/05/2017
Explanation:

Vancomycin is a very potent antibiotic that can cause nephrotoxicity and ototoxicity. Measuring for serum concentrations is a way to monitor for risk of nephrotoxicity as well as for therapeutic response. Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A trough should be obtained just prior (about 15-30 minutes) to administration of the next dose.

(Option 1) Unlike some chemotherapy medications, vancomycin does not commonly cause nausea or vomiting. Premedication with antiemetics is not required. However, premedication with antihistamines (diphenhydramine) is recommended if the client had developed red man syndrome, also known as red neck syndrome, with prior vancomycin infusion. This syndrome is characterized by red blotching of the face, neck, and chest due to too rapid administration.

(Option 2) Vancomycin should be administered over a minimum of 60 minutes. Too rapid administration can cause red man syndrome, considered a toxic effect rather than an allergic reaction.

(Option 4) The nurse would want to verify patency of the IV line prior to administration as thrombophlebitis is a possibility with vancomycin; however, a new IV line is not necessarily required.

Educational objective:
To measure for efficacy and risk of nephrotoxicity with vancomycin, the nurse should draw periodic trough levels just prior to administration of the next IV dose.

Decrease in blood pressure, increase in pulse rate, output greater than intake, hypernatremia, and decrease in serum potassium are manifestations that can indicate
hypotonic dehydration in a client receiving diuretic therapy.
Following repair of an abdominal aortic aneurysm, hemodynamic stability is a priority. Prolonged hypotension can lead to graft thrombosis. A falling blood pressure and rising pulse rate can also signify graft leakage.
Abdominal aortic aneurysms are surgically repaired when they measure about 6 cm or are causing symptoms. Repair can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or
The client must be monitored. Signs of graft leakage include a decreasing blood pressure and increasing pulse rate
via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm with synthetic graft placement.
after abdonminal aortic aneurysm are sugically repaired RN will monitor?
postoperatively for graft leakage and hemodynamic stability. Adequate blood pressure is necessary to maintain graft patency, and prolonged hypotension can lead to the formation of graft thrombosis
postoperatively for graft leakage and hemodynamic stability s/s?
-Signs of graft leakage include a decreasing blood pressure and increasing pulse rate
-A rigid, distended abdomen would indicate possible blood (graft leakage) in the cavity.
The complete blood count (CBC) should be assessed periodically with the administration of The nurse would want to assess the
hemoglobin,
hematocrit, and
platelet count levels.
If these levels are low, the client will be at risk for increased bleeding.
enoxaparin, anticoagulant.
Digoxin levels are not often prescribed unless there is suspicion of digoxin toxicity. However, if this value is available, the nurse should assess it. Digoxin toxicity can be seen with levels.
Potassium levels should also be monitored in the client receiving digoxin.
>2 ng/mL
Hypokalemia can potentiate digoxin toxicity.
Prednisone is a glucocorticoid that can increase glucose levels.
Glucose levels should be monitored periodically for clients receiving this medication.
Low-molecular-weight heparins, such as enoxaparin, produce a stable response at recommended dosages and negate the need for frequent monitoring of activated partial thromboplastin time (aPTT) or International Normalized Ratio (INR) levels. aPTT is monitored when administering unfractionated heparin.
Educational objective:
The nurse should routinely monitor laboratory values prior to administering medications. A CBC should be assessed periodically in the client receiving enoxaparin. Digoxin and potassium levels should be assessed with the administration of digoxin. Glucose levels should be monitored in the client receiving glucocorticoids.
INR is monitored if the client is receiving
warfarin.
The nurse should teach the client that incisional pain from thoracotomy incisions between the ribs may be very painful after MIDCAB surgery. The nurse should encourage the client to take pain medication before the pain is too intense. The client should also be instructed to cough, breathe deeply while splinting the chest with a pillow, and use the incentive spirometer routinely to reduce the incidence of postop complications
Nursing education about transdermal nitroglycerin includes
application of the patch to the upper arms or body, rotating the sites daily, removing the patch at night, taking no erectile dysfunction medications, and informing clients that headaches are common. Patches do not need to be removed for bathing.
NTG is a vasodilator used to treat stable angina. It is a sublingual tablet or spray that is placed
under the client’s tongue. It usually relieves pain in about 3 minutes and lasts 30-40 minutes. The recommended dose is 1 tablet or 1 spray taken sublingually for angina every 5 minutes for a maximum of 3 doses (Option 2). If symptoms are unchanged or worse 5 minutes after the first dose, emergency medical services (EMS) should be contacted
What will RN teach about NTG nitroglycerin Storage?
accessible at all times
stored away from light and heat sources including body heat
keep the tablets in the original container.
replaced every 6 months
Do not store in car
Waking up at night with chest pain can signify that
angina is occurring at rest and is no longer considered stable angina. This should be reported to the health care provider
Education about sublingual NTG should include placing the tablet or spray under the tongue; repeating the dose every 5 minutes, with up to 3 total doses if angina is not relieved; notifying EMS if the first dose does not improve the symptoms; keeping the tablets in the original container away from light and heat; and replacing the bottle every 6 months once opened.
What holds the highest priority for intervention when a client is experiencing chest pain.
elevated troponin value
positive troponin levels are indicative of myocardial injury and require immediate attention by the nurse. Normal values are <0.5 ng/mL (<0.5 mcg/L) for troponin I and <0.1 ng/mL (<0.1 mcg/L) for troponin T.
True or False
In congestive heart failure, large changes in clients established dietary habits are necessary to avoid the repeated hospitalizations caused by salt overload
TRUE
The nurse should recognize muscle cramps in the legs as a possible sign of
hypokalemia in the client taking diuretics. Muscle cramps should be reported to the health care provider in anticipation of checking a potassium level, adding a potassium supplement, and instructing the client to eat potassium-rich foods.
Bruising, especially on the upper extremities, is common with the use of
antiplatelet agents such as aspirin and clopidogrel. The nurse should teach the client to monitor for other, more severe signs of bleeding, such as blood in the stool.
The nurse caring for a client receiving a heparin infusion should monitor the aPTT and follow the heparin infusion protocol for titration. A therapeutic level is 1.5-2 times normal,
or an aPTT of 46-70 seconds.

The MAP refers to the average pressure within the arterial system felt by the vital organs. A normal MAP is between 70-105 mm Hg. If the MAP falls below <60 mm Hg, vital organs may be underperfused and can become ischemic.

MAP can be calculated using the formula below:

Mean Arterial Pressure = Systolic Blood Pressure + (Diastolic Blood Pressure × 2)dived 3

A normal MAP is 70-105 mm Hg.
A MAP <60 mm Hg will not allow
for adequate perfusion of vital organs.
implantable cardioverter defibrillator
(ICD)
Discharge teaching for the ICD is similar to that for the implantable pacemaker. Clients should avoid lifting the arm on the side of the ICD above the shoulder until approved by the HCP to avoid dislodging the lead wire system.
The nurse should teach the client to take potassium tablets
with plenty of water (≥4 oz [120 mL]) and to sit upright after ingestion to prevent pill-induced esophagitis. Potassium should be taken during or immediately following meals to prevent gastric upset. Sustained-release tablets should not be crushed.
Peripheral arterial disease (PAD)
is a chronic, atherosclerotic disease caused by buildup of plaque within the arteries. PAD commonly affects the lower extremities and can lead to tissue necrosis (gangrene).
Home management instructions for PAD include:
Lower the extremities below the heart when sitting and lying down – improves arterial blood flow
Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) – promotes collateral circulation and distal tissue perfusion
Perform daily skin care, including application of lotion – prevents skin breakdown from dry skin
Maintain mild warmth (eg, lightweight blankets, socks) – improves blood flow and circulation
Stop smoking – prevents vessel spasm and constriction
Avoid tight clothing and stress – prevents vasoconstriction
Take prescribed medications (eg, vasodilators, antiplatelets) – increases blood flow and prevents blood clot development
Peripheral artery disease increases the risk of tissue necrosis and limb loss. Management focuses on
improving blood flow and circulation to the extremities through lifestyle changes and medications.
A client in complete heart block is often bradycardic and hemodynamically unstable. Transcutaneous pacing should be used until a permanent pacemaker can be inserted.
Atropine, dopamine, or epinephrine may be used to increase heart rate and blood pressure until temporary pacing is started.
Buerger’s disease is a nonatherosclerotic vasculitis involving small to medium arteries and veins of the upper and lower extremities. Young male smokers are typically affected.
Clients should avoid exposure to cold weather and cease using tobacco and marijuana in all forms. Smoking cessation can be achieved with bupropion or varenicline but not with nicotine replacement products.
A large anterior wall MI can affect the pumping ability of the left ventricle, putting the client at risk for developing
heart failure and cardiogenic shock
after a A large anterior wall MI the nurse should monitor for
new development of pulmonary congestion on x-ray, auscultation of a new S3 heart sound, crackles on auscultation of breath sounds, or jugular venous distension can signal heart failure and should be reported immediately to the hcp
The nurse knows that after a MI
Dysrhythmias are a common complication after an MI.
After a MI Occasional PVCs are not significant, but the nurse should further assess
the client’s potassium level and assess the apical-radial pulse for the presence of a pulse deficit.
Once children with KD are discharged home, parents should be instructed
to check their temperature every 6 hours for the first 48 hours following the last fever and then daily until the follow-up visit. The health care provider should be notified if the child has fever as this may indicate a need for further treatment.
What is Kawasaki disease (KD)
a systemic vasculitis of childhood that presents with ≥5 days of fever, nonexudative conjunctivitis, lymphadenopathy, mucositis, hand and foot swelling, and a rash. First-line treatment consists of
TX for KD
IV immunoglobulin and aspirin to prevent coronary artery aneurysms.
Expected Pt c KD: TEACH PARENTS?
Irritability
is a hallmark finding in a child with KD, especially during the acute phase (due to fever and inflammation). Parents should be advised that irritability can last up to 2 months.Temporary joint pain
arthritis (eg, stiffness, decreased range of motion) may occur and persist for several weeks. Parents should be informed that range of motion exercises and warm baths will help reduce these symptoms and minimize discomfort.

(Option 4) Desquamation (skin peeling) of the hands and feet is an expected finding in KD. Parents should be informed that the peeling itself is not painful but that the new skin underneath may be red and sore.

Where will rn listen to murmur
Erb’s point is located at the third left intercostal space (ICS) near the sternum and is an appropriate location to auscultate heart sounds for murmurs.
Jugular venous distension should be assessed
with the client in semi-Fowler’s position (ie, head of the bed elevated at a 30- to 45-degree angle).
normal platelet count is
150,000-400,000/mm
Clients with any form of prosthetic material in their heart valves or who have unrepaired cyanotic congenital heart defect or prior history of IE should
take prophylactic antibiotics prior to dental procedures to prevent development of IE.
the brachial artery is used to detect a pulse in an
unresponsive client age <1 year.
The nurse should be concerned about the presence of_________________________________ in a client taking a nonselective beta-blocker like propranolol.
wheezing
Wheezing may indicate bronchoconstriction or bronchospasm. The nurse should assess for any history of asthma or other respiratory problems and report to the HCP.
in the client who has had minimally invasive endovascular repair of an abdominal aneurysmThe nurse needs to monitor
groin puncture sites, peripheral pulses, urine output, and kidney function
New onset of dependent edema in an elderly client ;assessment finding requires immediate intervention why?
possible heart failure the client needs further assessment for characteristic signs such as lung crackles and increased body weight (fluid retention)
The single most important factor in preventing strokes is
controlling hypertension
Teach pt. to take medication
Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client’s susceptibility to ventricular tachycardia.
The RN recoginzes this as?
Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval;.
Torsades de pointes
it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation
How will RN treat hypomagnesmia (1.5-2.5)
The American Heart Association recommends treatment with IV magnesium sulfate.
atrial fibrillation (AF) include an
irregularly irregular rhythm and replacement of P waves by fibrillatory waves
electrolyte disturbances increase the likelihood of developing AF, clients can have this chronic condition managed with
anticoagulation therapy. AF is usually associated with an underlying heart disease and is rarely immediately life-threatening.
Atrial flutter is characterized by
sawtooth-shaped flutter waves.
often associated with conduction system disease or drug toxicity (eg, beta blockers, calcium channel blockers).
Mobitz II (type II second-degree atrioventricular block
In a client with hypomagnesemia, it is important to assess the QT interval. The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia).
assess the QT interval.
The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia).
The nurse should follow the ABCs of assessment with the heart failure client who is short of breath and coughing.
Airway, breathing, and circulation should be assessed, including auscultation of breath sounds, measurement of respiratory rate, and oxygen saturation.
Postoperative blood loss >100 mL/hr should be
reported to the HCP immediately. The client may have a compromised suture site and can rapidly become hemodynamically unstable
A therapeutic INR is
2.5-3.5
Discharge teaching for the client with a permanent pacemaker should include the following
Clients with a pacemaker should
–avoid heavy lifting
–above-the-shoulder exercises until the HCP approves
–They should carry a pacemaker ID card, wear a medic alert bracelet,
–avoid MRI scans, never place a cell phone over the pacemaker, and inform airline security personnel
-Report fever or any signs of redness, swelling, or drainage at the incision site
–Avoid standing near antitheft detectors in store entryways. Walk through at a normal pace and do not linger near the device.
normal CVP is
2-8 mm Hg
what does CVP tell RN:
CVP is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects fluid volume problems.
What does a elevated CVP can indicate
right ventricular failure or fluid volume overload.
Clinical signs of fluid volume overload include the following:
Peripheral edema
Increased urine output that is dilute
Acute, rapid weight gain
Jugular venous distension
S3 heart sound in adults
Tachypnea, dyspnea, crackles in lungs
Bounding peripheral pulses
signs of deficient fluid volume or dehydration
Dry mucous membranes and hypotension
When teaching a client about risk factor modification related to CAD development, the nurse should focus on
modifiable risk factors such as control of hypertension, diabetes, elevated serum lipid levels, cessation of tobacco use, reduction of BMI if client is overweight, increase in physical activity, and management of psychological state.
IN an Obese Pt at risk for CAD:
focus teaching on reducing this client’s BMI, This is the only risk factor that is modifiable as the client’s other risk factors (ethnicity, gender, strong family history of cardiovascular disease) are non-modifiable. Teaching should focus on changing eating habits, reducing caloric intake to achieve a BMI of 18.5-24.9 kg/m2, increasing physical activity, avoiding consumption of large heavy meals, and abstaining from fad or crash diets. Ingestion of smaller and more frequent meals should be encouraged.
Hydrochlorothiazide and chlorthalidone are the
most commonly used thiazide diuretics for treating hypertension
The major side effects of thiazide diuretics include:
Hypokalemia (manifests as muscle cramps)
Hyponatremia (manifests as altered mental status and seizures)
Hyperuricemia (may worsen gout attacks)
Hyperglycemia (requires adjustment of diabetic medications)
Of the above side effects, hypokalemia is the most serious as it can lead to life-threatening cardiac arrhythmias.
The nurse should suspect hypokalemia in the presence of muscle cramps in a client taking diuretics. Hypokalemia can lead to dangerous ventricular dysrhythmias.
Venous thromboembolism includes both
DVT and pulmonary embolism (PE)
DVT is the most common form and occurs most often (80%) in the
proximal deep veins (iliac, femoral) of the lower extremities
Risk factors associated with DVT formation include the following:
Trauma (endothelial injury and venous stasis from immobility)
Major surgery (endothelial injury and venous stasis from immobility)
Prolonged immobilization (eg, stroke, long travel) causing venous stasis
Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava)
Oral contraceptives (estrogen is thrombotic)
Underlying malignancy (cancer cells release procoagulants)
Smoking (produces endothelial damage by inflammation)
Old age
Obesity and varicose veins (venous stasis)
Myeloproliferative disorders (increase blood viscosity)
DVT is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing a DVT include trauma, surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age
In the presence of acute decompensated heart failure (ADHF) and pulmonary edema, diuretic (eg, furosemide) administration is effective in removing excess fluid to reduce pulmonary congestion and improve oxygenation. Vasodilators (eg, nitroglycerin, nesiritide) and positive inotropes (eg, dopamine, dobutamine) are also used in the treatment of ADHF.
In PSVT, the heart rate can be 150-220/min. With prolonged episodes, the client may experience evidence of reduced cardiac output such as
hypotension, palpitations, dyspnea, and angina
Treatment PSVT
vagal maneuvers such as Valsalva, coughing, and carotid massage Beta blockers, calcium channel blockers, and amiodarone can also be considered as alternatives.
Adenosine is the drug of choice for PSVT treatment.
PSVT treatment
Due to its very short half-life, adenosine is administered rapidly An increased dose may be given twice if previous administration is ineffective. Beta blockers, calcium channel blockers, and amiodarone can also be considered as alternatives. If vagal maneuvers and drug therapy are unsuccessful, synchronized cardioversion may be used.
via IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose may be given twice if previous administration is ineffective. Beta blockers, calcium channel blockers, and amiodarone can also be considered as alternatives. If vagal maneuvers and drug therapy are unsuccessful, synchronized cardioversion may be used.
PSVT treatment if adenosine is ineffective?
synchronized cardioversion may be used.
The drug of choice in clients with PSVT is adenosine. It is given rapidly via IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose may be administered 2 more times if previous administration is ineffective.
When auscultating for a murmur associated with mitral valve stenosis, the nurse should place the stethoscope at the
5th intercostal space, midclavicular line.
Right-sided heart failure S/S
–Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities
–Jugular venous distension
–Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites.
–Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation –
–Hepatomegaly due to hepatic venous congestion
–hepatomegaly, splenomegaly), and ascites
In clients with right-sided heart failure, the heart cannot effectively pump blood to the lungs. Clinical manifestations result from systemic venous congestion and include peripheral edema, jugular venous distension, increased abdominal girth (hepatomegaly, splenomegaly), and ascites
A PT is exhibiting signs and symptoms (narrowed pulse pressure, hypotension, and jugular venous distension) of developing cardiac tamponade, WHAT WILL RN DO?
THIS IS a LIFE THREATENING complication of pericardial effusion.
fluid builds up in the pericardial sac and compresses the heart.
The heart is unable to contract effectively against the fluid, and cardiac output can drop drastically. Other important manifestations of tamponade include muffled or distant heart tones, pulsus paradoxus, dyspnea, tachypnea, and tachycardia.
pericardial effusion LIFE THREATING TX:
Emergency pericardiocentesis
Clients with advanced heart failure often have low cardiac output with resultant low blood pressure but remain asymptomatic. WHAT MEDS WILL RN CAUTION:
IV diuretics can worsen the hypotension.
Nitroglycerin and other nitrates increase cardiac blood flow and provide relief from the pain of ischemia in acute coronary syndrome by causing vasodilation. Their infusion should not cause systolic blood pressure to fall to <90 mm Hg or to drop >30 mm Hg below baseline
WHEN any diuretic is being prescribed RN KNOWS to review pt._________________________ before administration on meds
BP
K+
Teach pt to take K+ with
FULL GLASS OF H20 and sit up
Pt With active DVT is a HIGH
Priority
Propranolol is a nonselective beta-blocker caution in pt with
any history of asthma or respiratory problems
Coarctation of the aorta (COA) is an
obstructive congenital heart defect resulting in decreased cardiac output. Children with COA will have stronger pulses in the upper extremities and diminished pulses in the lower extremities. This is expected until the obstruction is repaired surgically.
patent ductus arteriosus (PDA)
occurs when fetal circulation persists after birth. A continuous machinery-like murmur is a normal finding with a PDA.
Tetralogy of Fallot (TOF) is a
cyanotic congenital heart defect. Right-sided (venous) blood is shunted through the left ventricle via the ventricular septal defect due to the resistance at the pulmonary artery (pulmonary stenosis, one of the components of TOF). This will cause abnormally low oxygen saturation (often in the range of 65%-85%), which is expected until the defect is repaired surgically.
All left-to-right cardiac shunts (eg, ventricular septal defect, atrial septal defect) will cause an increase in pulmonary blood flow. Shunt reversal can eventually result in heart failure. Children should be kept in an upright position and offered small, frequent feedings to decrease workload of the heart and lungs.
Open aneurysm repair involves a large abdominal incision and requires cross-clamping the aorta proximally and distally to the aneurysm. Establishing baseline data is essential .
for comparison with postoperative assessments
the nurse should pay special attention to the character and quality of peripheral pulses and renal and neurologic status. Dorsalis pedis and posterior tibial pulse sites should be marked for easy location postoperatively. A decreased or absent pulse with cool, pale, mottled, or painful extremity postoperatively can indicate embolization or graft occlusion. Graft occlusion may require reoperation
Preoperative assessment of the character and quality of peripheral pulses provides a baseline for
rapid postoperative assessment and identification of emergent complications (embolization, graft occlusion)
Heart failure may develop after surgical repair of tetralogy of Fallot, and infants and children can quickly decompensate hemodynamically when it occurs. Clinical manifestations are grouped into
3 primary categories— impaired myocardial pumping, pulmonary congestion, and systemic venous congestion
impaired myocardial pumping S/S
tachycardia
cool/pale extremities
weak peripheral pulses
decreased BP
decreased urine output
activity intolerance/ weakness and fatigue
Loss of appetite
pulmonary congestion S/S
Dyspnea
tachypnea
othrapnea
systemic venous congestion S/s
hepatomegaly
puffiness around the eyes
weight gain
acites
JVD
The client with symptomatic bradycardia should be treated initially.
with IV atropine
Transcutaneous pacing or infusion of dopamine or epinephrine may be considered if atropine is ineffective in
symptomatic bradycardia
The nurse should report______________________________________ immediately in a client with a thoracic aortic aneurysm. This could indicate that the aneurysm has increased in size and may require treatment.
swallowing difficulty
Clients in ventricular tachycardia (VT) can be
pulseless or have a pulse
The unstable client in VT with a pulse is treated
with synchronized cardioversion. The stable client in VT with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol).
loud, machine-like systolic and diastolic murmur heard on a premature newborn with
Patent ductus arteriosus (PDA)
acyanotic congenital defect more common in premature infants
The nurse should immediately report chest tube drainage >3 mL/kg/hr over 3 consecutive hours or 5-10 mL/kg over 1 hour. This could indicate postoperative hemorrhage. Cardiac tamponade can occur rapidly in children and can be life-threatening.

The nurse receives notification from the telemetry room that a client appears to be in ventricular fibrillation (VF). The nurse immediately goes to the client’s room and finds the client unresponsive and pulseless. Place the interventions in the appropriate order.

Educational objective:
VF is a lethal dysrhythmia. The client will not recover without immediate treatment. Interventions consist of activation of the emergency response system, CPR, defibrillation, and drug therapy (epinephrine and then amiodarone).

1. Call the emergency response team
2.Initiate cardiopulmonary resuscitation (CPR)
3.Defibrillate the client at 200 joules
4.Administer IV epinephrine 1 mg push
5.Administer intravenous (IV) amiodarone 300 mg push
Clinical manifestations characteristic of a lower-extremity DVT include
unilateral edema, calf pain or tenderness to touch, warmth and erythema, and low-grade temperature.
Signs of adequate hydration are
normal urine specific gravity (1.003 to 1.030), adequate volume of urine output (>30 mL/hr), and capillary refill of less than 3 seconds. Pulse pressure narrows in shock, and positive orthostatic vital signs (decreasing systolic blood pressure and rising heart rate) with position change indicate dehydration.
cardiac catheterization uses iodinated contrast to assess for artery obstruction.
Complications include allergic reactions, lactic acidosis, and kidney injury. Contrast should be avoided in clients who have allergies to iodine or shellfish, have taken metformin within 24 hours of the procedure, or have kidney disease.
normal range for hemoglobin in a 1-month-old is
12.5-20.5 g/dL
polycythemia
(elevated hemoglobin levels)
Infants with cyanotic cardiac defects can develop polycythemia as a
compensatory mechanism due to prolonged tissue hypoxia
Polycythemia will increase blood viscosity, placing an infant at risk
for stroke or thromboembolism
Clubbing is another manifestation of prolonged
hypoxia.
Tetralogy of Fallot (TOF) is a cyanotic cardiac defect. Infants with TOF will normally maintain oxygen saturations of
65%-85% until the defect is surgically corrected.
Pt. with polycythemia must stay
hydrated.
what is the most common cause of mortality in clients who have had cardiac arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia
Neurologic injury
Inducing therapeutic hypothermia in these clients within
6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes.
Inducing therapeutic hypothermia
indicated in all clients who are comatose or do not follow commands after resuscitation.
Inducing therapeutic hypothermia What is the process ?
The client is cooled to 89.6-93.2 F (32-34 C) for 24 hours before rewarming. Cooling is accomplished by cooling blankets; ice placed in the groin, axillae, and sides of the neck; and cold IV fluids. The nurse must closely assess the cardiac monitor (bradycardia is common), core body temperature, blood pressure (mean arterial pressure to be kept >80 mm Hg), and skin for thermal injury. The nurse must also apply neuroprotective strategies such as keeping the head of the bed elevated to 30 degrees. After 24 hours, the client is slowly rewarmed. generally kept NPO during therapeutic hypothermia and rewarming
Following return of spontaneous circulation in an out-of-hospital cardiac arrest, therapeutic hypothermia should be implemented for 24 hours in clients who are comatose or do not follow commands. Therapeutic hypothermia has been shown to improve neurologic outcomes and decrease mortality in these clients.
Adequacy of tissue perfusion in a client with shock syndrome and possible organ dysfunction is assessed by
the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity temperature, and peripheral pulses
Acute-onset dyspnea and cough with frothy, pink-tinged sputum indicate pulmonary edema. Auscultation reveals
crackles at the lung bases.
QRS complexes are wider than 0.12 seconds
Ventricular tachycardia (VT)
Pericardial effusion is a buildup of
fluid in the pericardium
Tamponade, a serious complication of
pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid).
Signs and symptoms of cardiac tamponade include:
Hypotension with narrowed pulse pressure (Option 1)
Muffled or distant heart tones (Option 4)
Jugular venous distension (Option 5)
Pulsus paradoxus
Dyspnea, tachypnea
Tachycardia
muffled or distant heart tones, narrowed pulse pressure, jugular venous distension, pulsus paradoxus, dyspnea, tachypnea, and tachycardia
cardiac tamponade
prepare for a pericardiocentesis
cardiac tamponade
LAB Review:
Blood pressure and serum potassium level are checked prior to administration of ACE inhibitors. Heart rate should be checked prior to administration of beta blockers. Aspirin is given to clients with normal platelet counts.
history of aortic abdominal aneurysm The nurse should listen for a bruit with the bell of the stethoscope over the
periumbilical or epigastric area
The nurse should assess the BNP level in clients admitted with heart failure exacerbations. Elevated BNP levels indicate increased ventricular stretch and correlate with severity of heart failure and fluid volume overload. Heart failure clients may also present with jugular venous distension, low serum sodium, and decreased urine output.
When administering furosemide, it is important to closely monitor
the client’s vital signs, serum electrolytes (potassium), and kidney function tests (blood urea nitrogen, creatinine) prior to administration to prevent side effects such as hypokalemia, hypotension, and kidney injury.
In neonatal resuscitation, the nurse’s fingers/thumbs are placed at the
middle third of the sternum, slightly below the nipple line. The xiphoid portion of the sternum should not be compressed as it may damage the neonate’s liver.
Coronary arteriogram requires that the client have nothing by mouth for 6-12 hours prior to the procedure and have an IV line started for sedation medications. The client may feel warm and flushed while the dye is being injected. The client is required to lie flat for several hours following the procedure to achieve hemostasis at the access site (femoral access). The client typically goes home the same day unless other interventions have been performed.
Discharge teaching for a client who has had DVT emphasizes minimization of risk factors (eg, venous stasis, hypercoagulability of blood, endothelial damage) and interventions to promote blood flow and venous return and prevent reoccurrence (eg, adequate fluid intake, frequent position changes, elevation of extremities, leg exercises, regular exercise, smoking cessation).
If bleeding occurs at a catheterization site in the groin, the nurse should apply direct pressure
approximately 2.5 cm (1″) above the insertion site
Atropine is given to the client with symptomatic bradycardia. The desired outcome would be an
increase in heart rate, evidence of normal sinus rhythm on the cardiac monitor, and reversal of any clinical symptoms associated with the bradycardia.
client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department ‘
What will RN suspect?
MI = Pt c chronic disease might not have the classic s/s
dull chest pain with radiation down the left arm.
classic heart attack symptoms of
“atypical” symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue.
MI
what is the difference in leads between & acute myocardial infarction,
acute pericarditis, ST-segment elevation is seen in almost all leads (as the entire pericardium is inflamed). This is in contrast to acute myocardial infarction, in which ST-segment elevation is seen in localized leads (depending on which vessel is occluded)
The rubbing together of the inflamed pericardial layers causes the characteristic high-pitched, leathery, and scratchy sound in what?
Pericardial friction rub is an expected finding with acute pericarditis.
A prolonged episode of SVT with a heart rate >180/min will cause decreased cardiac output and hypotension. The client may also experience palpitations, dyspnea, and angina
What will RN do?
Treatment includes vagal stimulation and drug therapy. Common vagal maneuvers include Valsalva, coughing, and carotid massage. IV adenosine is the drug of choice to convert SVT to a sinus rhythm. If vagal stimulation and drug therapy are ineffective and the client becomes hemodynamically unstable, synchronized cardioversion is used. Recurrent SVT may require radiofrequency catheter ablation.
Sinus tachycardia involves a heart rate of 101-200/min but also has a normal P wave preceding each QRS, with a normal shape and duration. The PR interval is normal (0.10-0.20 second) and the QRS is <0.12 second.
SVT
The nurse should have current assessment data and access to the client’s recent laboratory data, diagnostic studies, and medication administration record
before calling the HCP.

It is very important to rapidly diagnose and treat the client with chest pain and potential myocardial infarction to preserve cardiac muscle.

Initial interventions in emergency management of chest pain are as follows:

Assess airway, breathing, and circulation (ABCs)
Position client upright unless contraindicated
Apply oxygen, if the client is hypoxic
Obtain baseline vital signs, including oxygen saturation
Auscultate heart and lung sounds
Obtain a 12-lead electrocardiogram (ECG)
Insert 2-3 large-bore intravenous catheters
Assess pain using the PQRST method
Medicate for pain as prescribed (eg, nitroglycerin)
Initiate continuous electrocardiogram (ECG) monitoring (cardiac monitor)
Obtain baseline blood work (eg, cardiac markers, serum electrolytes)
Obtain portable chest x-ray
Assess for contraindications to antiplatelet and anticoagulant therapy
Administer aspirin unless contraindicated
Nurses must take presenting cardiac symptoms seriously until the cause is determined. Assess airway, breathing, and circulation, and obtain baseline pulse oximetry and vital signs. Then obtain electrocardiogram (ECG) results.
In IE, the vegetations over the valves can break off and embolize to various organs, resulting in life-threatening complications. These include the following:
Stroke – paralysis on one side
Spinal cord ischemia – paralysis of both legs
Ischemia to the extremities – pain, pallor, and cold foot or arm
Intestinal infarction – abdominal pain
Splenic infarction – left upper-quadrant pain
IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur. The onset of hemiplegia or painful, pale, cold foot/leg could indicate embolization
and should be reported to the HCP immediately.
Arterial ulcers form at the
most distal ends of the body, where circulation is poorest (eg, tips of the toes).
They are usually small, circular, deep ulcers with little exudate. This appearance differentiates arterial ulcers from venous ulcers.
Venous ulcers appear
as edematous, large, superficial wounds with large amounts of exudate. They are commonly found on the medial side of the ankles.
Signs of graft leakage that are important to monitor after repair of an abdominal aortic aneurysm include
pain in the back, pelvis, or groin; ecchymosis of the groin, scrotum, or penis; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased abdominal girth; and decreased urinary output.
hyperpigmented skin, low blood pressure, weight loss, and muscle weakness ARE S/S OF:
Addison’s disease (chronic adrenal insufficiency)
treat herpes infection as they shorten the duration and severity of active lesions
Acyclovir (Zovirax), famciclovir, and valacyclovir
Genital herpes is a sexually transmitted infection caused by a herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the body even when active lesions are healed. There is no cure for genital herpes; treatment is aimed at relieving symptoms and preventing the spread of infection. Touching the lesions and then rubbing or scratching another part of the body can spread the infection.
Therefore, gloves should be used when applying topical antiviral or analgesic (eg, lidocaine) medications.
During periods of active lesions, abstinence from sexual intercourse is indicated. Condoms should be used during periods of dormancy due to viral shedding.
Genital herpes
An impaled object should not be manipulated or removed at the scene as further trauma and bleeding of soft tissue and surrounding organs may occur. The embedded object is stabilized on scene to allow for initial client assessment and later transport to a health care facility where skilled trauma care is available.
First responders should not manipulate or remove the impaled object.
Manipulation or removal may cause further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client assessment and later during transport to a health care facility where skilled trauma care is available.
First responders (EMS providers) may remove the impaled object if it obstructs
the airway and prevents effective cardiopulmonary resuscitation.
Cold and clammy skin indicates that the sympathetic nervous system compensatory mechanism is failing and may mark the progression from the compensatory (II) to the progressive (III) stage of shock.
Immediate intervention is necessary to prevent further progression and is the most important finding for the nurse to report.
The presence of 2 or more of these findings indicates the syndrome SIRS.
Temperature (hyper- or hypothermia), respirations >20/min, heart rate >90/min, and WBC count >12,000/mm3 (12.0 x 109/L) are assessed to document SIRS.
The nurse should use the ___________________________ to avoid movement of an unstable spine.
jaw-thrust maneuver
a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern.
Torsades de pointes
torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. The first-line treatment is IV magnesium (Option 3). Treatment may also include defibrillation and discontinuation of any QT-prolonging medications.
electrolyte imbalances, especially hypomagnesemia,
TX: for torsades de pointes
The first-line treatment is IV magnesium
Treatment may also include defibrillation and discontinuation of any QT-prolonging medications
Adenosine treats
supraventricular tachycardia.
a vasopressor used to treat symptomatic hypotension.
Dopamine
used for heart rate control in tachyarrhythmias.
Metoprolol is a beta blocker
Triage in a mass casualty incident also known as,
disaster triage, focuses on saving the greatest number of people with the limited resources available.
Triage has the highest priority, indicating a life-threatening injury that a client will survive if treated in the next hour, usually with significant impairment to airway, breathing, or circulation.
Red
could likely wait 1-2 hours without loss of life or limb.
Yellow
is considered walking wounded and clients may wait hours for treatment.
Green
indicates that the victim is unlikely to survive transport to definitive clinical care due to either the severity of trauma, insufficient transportation resources, level of available care, etc.
Black
A pt. with sea saw respiration is considered in triage
“Red” Fail chest!
What is a fail chest?
a scenario where multiple ribs sustain multiple fractures and become independent of the chest wall, floating on top of the lung and pleura. The fractured segment moves paradoxically in relationship to the intact chest wall, pushing outward with expiration and inward with inspiration. In addition to being extremely painful, impaired respiration can occur and rib fragments may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time.
Tx: for fail chest?
Supplemental oxygen is often necessary, and a chest tube and intubation may be necessary to stabilize the client.
In disaster/MCI triage, the sickest go first, not
women and children.
If no s/s of shock, Extremity injuries can wait hours for the necessary surgery, what will be the RN interventions?
cover the injury with a sterile dressing, immobilize, and provide pain relief (if available). T
Asystole is characterized by the absence of all ventricular electrical activity. The client is pulseless, apneic, and unresponsive. Treatment includes
cardiopulmonary resuscitation, oxygenated ventilation, and advanced cardiovascular life-support measures (eg, epinephrine IV, advanced airway, treatment of reversible causes).
Defibrillation is not indicated when
electrical activity is absent (asystole) or when pulseless electrical activity is present.
Defibrillation is used for treating
ventricular fibrillation and pulseless ventricular tachycardia.
During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate?
Take no action the chest tube is functioning properly.
Where would RN know to look for an air leak would cause
bubbling in the air leak gauge (section C) or WATER SEAL CHAMBER not in the suction control chamber.
Gentle, continuous bubbling in the suction control chamber of a chest tube drainage unit indicates
the presence of suction in the system and is an expected finding.
Rapid response teams are formed as a means to get critical care assistance to the bedside of clients (not in intensive care) with acute significant changes in their condition. Common criteria include sudden, significant changes in pulse rate, respiration rate, systolic blood pressure, oxygen saturation, level of consciousness, and/or urine output.

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?

1. Client scheduled for discharge who has had a peripheral IV in place for 84 hours [20%]
2. Client with a do-not-resuscitate prescription who has swelling at the IV site [67%]
3. Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago [8%]
4. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag [3%]
Omitted
Correct answer
2
Answered correctly
67% Time: 6 seconds
Updated: 03/10/2017
Explanation:

During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness, drainage, edema, discomfort, warmth, coolness, hardness). Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site.

Interventions include:

Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity
Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness)
Elevating the affected extremity to decrease swelling
Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop
Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs.
(Option 1) Peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop. This client’s IV line will likely be discontinued at discharge and is not the highest priority.

(Option 3) It is important to flush saline locks every 8-12 hours as prescribed. However, this client is not the highest priority.

(Option 4) An IV infusing at 20 mL/hr will take 5 hours to complete when 100 mL remain in the bag.

Educational objective:
The IV site should be monitored for redness, edema, discomfort, drainage, hardness, warmth, or coolness. If infiltration occurs, discontinue the IV line immediately and restart it in another site.

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention?

1. Heating pad [46%]
2. Positioning for comfort [7%]
3. Rest from pain-aggravating activities [39%]
4. Stretching exercises [6%]
Omitted
Correct answer
3
Answered correctly
39% Time: 3 seconds
Updated: 05/25/2017
Explanation:

Acute exacerbation of chronic back pain is usually associated with inflammation triggered by (strenuous and/or repetitive) activities that stress the previously injured area. Interventions should be directed toward reducing inflammation. Nonpharmacologic intervention to treat the inflammation includes rest from pain-aggravating activities which may continue to promote inflammation and delay healing.

(Option 1) Applying heat to the injured area can promote the inflammatory process (via vasodilation); therefore, this is not the best intervention at this time. However, after the acute inflammation has resolved (usually within a few days) heat application would be appropriate to reduce pain and muscle spasms.

(Option 2) Although the nurse should teach the client to ensure positioning for comfort to reduce pain, this is less likely to impact the inflammatory processes causing the pain.

(Option 4) Stretching exercises can also be helpful for back pain but should begin after the acute pain and inflammation have subsided.

Educational objective:
Rest from activities that aggravate pain and inflammation is a nonpharmacologic comfort intervention to decrease the inflammation due to acute pain.

FUNDAMENTALS SECTION—————–

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?

1. Client scheduled for discharge who has had a peripheral IV in place for 84 hours [20%]
2. Client with a do-not-resuscitate prescription who has swelling at the IV site [67%]
3. Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago [8%]
4. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag [3%]
Omitted
Correct answer
2
Answered correctly
67% Time: 6 seconds
Updated: 03/10/2017
Explanation:

During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness, drainage, edema, discomfort, warmth, coolness, hardness). Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site.

Interventions include:

Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity
Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness)
Elevating the affected extremity to decrease swelling
Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop
Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs.
(Option 1) Peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop. This client’s IV line will likely be discontinued at discharge and is not the highest priority.

(Option 3) It is important to flush saline locks every 8-12 hours as prescribed. However, this client is not the highest priority.

(Option 4) An IV infusing at 20 mL/hr will take 5 hours to complete when 100 mL remain in the bag.

Educational objective:
The IV site should be monitored for redness, edema, discomfort, drainage, hardness, warmth, or coolness. If infiltration occurs, discontinue the IV line immediately and restart it in another site.

The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply.

1. Avoid infusion devices in confused clients as alarms can be disruptive
2. Cardiac and renal changes may put the client at risk for hypervolemia
3. Older adults may have more fragile veins, increasing the risk of infiltration
4. Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin
5. Use a 30-45-degree angle on insertion because older adults have deeper veins that roll
Omitted
Correct answer
2,3,4
Answered correctly
56% Time: 11 seconds
Updated: 04/26/2017
Explanation:

The nurse must consider several life span changes that occur with aging when initiating IV therapy and caring for IV infusions in the older adult. Important considerations include the following:

The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia.
Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance (Option 1).
Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours.
Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure.
Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the client when speaking.
Use the smallest gauge catheter (24-26 gauge) indicated for the client’s therapy as veins are more fragile.
Consider vein sites to promote client independence (non-dominant arm, avoiding back of the hand).
Use a 5-15-degree angle on insertion as veins of the elderly are usually more superficial (Option 5).
Educational objective:
Important age-related considerations for the older adult receiving IV therapy include consideration of renal and cardiac function to prevent hypervolemia, use of an infusion pump for control, close monitoring of the site for infiltration and infection, measures to prevent skin tears, and use of small-bore (24-26 gauge) IV catheters and correct technique (5-15-degree angle) for insertion of an IV into fragile veins.

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube. The client is receiving a hypertonic formula. What is the best nursing action?

1. Dilute the formula with water [5%]
2. Discontinue the tube feeding [10%]
3. Send a stool sample to the lab for culture and sensitivity [20%]
4. Slow the rate of administration of the feeding [63%]
Omitted
Correct answer
4
Answered correctly
63% Time: 10 seconds
Updated: 04/26/2017
Explanation:

Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their higher osmolality, hypertonic formulas sometimes cause nausea, vomiting, or diarrhea, especially during the initiation of total enteral nutrition. The gastrointestinal tract will pull fluid from the surrounding intra- and extravascular compartments to dilute the formula, making it similar to body fluid osmolality. This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, nausea, and vomiting. Slowing down the rate of administration of total enteral nutrition will usually alleviate these problems. The feeding can gradually progress to the established goal rate.

(Option 1) Diluting enteral formulas is not necessary. This practice may increase the risk of intolerance secondary to microbial contamination. A diluted formula supports microbial growth better than a full-strength formula. Diluting total enteral nutrition may also be detrimental because the client may receive inadequate nutrition; it will take a larger volume of fluid to provide the same number of calories and protein.

(Option 2) It is not necessary to discontinue the feeding; the client needs nutrition support.

(Option 3) Sending a stool sample for culture and sensitivity would be appropriate if bacterial contamination or a bacterial infection is suspected as the cause of the diarrhea. It is not the best nursing action in this situation.

Educational objective:
Complications of total enteral nutrition at the start of treatment are nausea, vomiting, and diarrhea. These signs and symptoms can usually be alleviated by slowing down the rate of administration and then gradually increasing the rate to the established goal.

A client with renal failure recently started dialysis and is unable to work due to ongoing health problems. The client’s spouse has started working for a cleaning service to replace the lost income. The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis. Which is the most appropriate first response by the nurse?

1. “How is your spouse’s new job going?” [3%]
2. “I notice that you seem frustrated.” [77%]
3. “It can take time to adjust to dialysis. We have a support group that can be helpful.” [17%]
4. “It’s normal to be angry when you can’t work any longer.” [0%]
Omitted
Correct answer
2
Answered correctly
77% Time: 4 seconds
Updated: 05/07/2017
Explanation:

The client with chronic illness who is unable to work may experience depression, grief, loss, a feeling of inadequacy, or a loss of meaning and purpose in life. It can take time to adjust and accept the new roles, and this stress can increase a person’s vulnerability to ongoing health problems.

This client has gone from being the main source of income, or “breadwinner,” to being someone who is unable to support the family. The client is now dependent on the spouse for financial stability and this is causing a strain. This type of role change can be particularly difficult for men who are used to providing for their families and for anyone who is well-established in a career.

The nurse has noticed a change in the client’s behavior but has not assessed the client to determine the factors contributing to this change. Assessment is needed before interventions can be planned. An open-ended reflective statement and nonverbal communication expressing acceptance and willingness to listen in the setting of a trusting relationship are appropriate to begin this assessment.

(Option 1) This response ignores the client’s feelings and closes off an opportunity to assess the client’s emotional state and the role change brought on by illness and the spouse’s new job.

(Option 3) The source of the client’s behavior change is not apparent at this point, so further assessment is needed. It is premature to intervene by recommending a support group.

(Option 4) The nurse is assuming that the client is angry about inability to work, but the client has not said this. Further assessment is needed to understand the client’s emotions and their source.

Educational objective:
Chronic illness can result in role changes that influence the client’s self-concept. The nurse can positively influence self-concept by empathizing, communicating acceptance, and assessing the client’s feelings and perceptions on the issue.

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube. The client is receiving a hypertonic formula. What is the best nursing action?

1. Dilute the formula with water [5%]
2. Discontinue the tube feeding [10%]
3. Send a stool sample to the lab for culture and sensitivity [20%]
4. Slow the rate of administration of the feeding [63%]
Omitted
Correct answer
4
Answered correctly
63% Time: 10 seconds
Updated: 04/26/2017
Explanation:

Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their higher osmolality, hypertonic formulas sometimes cause nausea, vomiting, or diarrhea, especially during the initiation of total enteral nutrition. The gastrointestinal tract will pull fluid from the surrounding intra- and extravascular compartments to dilute the formula, making it similar to body fluid osmolality. This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, nausea, and vomiting. Slowing down the rate of administration of total enteral nutrition will usually alleviate these problems. The feeding can gradually progress to the established goal rate.

(Option 1) Diluting enteral formulas is not necessary. This practice may increase the risk of intolerance secondary to microbial contamination. A diluted formula supports microbial growth better than a full-strength formula. Diluting total enteral nutrition may also be detrimental because the client may receive inadequate nutrition; it will take a larger volume of fluid to provide the same number of calories and protein.

(Option 2) It is not necessary to discontinue the feeding; the client needs nutrition support.

(Option 3) Sending a stool sample for culture and sensitivity would be appropriate if bacterial contamination or a bacterial infection is suspected as the cause of the diarrhea. It is not the best nursing action in this situation.

Educational objective:
Complications of total enteral nutrition at the start of treatment are nausea, vomiting, and diarrhea. These signs and symptoms can usually be alleviated by slowing down the rate of administration and then gradually increasing the rate to the established goal.

A client with renal failure recently started dialysis and is unable to work due to ongoing health problems. The client’s spouse has started working for a cleaning service to replace the lost income. The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis. Which is the most appropriate first response by the nurse?

1. “How is your spouse’s new job going?” [3%]
2. “I notice that you seem frustrated.” [77%]
3. “It can take time to adjust to dialysis. We have a support group that can be helpful.” [17%]
4. “It’s normal to be angry when you can’t work any longer.” [0%]
Omitted
Correct answer
2
Answered correctly
77% Time: 4 seconds
Updated: 05/07/2017
Explanation:

The client with chronic illness who is unable to work may experience depression, grief, loss, a feeling of inadequacy, or a loss of meaning and purpose in life. It can take time to adjust and accept the new roles, and this stress can increase a person’s vulnerability to ongoing health problems.

This client has gone from being the main source of income, or “breadwinner,” to being someone who is unable to support the family. The client is now dependent on the spouse for financial stability and this is causing a strain. This type of role change can be particularly difficult for men who are used to providing for their families and for anyone who is well-established in a career.

The nurse has noticed a change in the client’s behavior but has not assessed the client to determine the factors contributing to this change. Assessment is needed before interventions can be planned. An open-ended reflective statement and nonverbal communication expressing acceptance and willingness to listen in the setting of a trusting relationship are appropriate to begin this assessment.

(Option 1) This response ignores the client’s feelings and closes off an opportunity to assess the client’s emotional state and the role change brought on by illness and the spouse’s new job.

(Option 3) The source of the client’s behavior change is not apparent at this point, so further assessment is needed. It is premature to intervene by recommending a support group.

(Option 4) The nurse is assuming that the client is angry about inability to work, but the client has not said this. Further assessment is needed to understand the client’s emotions and their source.

Educational objective:
Chronic illness can result in role changes that influence the client’s self-concept. The nurse can positively influence self-concept by empathizing, communicating acceptance, and assessing the client’s feelings and perceptions on the issue.

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse?

1. Arrange for the client’s service dog to come to the health care facility as soon as possible [3%]
2. Describe the environment in detail so the client can ambulate safely with a cane [12%]
3. Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand [17%]
4. Walk slightly ahead of the client with the client’s hand resting on the nurse’s elbow [66%]
Omitted
Correct answer
4
Answered correctly
66% Time: 3 seconds
Updated: 05/23/2017
Explanation:

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.

A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which interventions would the nurse include in the plan of care to prevent wound dehiscence? Select all that apply.

1. Administer docusate orally, daily
2. Administer ondansetron IV PRN for nausea
3. Apply an abdominal binder
4. Implement caloric restriction to promote weight loss
5. Monitor blood sugar to maintain tight glucose control
Omitted
Correct answer
1,2,3,5
Answered correctly
19% Time: 2 seconds
Updated: 05/27/2017
Explanation:

The edges of a surgical wound may fail to approximate or they may separate due to a partial or total separation of the skin and tissue layers. This condition is known as dehiscence and is a complication of wound healing. Factors associated with dehiscence include conditions that impair circulation, tissue oxygenation, and wound healing (eg, diabetes, smoking, obesity, advanced age, malnutrition, infection, steroid use) and cause mechanical stress on the wound (eg, straining to cough, vomit, defecate). Interventions to prevent surgical wound dehiscence include:

Administering stool softeners such as docusate (Colace) to prevent straining during defecation and alleviate constipation caused by postoperative immobility and opioid pain medications (Option 1)
Administering antiemetics such as ondansetron (Zofran) as needed to prevent straining that can occur with vomiting (Option 2)
Applying an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing and moving (Option 3)
Monitoring blood sugar to maintain tight glycemic control (<140 mg/dL [7.8 mmol/L] fasting glucose, <180 mg/dL [10 mmol/L] random glucose) to help prevent infection and promote wound healing (Option 5)
Splinting the abdomen by holding a pillow or folded blanket against the abdomen to support the wound when coughing and moving
(Option 4) Nutritional therapy is critical to support normal wound healing. The wound healing process depends on adequate intake of calories and protein. Although this client is obese and should be educated on measures to promote weight loss, this is not the priority in the immediate postoperative period and would delay wound healing.

Educational objective:
Interventions to prevent wound dehiscence include use of stool softeners and antiemetics, application of an abdominal binder, and tight blood glucose control.

A client of the Jewish Orthodox faith with a history of type 2 diabetes mellitus is hospitalized, recovering from a total right hip arthroplasty. At noon, the client consumed the following meal: lean roast beef sandwich with lettuce and low-fat mayonnaise, carrot and celery sticks, and fresh fruit. What would be the most appropriate 2:00 PM snack for this client?

1. Angel food cake with fresh strawberries [8%]
2. Crackers and low-fat cheese [26%]
3. Nonfat plain yogurt [26%]
4. Pita chips and hummus [38%]
Omitted
Correct answer
4
Answered correctly
38% Time: 2 seconds
Updated: 04/26/2017
Explanation:

Individuals who practice Orthodox Judaism follow Kosher laws. These regulations are strict regarding the use of certain animal products (eg, no pork, shellfish, fish without scales) and the separation of meat/poultry from dairy. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product can be consumed. Certain foods, including fresh fruits and vegetables, grains, tea, and coffee, are considered neutral and can be consumed at any time. Pita chips and hummus are non-dairy foods and would be an appropriate snack. This choice also provides a combination of carbohydrates and protein, which will help in regulating blood glucose.

(Option 1) This choice would be allowable under Kosher rules; however, it is not the best choice for a client with diabetes due to the high carbohydrate content.

(Option 2) Low-fat cheese is a dairy product and cannot be consumed within 3-6 hours of a meat/poultry meal.

(Option 3) Yogurt is a dairy food and would not be an appropriate choice for a 2:00 PM snack.

Educational objective:
Clients of the Orthodox Jewish faith follow Kosher rules. These include no pork, shellfish, or fish without scales. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product can be consumed.

A client’s wife is panic-stricken at the thought of withdrawing all life support from her husband, who is dying from end-stage chronic obstructive pulmonary disease and sepsis. She asks the nurse what he will experience when mechanical ventilation is stopped. Which statement made by the nurse is most appropriate at this time?

1. “The healthcare provider will prescribe a continuous intravenous infusion of morphine to make him more comfortable.” [65%]
2. “To maintain blood flow to his heart and lungs, we will continue norepinephrine, the vasopressor, but discontinue all other medications.” [2%]
3. “To prevent aspiration, we will discontinue his feeding tube and begin total parenteral nutrition to meet his nutritional needs.” [2%]
4. “We will continue basic care, such as monitoring his vital signs, giving nutrition, and monitoring laboratory tests.” [29%]
Omitted
Correct answer
1
Answered correctly
65% Time: 2 seconds
Updated: 04/26/2017
Explanation:

The nursing goals in end-of-life care are to comfort and support the client and family when death is imminent. Morphine is commonly used to manage the dyspnea, tachycardia, and restlessness associated with withdrawing mechanical ventilator support. Intravenous benzodiazepines, (eg, midazolam, lorazepam) may be administered for additional comfort.

(Options 2 and 3) When a client is taken off life support, vasopressors, antibiotics, blood, hemodialysis, and nutritional support are commonly withheld.

(Option 4) Vital signs, laboratory testing, and nutritional support are detrimental to client comfort and are usually discontinued after the decision has been made to withdraw life support.

Educational objective:
When withdrawing life support, the major goal is client comfort. The primary nursing responsibility is to assess and intervene appropriately for symptoms of pain and discomfort.

A client with multiple co-morbidities, including chronic obstructive pulmonary disease, diabetes, and chronic kidney disease, has just been told by the health care provider of the need to start dialysis. The client is in tears and says to the nurse, “I don’t know what I’m going to do; everything was so overwhelming before, and now this.” Which is the best response by the nurse?

1. “But you need the dialysis to stay alive.” [0%]
2. “I hope that a kidney donor will be found for you very soon.” [0%]
3. “It won’t be so bad; you might even feel better with dialysis.” [0%]
4. “Tell me more about what has been overwhelming for you.” [99%]
Omitted
Correct answer
4
Answered correctly
99% Time: 2 seconds
Updated: 05/06/2017
Explanation:

It is not unusual for clients to feel overwhelmed when managing one or more chronic illnesses. Day-to-day self management includes engaging in activities that maintain and promote physical health, adhering to prescribed medications and treatments, keeping multiple health care appointments, making decisions about health care, and coping with the impact of the illness on physical and social functioning.

In this situation, the client felt overwhelmed even before receiving the news about the deteriorating kidney disease requiring dialysis. To help the client plan strategies for self-care and coping with health conditions, it is important for the nurse to identify past barriers to self care and assess aspects of the client’s health that were most difficult to manage. Exploring a topic or idea with such words as “Tell me more about…” or “Let’s discuss…” is a communication technique that will promote a therapeutic interaction with the client.

(Option 1) This may be a true statement; however, it does not explore the client’s feelings of being overwhelmed.

(Option 2) This does not explore the client’s feelings of being overwhelmed and does not facilitate a discussion of how the client might be able to manage illnesses in the future.

(Option 3) This is a non-therapeutic statement that dismisses the client’s sense of being overwhelmed.

Educational objective:
Clients with chronic diseases are often overwhelmed by the nature of the illnesses and the various day-to-day self management activities necessary to maintain and promote their physical health. Exploring a client’s feelings and assessing difficult aspects of self care will enable the nurse and client to identify more effective self-management strategies.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client’s family?

1. “He is critically ill and we are caring for his needs.” [46%]
2. “His heart has stopped and we are attempting to revive him.” [13%]
3. “I don’t know how he is doing but you need to come.” [1%]
4. “I will have the health care provider talk to you once you arrive.” [38%]
Omitted
Correct answer
1
Answered correctly
46% Time: 2 seconds
Updated: 06/02/2017
Explanation:

Beneficence is the ethical principle of doing good. It involves helping to meet the client’s (including the family) emotional needs through understanding. This can involve withholding information at times.

Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely.

(Option 2) This is a true statement but it is being given abruptly to the family without support or gradual adjustment. It might be so distressing that they cannot travel to the hospital safely.

(Option 3) This is not a true statement and violates the principle of veracity. It will do nothing to help the family and might even cause them alarm that a nurse there is not informed about what is going on with their child.

(Option 4) Although this is an option, it does nothing to deal with the situation and the family’s needs adequately. It also “passes the buck” to another provider, and even though this provider can speak to them, the nurse should deal with the family’s immediate needs at this point. Once they arrive, the health care provider is usually the one to tell family members about the client’s prognosis.

Educational objective:
The ethical principle of beneficence means doing good. It can involve not saying all known information immediately but delaying notification until appropriate support is in place.

A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker “force feed” the client. What is the priority nursing action?

1. Explain to the family that this is a normal physiological response to dying [21%]
2. Explore the family’s thoughts and concerns about the client’s refusal of food [55%]
3. Recommend a feeding tube [1%]
4. Tell the family that “force feeding” the client could cause the client to choke on the food [21%]
Omitted
Correct answer
2
Answered correctly
55% Time: 1 seconds
Updated: 12/17/2016
Explanation:

When a terminally ill person refuses food, family members often become upset and frustrated in their roles of nurturers and caregivers; they may feel personally rejected. Refusal of food is associated with “giving up” and is a reminder that their loved one is dying. It is not uncommon for family members to believe that a client would get stronger by eating instead of refusing food.

The registered nurse needs to explore family members’ concerns and fears and listen as they express their feelings. The nurse can help them identify other ways to express how they care. The nurse should also provide education about the effects of food and water during all stages of the illness.

(Option 1) Families and caregivers need to understand the effects of food and water in all stages of a terminal illness; however, it is more important to first explore the family’s feelings and concerns.

(Option 3) Although it is not unusual for a client to be admitted to hospice with a feeding tube already in place, tubes are generally not placed after a client begins receiving hospice services.

(Option 4) This is a true statement, but it is not the priority nursing action.

Educational objective:
It is very common for family members to become distressed when a terminally ill loved one refuses food. The nurse needs to explore their fears and concerns and help them identify other ways to express how they care.

The client screams at the nurse, “You are all incompetent here! I have been waiting for 2 hours!” How should the nurse respond initially?

1. “I know you are upset, but I will have to call security if you continue to scream.” [2%]
2. “I see that you are upset. Let’s focus on how I can help you.” [62%]
3. “I want you to know that the health care providers (HCPs) are all well-qualified professionals.” [0%]
4. “It is frustrating to wait so long, and I am sorry for the delay.” [34%]
Omitted
Correct answer
4
Answered correctly
34% Time: 10 seconds
Updated: 02/21/2017
Explanation:

Therapeutic communication is used to establish trust, encourage communication, and display respect for the client. Empathizing with the client’s feelings conveys concern and understanding on the part of the nurse and helps establish a therapeutic dialogue. It can be helpful to offer a “blameless apology,” in which the nurse apologizes for the problem (eg, long wait) without taking personal responsibility for causing it. This technique can be helpful for diffusing negative emotions as clients feel acknowledged for the “wrong” they believe they have endured (Option 4).

(Option 1) Security may be called if the client appears to be losing control or is a risk to self or others. However, initially calling security or using an authoritative approach may further escalate the situation and does not address the client’s concern. The nurse should initially try to diffuse the situation and the client’s anger.

(Option 2) Although sharing an observation is therapeutic, attempting to change the subject will only further infuriate the client. Clients want their feelings to be recognized and validated.

(Option 3) A defensive response may communicate that the client’s feelings are wrong or lack importance. In this example, the client knows that the HCPs are qualified; stating this information is defensive and ignores the client’s concern.

Educational objective:
When a client is angry and upset, therapeutic communication skills such as acknowledging the feeling, empathy, active listening, and offering a blameless apology may help deescalate the situation. The nurse should not initially ignore the client or use threats, authoritative rules, or aggressive behaviors.

Which emergency department clients cannot be allowed to sign out against medical advice (AMA)? Select all that apply.

1. Client who drank 1 bottle of vodka 2 hours ago
2. Client who hears voice commands to kill the employer
3. Client with ST elevation on electrocardiogram tracing
4. A pregnant 14-year-old client with vaginal spotting
5. Client who insists on being the embodiment of Jesus Christ
Omitted
Correct answer
1,2,5
Answered correctly
34% Time: 5 seconds
Updated: 12/22/2016
Explanation:

The client must be competent to sign out AMA. This includes not being impaired by drugs or alcohol. Adults can be incompetent due to unconsciousness, altered consciousness, mental illness, or chemical influence. The client who drank 1 bottle of vodka is intoxicated and the client who insists on being the embodiment of Jesus Christ is not in touch with reality. The client who hears voices has psychotic symptoms and is potentially homicidal. Clients cannot be allowed to leave AMA if they are a danger to themselves or others.

If a competent adult leaves AMA, documentation must include discussion about the risks of the client’s decision and the client’s understanding of these risks (“informed refusal”). Reasonable steps should be taken to obtain the client’s signature. However clients cannot be held against their will for refusing to sign. This process should be witnessed and documented.

(Option 3) Clients have right to sign out AMA even if it is not within their best health interests to do so. The clients leaving AMA can and should have normal discharge instructions and the knowledge that they can return at any time.

(Option 4) A underage client can be considered an adult (an emancipated minor) for consent purposes without parental involvement. Common criteria for an emancipated minor include marriage, membership in the armed forces, living apart from one’s parents, financial independence, pregnancy/parenthood, or a court decision.

Educational objective:
For a client to sign out AMA, the client must be competent and cannot be impaired by drugs or alcohol. Clients cannot be a danger to themselves (suicidal) or others (homicidal). An emancipated minor or a health care provider-determined “mature minor” can give consent.

A nurse is documenting notes in the client’s electronic record after making rounds on assigned clients. Which entry is an appropriate documentation?

1. Client appears to be sleeping. Eyes closed. [4%]
2. Client reports, “I’m in pain.” Medication provided. [9%]
3. Inspiratory wheezes heard in bilateral lower lung fields [82%]
4. Voided x 1 [3%]
Omitted
Correct answer
3
Answered correctly
82% Time: 1 seconds
Updated: 03/04/2017
Explanation:

The electronic record is a legal document and should contain factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. “Inspiratory wheezes heard in bilateral lung fields” best fits these criteria. The nurse should avoid vague terms such as “appears,” “seems,” and “normal.” These words suggest that the nurse is stating an opinion and do not accurately communicate facts or provide information on behaviors exhibited by the client. The nurse should provide exact measurements, establish accuracy, and not provide opinions or assumptions.

(Option 1) The nurse should not use the word “appears” as it is too vague. “Eyes closed” is a factual observation. A more accurate entry would be, “Client lying in bed with eyes closed. Respirations even and unlabored.”

(Option 2) It is a good practice to document client quotes. However, in this case, the nurse should have elicited more information from the client, such as a pain scale, and then documented the analgesic the client was given.

(Option 4) This documentation would be more descriptive if it listed how much urine, its color and clarity, and if an odor was present.

Educational objective:
Nursing documentation should be factual, descriptive, and contain objective information that the nurse sees, hears, feels, or smells. It must include direct observation and measurement.

Which client is at the greatest risk for development of hospital-acquired pressure ulcers?

1. 25-year-old client with quadriplegia, urosepsis, temperature of 101 F (38.3 C), and white blood cell count of 18,000/mm3 (18.0 x 109/L) [46%]
2. 50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg [26%]
3. 80-year-old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L) [23%]
4. 87-year-old client 2 days post open cholecystectomy [3%]
Omitted
Correct answer
2
Answered correctly
26% Time: 1 seconds
Updated: 03/19/2017
Explanation:

Pressure ulcers are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk.

This client (Option 2) has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 g/dL (<160 mg/L), indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving norepinephrine (Levophed), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and the ability to provide adequate nutrition to the cells. (Option 1) This client has 4 risk factors: a deficit in independent mobility and activity, spinal cord injury with quadriplegia, decreased sensation, and fever and infection. (Option 3) This client has 3 risk factors: advanced age, surgery, and dementia. Hemoglobin is within the normal range. (Option 4) This client has 2 risk factors: advanced age and surgery. Surgery can be associated with deep-tissue injury ulcers. Positioning and immobility during the surgical procedures (>2½ hours) and receiving anesthetic and vasoactive drugs (to treat hypotension) present a special risk for the development of deep-tissue injury in postoperative clients.

Educational objective:
Although pressure ulcers can develop in any client with limited mobility and activity, those at most risk include older adults; those with quadriplegia; the critically ill; and those with fracture of a long bone or hip, incontinence, nutritional deficits, chronic illness, renal failure, anemia, oxygenation and circulation problems, infection, or fever.

The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out “Help me!” What action should the nurse take first?

1. Administer midazolam per protocol [20%]
2. Check the client’s pulse oximeter [51%]
3. Give more morphine per protocol [7%]
4. Open the airway with head tilt-chin lift [19%]
Omitted
Correct answer
2
Answered correctly
51% Time: 1 seconds
Updated: 01/16/2017
Explanation:

When there is new, sudden onset of restlessness/agitation, the nurse should first think about oxygenation (or blood glucose). The desired level of sedation is level 3 on the Ramsay Sedation Scale, during which the client is drowsy but responds to a voice command.

(Option 1) Adequate oxygenation should be established first before administering additional benzodiazepine for sedation.

(Option 3) Oxygenation should be assessed before administering additional narcotics for pain. Change in the level of consciousness (restlessness/agitation or lethargy/sedation) can be an indication of excess medication and should be assessed before administering additional drugs.

(Option 4) If the client is speaking, the airway is open. Opening the airway would be an initial response if there is new onset of snoring respirations (the tongue falling back due to relaxation and blocking the airway). Normal respirations should be effortless and quiet.

Educational objective:
When new-onset restlessness occurs during procedural sedation, oxygenation should be considered first before administering additional medications. If the client is snoring, opening the airway should be considered.

Which positions are correct when caring for clients undergoing therapeutic procedures? Select all that apply.

1. High-Fowler’s for a paracentesis in cirrhosis
2. Left side after liver biopsy in hepatitis
3. Semi-Fowler’s after a cardiac catheterization
4. Sims for soap-suds enema administration
5. Supine position after lumbar puncture
Omitted
Correct answer
1,4,5
Answered correctly
18% Time: 7 seconds
Updated: 05/27/2017
Explanation:

A therapeutic/comfort paracentesis in cirrhosis requires the client to be upright so that the fluid is in the lower abdomen where the trocar will be placed for draining it (Option 1).

When in the Sims, or left lateral recumbent, position, the client is lying on the left side with the left leg straight and the right hip and knee flexed. It is a common position for enema administration (Option 4).

Before a lumbar puncture (spinal tap), the client is placed in the fetal position or bent over a table to separate the vertebrae. Afterwards, the client is placed flat in bed in the prone or supine position for 4 to 8 hours. This will minimize the risk for a “spinal” headache from the loss of cerebrospinal fluid (Option 5).

(Option 2) Before a liver biopsy, the client is placed supine with the right arm above the head. The client is instructed to exhale fully and to not breathe when the needle is inserted. The risk after a liver biopsy is for internal bleeding as liver pathology affects coagulation factors. After the biopsy, the client is placed supine on the right side for 12-14 hours so that the heavy liver falls down on itself and provides internal direct pressure to minimize bleeding.

(Option 3) The client is laid flat for hours after a percutaneous coronary intervention (PCI) to prevent pressure at the insertion site of a major vessel so that there is no hemorrhage or hematoma.

Educational objective:
Use Sims position for enema administration, sitting upright before a paracentesis, and supine after a lumbar puncture. Place a client on right side after a liver biopsy, and keep the client supine after a PCI.

A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate?

1. “Please try not to worry, you have an excellent surgeon.” [0%]
2. “Tell me about how you feel about your surgery.” [93%]
3. “Why are you considering refusing the surgery?” [2%]
4. “You have the right to make your own decisions and can refuse the surgery.” [3%]
Omitted
Correct answer
2
Answered correctly
93% Time: 1 seconds
Updated: 12/15/2016
Explanation:

“Tell me about how you feel about your surgery,” is the most appropriate statement to encourage the client to express the source of anxiety. Using an open-ended question enables the client to take control of the conversation and direct it to concerns about the surgery. The nurse can then address the specific concerns identified and provide individualized explanations and support.

(Option 1) This statement is nontherapeutic as giving false reassurance minimizes the client’s concerns and diminishes trust between the nurse and client.

(Option 3) This statement is nontherapeutic and intimidating. Asking “why” and “how” is an ineffective method of gathering information.

(Option 4) A client may share a decision with the nurse in an effort to discuss feelings. This statement is nontherapeutic because giving approval of the client’s decision does not encourage the client to express concerns about the surgery.

Educational objective:
Therapeutic conversation techniques (eg, active listening, using open-ended questions) encourage the client to express feelings and ideas and establish an open, trusting relationship with the nurse. Nontherapeutic communication techniques (eg, expressing approval or disapproval, giving advice, asking why) discourage expression of feelings and ideas and close down the conversation between the nurse and client.

A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate?

1. “Please try not to worry, you have an excellent surgeon.” [0%]
2. “Tell me about how you feel about your surgery.” [93%]
3. “Why are you considering refusing the surgery?” [2%]
4. “You have the right to make your own decisions and can refuse the surgery.” [3%]
Omitted
Correct answer
2
Answered correctly
93% Time: 1 seconds
Updated: 12/15/2016
Explanation:

“Tell me about how you feel about your surgery,” is the most appropriate statement to encourage the client to express the source of anxiety. Using an open-ended question enables the client to take control of the conversation and direct it to concerns about the surgery. The nurse can then address the specific concerns identified and provide individualized explanations and support.

(Option 1) This statement is nontherapeutic as giving false reassurance minimizes the client’s concerns and diminishes trust between the nurse and client.

(Option 3) This statement is nontherapeutic and intimidating. Asking “why” and “how” is an ineffective method of gathering information.

(Option 4) A client may share a decision with the nurse in an effort to discuss feelings. This statement is nontherapeutic because giving approval of the client’s decision does not encourage the client to express concerns about the surgery.

Educational objective:
Therapeutic conversation techniques (eg, active listening, using open-ended questions) encourage the client to express feelings and ideas and establish an open, trusting relationship with the nurse. Nontherapeutic communication techniques (eg, expressing approval or disapproval, giving advice, asking why) discourage expression of feelings and ideas and close down the conversation between the nurse and client.

A teenage client with sickle cell disease is admitted with a diagnosis of crisis. The client’s current prescription is morphine 2 mg intravenous push every 4 hours prn. The client appears comfortable while watching television and tells the nurse “I have severe intolerable pain,” and rates it a “10.” What action should the nurse take?

1. Call the client’s health care provider (HCP) to obtain a ibuprofen prescription for pain relief [13%]
2. Call the HCP for patient-control analgesia (PCA) at a higher dose of the same drug [43%]
3. Contact the HCP who issued the prescription to switch to meperidine [7%]
4. Realize the client is exhibiting signs of addictive behavior and needs an appropriate consult [35%]
Omitted
Correct answer
2
Answered correctly
43% Time: 1 seconds
Updated: 04/30/2017
Explanation:

Clients with sickle cell crisis often have excruciating pain related to the occlusion from the sickling and resulting ischemia. These individuals usually need large doses of narcotics as prior treatment has led to drug tolerance; they may also metabolize the drugs differently. Using only external cues to judge a client’s pain is invalid as these clients have often learned how to distract themselves from focusing on the pain. Use of continuous PCA is recommended for relief rather than prn administration.

(Option 1) Nonsteroidal anti-inflammatory drugs (eg, ibuprofen) are not very effective in treating the pain of sickle cell crisis.

(Option 3) Meperidine (Demerol) is contraindicated for a sickle cell crisis as large frequent doses can result in normeperidine (toxic metabolite) accumulation. Symptoms start with tremors and can result in a seizure.

(Option 4) Clients with sickle cell crisis are often undertreated due to the suspicion of drug abuse. However, studies have shown that the risk of abuse is small (0%-9%) and this range is similar to substance abuse risk in the general population. Therefore, the client’s self-report is valid and appropriate treatment in the acute setting is warranted.

Educational objective:
Clients with sickle cell crisis often have excruciating pain and need large doses of narcotics. The most effective method is PCA of morphine or hydromorphone (Dilaudid).

A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? Select all that apply.

1. Report any itching, tingling, or numbness around your incisions
2. Report any redness, swelling, warmth, or drainage from your incisions
3. Soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion
4. Wash incisions daily with soap and water in the shower and gently pat them dry
5. Wear an elastic compression hose on your legs and elevate them while sitting
Omitted
Correct answer
2,4,5
Answered correctly
30% Time: 1 seconds
Updated: 01/01/2017
Explanation:

Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these instructions are as follows:

Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4).
Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1).
Tub baths should be avoided due to risk of introducing infection (Option 3).
Do not apply powders or lotions on incisions as these trap the bacteria at the incision (Option 3).
Report any redness, swelling, and increase in drainage or if the incision has opened (Option 2).
Wear a supportive elastic hose on the legs. Elevate legs when sitting to decrease swelling (Option 5).
Educational objective:
The nurse should instruct the client with chest and leg incisions from CABG to wash them daily with soap and water in the shower. In addition, the client must be instructed not to apply any powders or lotions to the incisions, to report any redness, swelling or increase in drainage, and to wear an elastic compression hose on the legs.

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?

1. Administer an inhaled bronchodilator [10%]
2. Check marked insertion depth of the tube [70%]
3. Request a prescription for a diuretic [10%]
4. Start the client on incentive spirometry [9%]
Omitted
Correct answer
2
Answered correctly
70% Time: 1 seconds
Updated: 02/05/2017
Explanation:

A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings.

If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg, crackles, wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure insertion depth, obtain x-ray, assess aspirate pH) (Option 2). Some facilities use capnography to determine placement; if a sensor detects exhaled CO2 from the tube, it is in the client’s airway and must be removed immediately.

(Option 1) An inhaled bronchodilator may be prescribed to treat aspiration pneumonia, but the priority is to stop the feeding and check tube placement to prevent additional aspiration.

(Option 3) Crackles may be heard with fluid overload, aspiration, or pneumonia. A diuretic would be appropriate if a client is experiencing pulmonary edema from fluid overload. If a client receiving enteral feedings develops signs of aspiration, the nurse should initially hold feedings and assess tube placement.

(Option 4) Incentive spirometry promotes expansion of the lungs and resolves atelectasis; however, the priority for this client is assessing for and preventing aspiration.

Educational objective:
Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped immediately and tube placement checked if the client develops signs of aspiration.

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client’s family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply.

1. Palliative care focuses on quality of life and can be provided at any time
2. Palliative care is only possible with a terminal diagnosis of ≤6 months
3. Palliative care is provided by a multidisciplinary team
4. Palliative care is another term for hospice care
5. Palliative care provides relief from symptoms associated with chronic illnesses
Omitted
Correct answer
1,3,5
Answered correctly
38% Time: 1 seconds
Updated: 05/03/2017
Explanation:

Palliative care is a model of treatment that involves managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life for clients and families facing serious illnesses. An interdisciplinary palliative assessment team often includes nursing staff, chaplains, social workers, therapists, and nutritionists who work together on a comprehensive treatment plan.

This model of care has been found to decrease unnecessary medical interventions and reduce depressive symptoms. Families of clients who receive palliative care interventions also experience lower rates of prolonged grief and post-traumatic stress disorder.

(Option 2) Palliative care is not limited to the last 6 months of life and can begin immediately after diagnosis of terminal disease (eg, advanced heart failure or cancer).

(Option 4) The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment.

Educational objective:
Palliative care focuses on quality of life and symptom management (eg, pain, dyspnea, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, depression). It can be given concurrently with life-prolonging treatment in the setting of terminal disease. Palliative care is provided by a multidisciplinary care team with a focus on the clients and their families.

The emergency department nurse would administer a prescribed isotonic crystalloid solution to which client?

1. 25-year-old with a closed-head injury and signs of increasing intracranial pressure (ICP) [13%]
2. 45-year-old with acute gastroenteritis and dehydration [61%]
3. 68-year-old with chronic renal failure and hypertensive crisis [8%]
4. 60-year-old with seizures and serum sodium of 112 mEq/L [17%]
Omitted
Correct answer
2
Answered correctly
61% Time: 1 seconds
Updated: 04/26/2017
Explanation:

Acute gastroenteritis is associated with nausea, vomiting, diarrhea, and dehydration. An isotonic crystalloid intravenous (IV) solution (eg, 0.9% normal saline, lactated Ringer’s) has the same tonicity as plasma and when infused remains in the vascular compartment, quickly increasing circulating volume. It is appropriate to correct the extracellular fluid volume deficit (dehydration) in this client.

(Option 1) A hypertonic, rather than isotonic, solution would be infused in clients with ICP. Increasing circulating volume would only further increase ICP.

(Option 3) Isotonic solutions can exacerbate fluid overload in chronic renal failure and increase blood pressure.

(Option 4) Clients with severe hyponatremia and neurologic manifestations need rapid correction of hyponatremia with hypertonic saline (3% saline).

Educational objective:
Depending on the type/tonicity of intravenous (IV) solution infused, fluids can remain in the vascular compartment or can shift from the extracellular to intracellular compartments, and vice versa. The nurse must be able to assess which type of IV fluid is appropriate in relation to a client’s diagnosis and condition.

.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action?

1. Ask the client to explain the bruises on the torso [13%]
2. Assess the client’s general hygiene and nutritional status [51%]
3. Report the bruises to the client’s health care provider (HCP) [30%]
4. Talk to the client’s child about the injuries [4%]
Omitted
Correct answer
2
Answered correctly
51% Time: 1 seconds
Updated: 01/16/2017
Explanation:

The client’s injuries are inconsistent with the explanation given in that bumping into furniture could explain bruising on the extremities but does not account for the bruises on the torso (trunk). In addition, the bruises are in various stages of healing, which suggests that the injuries occurred over multiple occasions.

The nurse’s findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse’s suspicions and to determine the extent of the abuse. The nurse will assess the client for general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements by the client suggesting neglect. During the assessment and client interview, the nurse will need to maintain a neutral, nonjudgmental attitude to facilitate a trusting nurse-client relationship.

(Option 1) Asking the client to explain the bruises on the torso is a “why” type of question, places the client on the defensive, and does not facilitate a trusting nurse-client relationship.

(Option 3) Reporting the bruises to the HCP is an appropriate nursing action but is not the priority. The nurse needs additional information about the client’s status and situation.

(Option 4) Talking to the client’s child and/or other family members may be an appropriate nursing action. However, the nurse needs more information about the client’s status to determine needed interventions. Further assessment for indications of elder abuse is the priority.

Educational objective:
When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client’s general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, “I’m so worried that my future spouse is going to call off our engagement.” What is the best response by the nurse?

1. “Are you concerned about how the surgery will affect your sexuality?” [25%]
2. “If you are concerned about infertility, you could always bank your sperm.” [3%]
3. “The cancer is at an early stage. You are going to be fine.” [0%]
4. “What have you and your future spouse discussed about your condition?” [71%]
Omitted
Correct answer
4
Answered correctly
71% Time: 5 seconds
Updated: 01/14/2017
Explanation:

A diagnosis of testicular cancer is very often a source of anxiety for a client and can cause concern about sexual performance and fertility. How a client’s sexuality is affected by this diagnosis depends on how advanced the cancer is and the course of prescribed treatment. Decisions about sperm banking and/or whether the client wants to procreate in the future are best made prior to surgery, radiation, and/or chemotherapy. The client and significant others need to be given counseling and the opportunity to discuss the potential effects of treatment and the options for preserving sperm.

In this scenario, the client’s stated concern about the future with the partner may be the way of voicing concern about how the surgery will affect sexuality. In order to determine what counseling or information this client needs, it is most important for the nurse to first assess the client’s knowledge of the condition and what the client and the future spouse have already discussed. In addition, by using the therapeutic communication techniques of presenting a general lead and exploration, the nurse can facilitate the conversation and the nurse-client relationship.

(Option 1) This is not the best response as it requires a short, single answer from the client and does not provide the opportunity for exploration or elaboration. “Yes” or “no” questions are useful and necessary in some client-nurse interactions. However, generally they are considered to be nontherapeutic as they are not conversation enhancers.

(Option 2) Banking sperm is an option for clients with testicular cancer. However, it is more important for the nurse to first explore the client’s concerns and knowledge about the condition.

(Option 3) This statement by the nurse may be giving false reassurance to the client. In addition, it blocks further discussion or exploration of the client’s knowledge about the condition and related concerns.

Educational objective:
A diagnosis of cancer is a cause of anxiety for any client due to concerns about prognosis. A client with a diagnosis of testicular cancer will have additional concerns about sexual performance and fertility. Using therapeutic communication techniques, such as a broad opening and a general lead and exploration, will facilitate the nurse-client relationship and a meaningful discussion about the condition and concerns.

Exhibit

The nurse reviews the laboratory results for an adult male client admitted with septic shock. Which value requires the most immediate action? Click on the exhibit button for additional information.

1. Blood urea nitrogen [17%]
2. Creatinine [2%]
3. Hematocrit [1%]
4. Potassium [78%]
Omitted
Correct answer
4
Answered correctly
78% Time: 1 seconds
Updated: 05/27/2017
Explanation:

Serum laboratory test Normal values (adult male)
Blood urea nitrogen 6-20 mg/dL (2.1-7.1 mmol/L)
Creatinine 0.6-1.3 mg/dL (53-115 µmol/L)
Hematocrit 39%-50% (0.39-0.50)
Hemoglobin 13.2-17.3 g/dL (132-173 g/L)
Potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L)
Serum potassium may increase in clients in progressive shock as a result of metabolic acidosis, which can cause a shift of potassium from the intracellular to extracellular compartments. Because the most significant manifestation of hyperkalemia is a disturbance in cardiac conduction and the development of cardiac dysrhythmias, correction of the imbalance requires immediate action.

(Option 1) Although a blood urea nitrogen level of 44.4 mg/dL (15.9 mmol/L) is elevated, it does not require immediate action. It can increase in clients in a shock state as the result of decreased perfusion to the kidneys (pre-renal azotemia) or extra-renal factors such as dehydration, fever, or gastrointestinal bleed.

(Option 2) Normal creatinine is 0.6-1.3 mg/dL (53-115 µmol/L).

(Option 3) Normal hematocrit level is 39%-50% (0.39-0.50).

Educational objective:
The most significant manifestations of hyperkalemia are disturbances in cardiac conduction and the development of potentially life-threatening cardiac dysrhythmias.

Before examining the infant of a Mexican American mother, the nurse compliments the child’s outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take?

1. Ask the mother’s permission to touch the child’s hand [44%]
2. Interview the mother about the reason for bringing the child to the clinic [38%]
3. Reassure the mother that there is no reason for distress [11%]
4. Suggest postponing the examination until the mother calms down [4%]
Omitted
Correct answer
1
Answered correctly
44% Time: 1 seconds
Updated: 02/14/2017
Explanation:

In Latin American culture, an illness called “mal de ojo” (“evil eye”) is believed to be caused when a stranger or someone perceived as powerful admires or compliments a child. The “illness,” or “curse,” is usually manifested by vomiting, fever, and crying. The mal de ojo curse can be broken if the admirer touches the child while speaking to the child or immediately afterward (Option 1). Mexican American mothers may worry when strangers compliment their babies without touching them. To protect against mal de ojo, the child may wear charms or beaded bracelets.

If a child is believed to be afflicted with mal de ojo, the parents may consult a traditional healer, or curandero, who may perform rituals meant to cure the child of the curse.

(Option 2) Asking the mother about the reason for bringing the child to the clinic will not relieve the mother’s distress.

(Option 3) This response is nontherapeutic and dismissive, and indicates the nurse’s lack of cultural awareness.

(Option 4) Postponing the examination does not address the cause of the mother’s distress.

Educational objective:
Many Latin Americans believe in “mal de ojo,” or “evil eye,” a cultural belief in an illness thought to be manifested in children by vomiting, fever, and crying. It is believed to be caused when a stranger admires a child without touching the child at the same time or immediately afterward.

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse?

1. “Have you shared your concerns with your health care provider (HCP)?” [13%]
2. “If I were you, I would be more worried about whether the melanoma has spread.” [0%]
3. “Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications.” [79%]
4. “There is special make-up you can use to hide any facial scars left from the surgery.” [6%]
Omitted
Correct answer
3
Answered correctly
79% Time: 1 seconds
Updated: 12/16/2016
Explanation:

Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and issues related to altered body image. The best response by the nurse uses 2 therapeutic approaches aimed at reducing the client’s concerns and anxiety:

The client is provided with factual information about facial surgery and the healing process.

The client is given assurance and support that something can be done to minimize the complications of wound healing. This will provide the client with a plan of action and a sense of control over the condition and post-surgical course. It is impossible to predict the lasting effect of the surgery on the client’s facial appearance; however, teaching on managing wound care will help lessen the client’s anxiety.

(Option 1) This is not the best or priority response. Although the HCP will be able to give the client more information and details about the surgery and potential outcomes, the response suggests that the nurse has little or no role in providing information or teaching the client about the upcoming procedure. The response is also a “yes” or “no” question; closed-ended questions tend to minimize nurse-client interactions.

(Option 2) This is a non-therapeutic response; it gives advice to the client, suggests that the nurse “knows better,” and minimizes the client’s concerns. It also introduces a more serious issue about the diagnosis.

(Option 4) This is a non-therapeutic response. Although it is true that there are methods to conceal scars and other skin discolorations, the response is dismissive and does not address the client’s concerns.

Educational objective:
Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and altered body image. Providing information about the surgical procedure, healing process, and self-care activities, and giving support will lessen anxiety and give the client a sense of control.

An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents’ primary language is Vietnamese and their English proficiency is very limited. What is the best approach for the nurse to use when instructing the parents on how to care for the child at home?

1. Demonstrate the procedure using simple English phrases [13%]
2. Give the parents written instructions with picture illustrations [6%]
3. Tell the parents to have a friend or relative come in to translate [2%]
4. Use an interpreter via the telephone interpretation service [77%]
Omitted
Correct answer
4
Answered correctly
77% Time: 1 seconds
Updated: 04/15/2017
Explanation:

Effective teaching can be accomplished only with effective communication, which can be compromised by language barriers, cultural differences, and low health literacy. When an interpreter is necessary, using a translator who is skilled in medical terminology is the best approach to provide accurate information (Option 4). Hearing instructions and information in one’s primary language decreases the risk of adverse clinical consequences.

When a professional medical translator is unavailable, language lines, telephone systems, and remote video interpreting services can be used. Translation by family members and friends should only be used as a last resort and only with the permission of the client, especially in situations where sensitive information needs to be communicated (Option 3). Children should not be used as translators except in an emergency situation when there are no other options.

(Option 1) This client’s parents have very limited English language proficiency; this approach will not be effective in providing instructions about the child’s care at home.

(Option 2) Providing written materials without verbal teaching does not give the client (or the client’s legal guardian) the chance to ask questions, nor does it give the nurse the opportunity to assess the client’s understanding of the given information.

Educational objective:
When language is a barrier to effective communication and teaching, the nurse should use a trained medical interpreter for translation purposes.

A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond?

1. “Don’t worry. You’ll feel better in a few weeks.” [0%]
2. “How well are you sleeping at night?” [45%]
3. “These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again.” [46%]
4. “You may be experiencing depression. I’ll call the health care provider and see if we can get a prescription for an antidepressant.” [7%]
Omitted
Correct answer
3
Answered correctly
46% Time: 3 seconds
Updated: 02/05/2017
Explanation:

Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder (Option 3).

(Option 1) The client will most likely feel better in a few weeks, but this statement is not therapeutic and does not really provide any useful information.

(Option 2) This is good information for the nurse to have, but it does not directly relate to the client’s issues of forgetfulness and becoming teary often.

(Option 4) Two weeks postoperative is most likely too early for a diagnosis of depression. Depression can occur after a major illness or surgery, but antidepressants would be considered only for persistent symptoms.

Educational objective:
The nurse should teach the client that possible memory impairment and problems with concentration, language comprehension, social integration, and emotional lability are common following major surgery. Symptoms typically resolve after 4-6 weeks or when healing is complete. Persistent problems should be reported to the health care provider.

The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply.

1. Cervical cancer
2. Hypertension
3. Ischemic stroke
4. Osteoporosis
5. Skin melanoma
Omitted
Correct answer
1,2,3
Answered correctly
33% Time: 1 seconds
Updated: 12/05/2016
Explanation:

The incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women (Option 1).

African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among the women than men in this ethnic group. The mortality rate for hypertension among African American women is higher than that for white American women (Option 2).

African Americans have a higher incidence of ischemic stroke than whites or Hispanics. Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia (Option 3).

(Option 4) White and Asian women have a higher incidence of osteoporosis than African Americans, but the disease affects all ethnic groups.

(Option 5) Melanoma of the skin is more common in people who are of white ancestry, light-skinned, and over age 60 with frequent sun exposure. The incidence of melanoma is 10 times higher in white Americans than African Americans.

Educational objective:
African Americans have the highest incidence of hypertension in the world as well as increased incidence of stroke and cervical cancer. Whites have a high incidence of osteoporosis and skin cancer (melanoma).

An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been placed on a dysphagia diet. Which actions require intervention by the registered nurse? Select all that apply.

1. The UAP adds milk to mashed potatoes to make them thinner
2. The UAP encourages the client to occasionally turn the head to the left
3. The UAP helps the client sit in an upright position
4. The UAP places food on the strong side of the client’s mouth
5. The UAP puts a straw in a fruit smoothie to prevent spilling
Omitted
Correct answer
1,5
Answered correctly
41% Time: 1 seconds
Updated: 04/20/2017
Explanation:

Clients with dysphagia are at risk for aspiration and aspiration pneumonia. Dietary modifications and swallowing rehabilitation measures can reduce the risk of aspiration in clients who can tolerate oral feedings. Specific techniques include the following:

Modification of food consistency (pureed, mechanically altered, soft)
Thickened liquids
Having the client sit upright at a 90-degree angle (Option 3)
Placing food on the stronger side of the mouth to aid in bolus formation (Option 4)
Tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis
Some clients who have suffered a cerebrovascular accident (CVA) are also left with visual impairment such as hemianopsia; in this condition, a person sees only a portion of the visual field from each eye. A client with a right-sided CVA may have left-sided hemianopsia. Having the client turn the head during a meal will help the client see everything on the plate (Option 2).

(Option 1) Adding milk to mashed potatoes will alter the consistency; if the consistency is too thin, the client will be at increased risk of aspiration.

(Option 5) Using a straw for drinking liquids might cause increased swallowing difficulty and choking. Controlling liquid intake through a straw is more difficult than drinking straight from a cup or glass.

Educational objective:
Measures for reducing the risk of aspiration for clients with dysphagia include diet modification (pureed, mechanically altered, soft), thickened liquids, positioning the client in an upright position, placing food on the stronger side of the mouth, and flexing the chin slightly downward. A client with visual impairment should be reminded to turn the head from time to time while eating.

Block Time Remaining: 01:34:57
TIMEDTUTOR
Test Id: 80617473
QId: 31936 (921666)
35 of 71
A A A
The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation?1. Continue teaching the client and verify understanding by return demonstration [90%]
2. Discuss how important it is for the client to pay attention during the teaching [2%]
3. Maintain eye contact during the teaching by following the client’s movements [2%]
4. Provide written instructions and a private place for the client to learn independently [5%]
Omitted
Correct answer
1
Answered correctly
90% Time: 1 seconds
Updated: 12/11/2016
Explanation:

Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences (ie, verbal and nonverbal communication styles including the use of silence). The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration.

(Option 2) Lecturing the client about the importance of listening to the instructions for insulin self-injection would most likely be interpreted as degrading and disrespectful.

(Option 3) In the American Indian culture, it is disrespectful to maintain eye contact during a conversation.

(Option 4) A client learning the process of self-administration of insulin requires guidance and evaluation from the registered nurse before, during, and after the teaching session. The client should not be sent to a quiet place to learn the procedure independently.

Educational objective:
Individuals of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away during conversations in an attempt to prevent it. The nurse demonstrates culturally competent care by respecting and accepting this cultural communication pattern.
d.

Block Time Remaining: 01:34:56
TIMEDTUTOR
Test Id: 80617473
QId: 34120 (921666)
36 of 71
A A A
The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states “I cannot take the medication in this form.” What is the nurse’s first action?1. Ask the health care provider to prescribe a different calcium channel blocker [13%]
2. Consult with the pharmacist to see if an alternate form of the drug is available [76%]
3. Open the capsule and sprinkle the medication in a cup of applesauce [6%]
4. Warn the client about the dangers of uncontrolled hypertension [3%]
Omitted
Correct answer
2
Answered correctly
76% Time: 1 seconds
Updated: 03/25/2017
Explanation:

Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher (fit to be consumed). Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill.

(Option 1) It is not necessary to ask the health care provider to prescribe a different medication unless the religious dietary laws cannot be relaxed or the client desires a kosher alternate form of diltiazem (Cardizem) that is unavailable.

(Option 3) Extended-release capsules should be swallowed whole. Crushing or breaking the capsule may cause uncontrolled delivery of the medication and increase the risk of overdose or other serious adverse effects.

(Option 4) Although it is important to perform client teaching, the nurse should first assess the reason for this client’s nonadherence to the prescribed regimen. Additionally, the nurse should avoid using scare tactics in client teaching.

Educational objective:
Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill.

A client is taking morphine sulfate for acute pain. The client stands, is immediately “lightheaded,” and calls for the nurse. What is the nurse’s priority action?

1. Assess the client’s orthostatic blood pressure [14%]
2. Assist the client to a sitting position [81%]
3. Hold and walk with the client [0%]
4. Keep the client on bed rest [4%]
Omitted
Correct answer
2
Answered correctly
81% Time: 1 seconds
Updated: 06/01/2017
Explanation:

Opioids, including morphine sulfate, dilate peripheral blood vessels and can cause hypotension. The side effect is not as noticeable when the client is lying down; however, once the client attempts to stand, it can cause orthostatic hypotension. It is more common in clients who have some underlying volume depletion (eg, opioid-induced nausea/vomiting). Due to the safety risk, clients must be taught to rise slowly from a sitting to a standing position. The nurse should first assist the client to sit if the client feels lightheaded in a standing position. Safety is the client’s priority. If orthostasis is evident, fluid bolus may be needed and should be communicated to the health care provider.

(Options 1 and 4) Assessing the client’s orthostatic vital signs and recommending bed rest until the lightheadedness resolves are important but not first-priority actions.

(Option 3) Walking with the client is not recommended when the client is symptomatic on standing.

Educational objective:
Client safety is the priority action in any situation. The nurse should assist the client to a safe position prior to proceeding with other interventions.

Block Time Remaining: 01:34:54
TIMEDTUTOR
Test Id: 80617473
QId: 31943 (921666)
38 of 71
A A A
A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client’s Jehovah’s Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply.1. Epoetin alfa
2. Fresh frozen plasma
3. Homologous packed red blood cells
4. Normal saline
5. Platelet transfusion
Omitted
Correct answer
1,4
Answered correctly
63% Time: 1 seconds
Updated: 05/30/2017
Explanation:

Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah’s Witnesses is that transfusions containing blood in any form are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma) (Options 2, 3, and 5). Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer’s, dextran, and hetastarch. These can be administered safely to clients who refuse blood products (Option 4).

Recombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah’s Witnesses. These medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and hemoglobin levels (Option 1).

Educational objective:
Jehovah’s Witnesses believe that transfusion of blood and blood products is not acceptable. Acceptable blood product alternatives include non-blood volume expanders (eg, saline, lactated Ringer’s, dextran, hetastarch) and albumin-free erythropoietin. Unacceptable treatments are transfusions of whole blood, red cells, white cells, platelets, and plasma.
.

Block Time Remaining: 01:34:53
TIMEDTUTOR
Test Id: 80617473
QId: 32372 (921666)
39 of 71
A A A
A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first?1. Ask another nurse to help [3%]
2. Delegate the task to unlicensed assistive personnel [1%]
3. Premedicate the client for pain [7%]
4. Verify the client’s activity prescription [88%]
Omitted
Correct answer
4
Answered correctly
88% Time: 1 seconds
Updated: 02/28/2017
Explanation:

A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall.

(Option 1) A client who had knee surgery will likely be unable to bear any weight on the affected limb. Depending on the client’s size, it may be prudent for the nurse to get additional help. This could be requested after the activity prescription has been verified.

(Option 2) Assistance with ambulation is often delegated to unlicensed assistive personnel (UAP); however, the nurse should verify the prescription first. It would also be prudent to have the UAP assist the nurse as this is the client’s first time up after surgery.

(Option 3) The nurse should assess the client’s pain level before providing pain medication.

Educational objective:
The nurse should verify activity prescriptions before getting clients out of bed after surgery or a procedure. The nurse should be present when these clients begin ambulating and may need assistance from another nurse or unlicensed assistive personnel.

Block Time Remaining: 01:34:51
TIMEDTUTOR
Test Id: 80617473
QId: 31390 (921666)
40 of 71
A A A
The nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension. Which teaching strategy implemented by the nurse is most likely to be effective for this client?1. Leave diet pamphlets for the client to review at a later time [9%]
2. Refer the client to the nurse case manager to follow up with diet instructions [6%]
3. Sit with the client during meal selections and assist with identification of low sodium options [80%]
4. Turn the television on in the client’s room to the patient education channel to watch [3%]
Omitted
Correct answer
3
Answered correctly
80% Time: 2 seconds
Updated: 01/14/2017
Explanation:

When teaching clients and caregivers, the nurse must keep in mind several principles of adult learning. These include the learner’s:

Need to know
Readiness to learn
Prior experiences
Motivation to learn
Orientation to learning
Self-concept
Adults learn best when teaching provides information that the client views as being needed immediately. Readiness to learn is increased if the client perceives a need, has the belief that the change in behavior has value, or perceives the learning activity as new and stimulating.

The client’s age and occupation may help to determine the vocabulary the nurse uses during teaching. Sitting down with the client to assist with the choice of items on the menu that are low in sodium actively involves the client and provides immediately applicable information.

(Option 1) Pamphlets will be helpful to reinforce the teaching that the nurse has already done in the hospital with the client directly.

(Option 2) The primary nurse or the nurse case manager can refer the client to be seen by a dietician before leaving the hospital or to follow up with one when discharged. This will be helpful to the client, but the opportunity to teach when the information is immediately applicable is preferred.

(Option 4) The hospital’s education channel is a good source of information for the client, but it does not actively involve the client in the teaching.

Educational objective:
The nurse should actively engage the client in teachings that the client is ready to receive and perceives as an immediate need.

Block Time Remaining: 01:34:49
TIMEDTUTOR
Test Id: 80617473
QId: 33993 (921666)
41 of 71
A A A
A Muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury. In providing culturally competent care for this client, which consideration is most important?1. Allowing the client’s husband to be with her during clinical examinations [17%]
2. Assigning the client to a private room [2%]
3. Ensuring that female health care workers are available to provide care to the client [79%]
4. Obtaining the services of a local Muslim imam [1%]
Omitted
Correct answer
3
Answered correctly
79% Time: 2 seconds
Updated: 02/08/2017
Explanation:

For the observant Muslim client, maintaining modesty is an important moral value. Covering up the body is essential when a Muslim woman is in the presence of a man who is not related to her, even if the man is a health care provider. Special provision should be made for female health care workers to provide care and examine Muslim women. If a female health care provider is not available, a female nurse or clinical staff person should be present. In addition, privacy screens should be used and room doors should be kept closed consistently.

(Option 1) A husband will often request to be with his wife during an examination; efforts should be made to fulfill this request, but it is not the priority consideration.

(Option 2) A private room may not be necessary. This client should be assigned to a room with another Muslim woman or a woman with similar practices regarding modesty. Otherwise, male visitors to the client’s roommate could be problematic and cause distress.

(Option 4) Consulting with a local Muslim imam or hospital chaplaincy staff may enhance culturally congruent care; however, this is not the most pressing consideration.

Educational objective:
In the care of female Muslim clients, modesty is highly valued and most body parts are covered. Female health care workers should be available to provide care and conduct examinations. If a male health care provider must be involved in care, female clinical staff should also be present whenever possible.
d.

Block Time Remaining: 01:34:47
TIMEDTUTOR
Test Id: 80617473
QId: 30783 (921666)
42 of 71
A A A
The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, “I’m so tired of people telling me what to do! I’m going to eat what I want, so leave me alone!” Which of the following is the most appropriate response by the nurse?1. “I can tell that you want me to go, so I will call in a few days to see how you are doing.” [0%]
2. “I know you are frustrated with losing control of your life.” [4%]
3. “It sounds like you are angry. Tell me what’s bothering you.” [94%]
4. “Okay. I’ll just check your blood pressure and then go.” [0%]
Omitted
Correct answer
3
Answered correctly
94% Time: 2 seconds
Updated: 05/07/2017
Explanation:

The client exhibits anger, which is likely a sign of grief due to loss of control from illness. However, the source of the client’s anger is not clear. Therefore, further assessment is now indicated to understand more about the client’s feelings and perceptions. Verbalizing feelings may also help the client to move past anger toward acceptance of the loss.

The nurse’s statement, “It sounds like you are angry” reflects the nurse’s perception of the client’s emotion and will allow the client to clarify feelings. The open-ended probing statement, “Tell me what’s bothering you,” facilitates assessment of the client’s concerns without making any assumptions about them. This approach will promote accurate assessment of the client’s needs and concerns. It will also prevent premature closure, incorrect assumptions, and escalation of the client’s anger.

(Option 1) This client’s angry response likely indicates an unmet need. Further assessment is indicated if the client is willing to talk. This response shuts the door on further assessment.

(Option 2) The nurse is making an assumption that the source of the client’s frustration is loss of control. This assumption may cause the nurse to draw inaccurate conclusions about the client’s concerns, contributing to further escalation of anger.

(Option 4) This response will probably diffuse the situation, but further assessment of the client’s concern is more important. If the client remains angry and the nurse attempts to take blood pressure after being told to leave, the client may become angrier, putting the nurse’s safety at risk.

Educational objective:
The client with serious illness who exhibits anger may be experiencing anxiety, grief, or fear. The nurse should remain at a safe distance while attempting to diffuse the situation; assess the client’s concerns using a calm, non-threatening approach; reflect the client’s statements; and try to understand the client’s feelings, perceptions, and beliefs to address the priority problem.

Block Time Remaining: 01:34:46
TIMEDTUTOR
Test Id: 80617473
QId: 33851 (921666)
43 of 71
A A A
The family of a terminally ill, dying client verbalizes concern that the client is becoming dehydrated due to poor fluid intake. When the family asks the nurse about administering IV fluids, the nurse’s response is based on an understanding of which statement?1. Providing artificial hydration at the end of life will make the client feel more comfortable [25%]
2. The decision whether to provide artificial hydration should consider client preferences and goals [56%]
3. The health care provider will prescribe artificial hydration when the client can no longer swallow [11%]
4. Withholding artificial hydration at the end of life speeds up the dying process [6%]
Omitted
Correct answer
2
Answered correctly
56% Time: 1 seconds
Updated: 02/07/2017
Explanation:

The decision about providing artificial nutrition to a dying client is complex. Although certain situations involving terminal illness, such as a terminally ill client who wants to attend an important family function, can justify the decision to provide IV fluids, providing artificial hydration in other situations may not be justified and may even be harmful. Ethical principles dictate that client preferences should be respected and that clients/family members have the right to make decisions about artificial nutrition and hydration at the end of life.

(Option 1) Artificial hydration does not seem to help dying clients feel more comfortable, and IV fluids could cause distressful symptoms such as respiratory distress, vomiting and diarrhea, and the need for urinary catheterization.

(Option 3) The majority of hospice and palliative health care providers do not recommend routine administration of artificial hydration.

(Option 4) There is no evidence that withholding artificial hydration at the end of life speeds up the dying process. Research indicates that dying clients who do not receive artificial hydration live just as long as those who do receive IV fluids.

Educational objective:
The majority of hospice and palliative health care providers do not recommend routine administration of artificial hydration; however, client preferences should be respected – clients/family members have the right to make decisions about artificial nutrition and hydration at the end of life.
.

Block Time Remaining: 01:34:45
TIMEDTUTOR
Test Id: 80617473
QId: 31464 (921666)
44 of 71
A A A
A client who lives alone had a total laryngectomy for laryngeal cancer 3 months ago. The client has a tracheoesophageal puncture (TEP) to enable speech and tells the nurse, “It’s a good thing it’s cold outside, so I can keep the hole in my neck covered up with a scarf. I don’t know what I’ll do when the weather gets warmer.” What is the most appropriate nursing diagnosis?1. Disturbed body image [83%]
2. Impaired verbal communication [1%]
3. Ineffective coping [5%]
4. Ineffective self-health maintenance [10%]
Omitted
Correct answer
1
Answered correctly
83% Time: 1 seconds
Updated: 03/02/2017
Explanation:

Body image is a person’s attitude about the actual or perceived structure or function of one’s body. A variation from what is considered normal (eg, being a mouth breather) can result in a disturbance or dissatisfaction with one’s physical self.

Disturbed body image is related to the presence of the laryngectomy stoma (secondary to laryngeal cancer) and altered verbal communication, as evidenced by negative feelings about having to keep the “hole in my neck covered up” and the presence of the TEP.

(Option 2) This client has a TEP and is able to speak and communicate.

(Option 3) This client is at risk for ineffective coping related to lack of a support system due to living alone. However, the client is now demonstrating the ability to manage stress and problem solve (eg, wearing a scarf). There are no assessment data to support ineffective coping as a problem at this time.

(Option 4) Ineffective self-health maintenance refers to the inability to identify, manage, and/or seek help maintaining one’s health. Common related factors include cognitive impairment, adverse personal habits (eg, drug and alcohol abuse, poor diet), lack of access to care, and ineffective coping. This client does not currently exhibit any such factors to support this nursing diagnosis.

Educational objective:
Clients who undergo a total laryngectomy face life-altering physical and psychological challenges. These include the inability to breathe normally, loss of speech, inability to taste and smell, and the presence of a permanent tracheal stoma. Disturbed body image, impaired verbal communication, ineffective coping, and ineffective self-health maintenance are appropriate nursing diagnoses for a client with a total laryngectomy.
.

Block Time Remaining: 01:34:43
TIMEDTUTOR
Test Id: 80617473
QId: 34776 (921666)
45 of 71
A A A
When assessing the client’s pain level, what will the nurse determine is the most reliable indicator of the pain?1. Client’s ethnic background [1%]
2. Client’s report of symptoms [77%]
3. Client’s vital signs [18%]
4. Extent of client’s injury [1%]
Omitted
Correct answer
2
Answered correctly
77% Time: 2 seconds
Updated: 03/23/2017
Explanation:

The client’s self-report of symptoms is always the most reliable indicator of the client’s pain. The nurse does not have the ability to determine the extent of pain the client is experiencing—only the client can report this. In the nonverbal client, the nurse may use nonverbal pain scales such as the Wong-Baker pain rating scale.

(Option 1) Although clients from various ethnic backgrounds may express pain differently, it is not appropriate for the nurse to assume that ethnic background is a reliable source of information when determining pain.

(Option 3) Although changes in vital signs may occur in acute pain (generally increased respiratory rate and heart rate), these changes are not the most reliable source of information when determining pain.

(Option 4) The extent of a client’s injury is not a reliable source of information when determining pain because all clients experience pain differently. What one client may feel as excruciating pain another client may not.

Educational objective:
The most reliable indicator for the client’s pain is the client’s self-report of symptoms. Nurses should not assume what the client’s pain level is based on injury or ethnicity. Although a change in vital signs may occur in the client in pain, this is not the most reliable indicator.

Block Time Remaining: 01:34:42
TIMEDTUTOR
Test Id: 80617473
QId: 32631 (921666)
46 of 71
A A A
The nurse is providing postmortem care for a client who has died after a long hospitalization. The client had a do-not-resuscitate order in place at the time of death. Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home? Select all that apply.1. Allow family member to assist with care
2. Call the medical examiner for an autopsy
3. Gently close the client’s eyes
4. Place a pad under the perineum
5. Remove the client’s dentures
Omitted
Correct answer
1,3,4
Answered correctly
42% Time: 1 seconds
Updated: 02/06/2017
Explanation:

Postmortem care is conducted with respect and dignity. The nurse should provide opportunities for family participation and accommodate religious and cultural rituals when possible (Option 1).

To perform postmortem care:

Maintain standard or isolation precautions in place at the time of death.
Gently close the client’s eyes (Option 3).
Remove tubes and dressings per policy, unless an autopsy or organ harvest is pending.
Straighten and wash the body and change the linens. Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased.
Leave dentures in place, or replace if removed, to maintain the shape of the face; it is difficult to place dentures once rigor mortis sets in (Option 5). A towel folded under the chin may be needed to keep the jaw closed.
Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters (Option 4).
Place a pillow under the head to prevent blood from pooling and discoloring the face.
Remove equipment and soiled linens from the room.
Give client’s belongings to a family member or send with the body.
(Option 2) This client’s death was expected. It is not necessary to contact the medical examiner for autopsy.

Educational objective:
Postmortem care involves preparing the body for presentation to the family and includes hygiene (removing soiled linens and dressings, cleaning the body and room) and positioning (head on pillow, pad under perineum, mouth and eyes closed).

Block Time Remaining: 01:34:41
TIMEDTUTOR
Test Id: 80617473
QId: 30812 (921666)
47 of 71
A A A
The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel. The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain. Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication. What is the most appropriate action for the RN to take?1. Administer the hydromorphone [17%]
2. Ask the licensed practical nurse to administer the medication [2%]
3. Ask the unlicensed assistive personnel to take repeat vital signs [22%]
4. Contact the health care provider [57%]
Omitted
Correct answer
4
Answered correctly
57% Time: 1 seconds
Updated: 01/22/2017
Explanation:

A STAT order indicates that the medication should be given immediately and only one time. A new prescription for the medication must be acquired before the dose can be repeated. The most appropriate action is to contact the health care provider to request an as-needed prescription for pain medication.

(Option 1) A STAT medication dose was administered and cannot be repeated without a new prescription.

(Option 2) In most states, the registered nurse (RN) cannot delegate the administration of IV opioids to the licensed practical nurse, and it cannot be administered without a new prescription.

(Option 3) The RN can delegate repeat vital sign checks to the unlicensed assistive personnel, but it is not the most appropriate action.

Educational objective:
A STAT order indicates that a medication is to be given immediately and only once.

Block Time Remaining: 01:34:40
TIMEDTUTOR
Test Id: 80617473
QId: 30085 (921666)
48 of 71
A A A
The health care provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock. The nurse should anticipate the rapid infusion of which intravenous solution initially?1. 0.9% Sodium chloride [65%]
2. 5% Albumin [4%]
3. Dextrose 5% and lactated Ringer’s [25%]
4. Dextrose 5% and water [3%]
Omitted
Correct answer
1
Answered correctly
65% Time: 1 seconds
Updated: 04/26/2017
Explanation:

Normal saline is the fluid of choice for rapid correction of hypotension in most situations, including hypovolemic and septic shock. It can be administered in large quantities rather rapidly and is inexpensive.

(Option 2) When 5% albumin, a colloid solution, is infused into the intravascular space, it mobilizes fluid from the extravascular tissues into the extracellular vascular space. Although it is equally effective in expanding intravascular fluid volume, it is expensive and not the initial fluid of choice. It can be used in clients with low intravascular protein (albumin) content and hypotension but increased fluid in extravascular tissues (eg, cirrhosis with ascites).

(Option 3) When dextrose 5% and lactated Ringer’s, a hypertonic solution, is infused into the intravascular space, it mobilizes fluid from the extravascular tissue into the extracellular vascular space. Although it may be used to expand fluid volume, it is not the initial intravenous fluid of choice.

(Option 4) When the dextrose in dextrose 5% and water is metabolized, a hypotonic solution is left. In large volumes, it can cause shift of the fluid into the extravascular compartment, which may cause further hypotension in clients with low blood pressure. Hypotonic solutions (0.45% saline or dextrose 5% and water) are typically used to treat hypernatremia.

Educational objective:
Isotonic solutions are used for immediate fluid resuscitation in clients with hypovolemic shock.

Block Time Remaining: 01:34:39
TIMEDTUTOR
Test Id: 80617473
QId: 31389 (921666)
49 of 71
A A A
The nurse is providing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply.1. Conduct teaching sessions while a family member is present
2. Discourage the client from using the internet to look up health information
3. Have client watch a DVD about heart failure management
4. Print out pictures of a food label and review where to look for sodium content
5. Speak slowly and loudly so the client can understand you
Omitted
Correct answer
1,3,4
Answered correctly
59% Time: 1 seconds
Updated: 01/09/2017
Explanation:

The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows:

Using pictures and simplified text is beneficial to the older adult with low literacy.
Including a family member in the teaching process will assist the client in reinforcement of the material at a later date.
Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory content in lay person’s language.
(Option 2) Older adults are using the internet in increasing numbers as are clients with low literacy. Several organizations are developing and promoting user-friendly websites. Society in general relies heavily on web-based health information. It is important for the nurse to teach the client and possibly supply a list of reputable sites for the client to view.

(Option 5) Unless the client is hard of hearing, speaking slowly and loudly is unnecessary and demeaning.

Educational objective:
For a client with low literacy, the nurse should use multiple teaching strategies including professionally produced educational programs, pictures with simplified text, and inclusion of a family member during teaching sessions.

Block Time Remaining: 01:34:37
TIMEDTUTOR
Test Id: 80617473
QId: 30697 (921666)
50 of 71
A A A
The nurse is caring for a client with end-stage liver disease who was admitted for bleeding esophageal varices. The bleeding varices were banded successfully, but the client declined having a transjugular intrahepatic portal-systemic shunt (TIPS) procedure and opted for do not resuscitate (DNR) status. Which topic is most important for the nurse to discuss with the client and family at discharge?1. Complete abstinence from alcohol [9%]
2. Proper use of medications including lactulose [10%]
3. The importance of calling the healthcare provider (HCP) immediately if bleeding recurs [30%]
4. The purpose and use of the DNR bracelet [48%]
Omitted
Correct answer
4
Answered correctly
48% Time: 2 seconds
Updated: 01/16/2017
Explanation:

A client with end-stage liver disease is at high risk for life-threatening events such as bleeding esophageal varices and hepatic encephalopathy. This client continues to be at risk for bleeding varices due to the declined TIPS procedure, which could have prevented further esophageal varices by treating the portal hypertension.

This client who is DNR in the hospital should be discharged with a DNR bracelet or an active Physician Orders for Life-Sustaining Treatment (POLST) form in the community setting. This should be done to ensure that the client’s wishes for emergency care will be carried out by first responders.

(Option 1) Abstinence from alcohol will help delay the progression of end-stage liver disease and its complications. However, this is not always realistic for a client with long-term alcohol addiction. In addition, this client with end-stage liver disease who has chosen to be DNR may also choose to continue drinking if this is deemed important to quality of life. Even though the nurse may not approve of this choice, the client is the one who ultimately makes personal lifestyle and health management decisions.

(Option 2) Lactulose and other medications are necessary for managing end-stage liver disease. However, this topic is less important than emergency response and advance care planning issues, particularly in a client with a new DNR order and recent history of bleeding esophageal varices.

(Option 3) Although the client and family should know what to do if bleeding recurs, it would be more appropriate to call 911 than the HCP in this emergency situation. In addition, this topic is not as important as the discussion on DNR bracelet use which already covers emergency care for any type of situation.

Educational objective:
Discharge planning and teaching for the client with a new DNR order should include a method of ensuring that the DNR order will be carried out in the community and home. DNR bracelets and POLST forms are community-based systems that provide emergency responders with the legal documentation needed to withhold resuscitation.

Block Time Remaining: 01:34:34
TIMEDTUTOR
Test Id: 80617473
QId: 31268 (921666)
51 of 71
A A A
A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply.1. Ask the client to nod so the nurse can confirm the client understands the situation
2. Attempt to use a female interpreter to avoid gender sensitivity
3. Make good eye contact with the client (rather than the interpreter) when speaking
4. Preferably use a personal friend or relative to facilitate client privacy under HIPAA
5. Teach about one intervention at a time and in the order it will occur
Omitted
Correct answer
2,3,5
Answered correctly
48% Time: 3 seconds
Updated: 01/03/2017
Explanation:

Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly personal or sensitive (Option 2).

The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the client’s words literally. Communication is with the client, not the interpreter. The nurse should use basic English rather than medical terms, speak slowly, and pause after 1-2 sentences to allow for translation (Option 3).

Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to understand. For example, the nurse can indicate that there will be surgery and then a follow-up visit as opposed to, “You’ll follow up with the health care provider after your procedure” (Option 5).

(Option 1) The nurse should obtain feedback to be certain that the client understands. This feedback should extend beyond nodding as some people nod to indicate that they are listening or nod in agreement to “save face” even though they do not understand. It is better to use a tactic such as having the client repeat back information (which is then translated into English).

(Option 4) Using a fee-based agency or language line is preferred if an appropriate bilingual employee is not available. The client may not want the friend/relative to know about this personal situation, or the person may not be able to adequately translate medical concepts and/or understand client rights.

Educational objective:
When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex individual rather than a family member or personal friend. The nurse should speak slowly and directly to the client, not the interpreter; provide information in the sequence it will occur; and obtain feedback of comprehension beyond merely nodding.

Block Time Remaining: 01:34:33
TIMEDTUTOR
Test Id: 80617473
QId: 34004 (921666)
52 of 71
A A A
A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply.1. Ask a family member about the client’s preferences for room arrangement
2. Offer the client an elbow to hold, and walk a half-step ahead for guidance
3. Say “goodbye” when leaving the room to help orient the client
4. Speak slowly and slightly louder so the client can understand
5. Use a clock-face pattern to explain food arrangement on the client’s meal tray
Omitted
Correct answer
2,3,5
Answered correctly
53% Time: 1 seconds
Updated: 05/23/2017
Explanation:

The nurse should create a therapeutic and safe environment for the client who is blind while fostering as much independence as possible. Nursing interventions include the following:

Offer the client an elbow for guidance while walking slightly ahead and describing the environment (Option 2).
Announce room entry and exit to orient and avoid startling the client (Option 3).
Describe the location of items (eg, food, hygiene supplies) using a clock-face orientation so the client can find them easily (Option 5).
Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation.
Orient the client to the room and maintain this orientation for safety.
(Option 1) Asking the caregiver or family member about the client’s personal preferences does not promote independence or self-advocacy. The nurse should ask the client directly about the desired room arrangement.

(Option 4) The nurse should speak to the client in a normal tone of voice to facilitate communication. Speaking slowly and slightly louder would be useful for a client with a hearing deficit.

Educational objective:
When caring for a client who is blind, the nurse should create a safe therapeutic environment and foster client independence by orienting the client to the surroundings, announcing room entry and exit, guiding the client by offering an elbow and walking slightly in front, using a clock-face description to orient the client to the location of objects, and asking the client directly about preferences.

Block Time Remaining: 01:34:31
TIMEDTUTOR
Test Id: 80617473
QId: 30426 (921666)
53 of 71
A A A
It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client’s spouse and child are to arrive at 0900. Which intervention should the nurse carry out first?1. Administer pain medication [20%]
2. Call the health care provider to meet with the family to obtain informed consent [23%]
3. Complete the preoperative checklist [4%]
4. Perform the morning assessment [51%]
Omitted
Correct answer
4
Answered correctly
51% Time: 2 seconds
Updated: 04/26/2017
Explanation:

The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist.

(Option 1) Pain medicine is not due until 0730 and can be administered after the initial assessment if necessary.

(Option 2) The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it.

(Option 3) The preoperative checklist can be completed after consent is obtained.

Educational objective:
Before surgery, the nurse makes sure informed consent is obtained, performs a complete physical assessment to collect baseline data and determine the client’s physiologic and psychologic status, and completes the preoperative checklist.

Block Time Remaining: 01:34:30
TIMEDTUTOR
Test Id: 80617473
QId: 31485 (921666)
54 of 71
A A A
In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit?1. High-Fowler’s position with the affected side’s arm resting on the bed [3%]
2. Semi-Fowler’s position with the affected side’s arm on several pillows [82%]
3. Supine with the affected side’s arm on several pillows [11%]
4. Supine with the affected side’s arm resting on the bed [3%]
Omitted
Correct answer
2
Answered correctly
82% Time: 1 seconds
Updated: 02/03/2017
Explanation:

Immediately after mastectomy surgery, the client is placed in a semi-Fowler’s position with the affected side’s arm and hand elevated on several pillows to promote drainage and prevent venous and lymphatic pooling. Flexing and bending of the affected side’s fingers is begun immediately with gradual increase in arm movement over the next few postoperative days. Postoperative arm and shoulder exercises are initiated slowly with the goal of full range of motion of the affected side within 4-6 weeks of the mastectomy.

(Option 1) Placing the client in a high-Fowler’s position immediately after anesthesia might cause a decrease in blood pressure and subsequent dizziness. Resting the affected side’s arm on the bed would place the arm in a dependent position, which would lead to swelling due to decrease in lymphatic and venous drainage.

(Options 3 and 4) Raising the head of the bed slightly would promote ease of breathing. Resting the arm on several pillows would promote drainage and prevent lymphatic pooling.

Educational objective:
Immediately post mastectomy, the client is placed in a semi-Fowler’s position to promote ease of breathing. The affected side’s arm and hand should be elevated on several pillows to promote drainage and prevent lymphatic pooling.

Block Time Remaining: 01:34:29
TIMEDTUTOR
Test Id: 80617473
QId: 30752 (921666)
55 of 71
A A A
A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, “The radiology technician told me that it looks really bad – the tumor in my breast is very large.” Which is the best response by the nurse?1. “I can see that you are very upset. Let’s talk about what happened.” [93%]
2. “I’ll report the technician to the head of the radiology department.” [0%]
3. “The technician never should have said that to you.” [1%]
4. “Your health care provider will discuss treatment options with you.” [4%]
Omitted
Correct answer
1
Answered correctly
93% Time: 1 seconds
Updated: 05/06/2017
Explanation:

Acknowledging that the client is upset conveys concern and understanding on the part of the nurse and helps establish a therapeutic dialogue.

The client can vent feelings and discuss fears because the nurse provides the opportunity to talk about what happened (focusing and listening). This action also establishes interpersonal sensitivity and helps the nurse relate therapeutically to the client. Clients who feel threatened or injured by their medical condition(s) need to feel safe and supported. The nurse is in a unique position to provide the nurturing and caring that clients need as they cope with medical diagnoses and difficult situations.

(Option 2) This is not an appropriate response; the proper chain of command would have the nurse report the event to a supervisor.

(Option 3) This statement may be true, but it does not facilitate a dialogue about the client’s feelings and fears.

(Option 4) This response does not address the client’s feelings or what happened during the mammogram.

Educational objective:
Therapeutic communication techniques such as acknowledgement of feelings, focusing, and listening can help establish a dialogue and relationship with a client that is protective, supportive, nurturing, and caring.

Block Time Remaining: 01:34:21
TIMEDTUTOR
Test Id: 80617473
QId: 30751 (921666)
57 of 71
A A A
A client has been hospitalized with bipolar disorder, manic episode. The nursing care plan includes the diagnosis “Imbalanced nutrition: less than body requirements.” Which of the following meal selections would be best for the client?1. Banana smoothie, hamburger, French fries [26%]
2. Carrot sticks, turkey wrap sandwich, lemonade [39%]
3. Chicken and rice, fresh orange slices, iced tea [15%]
4. Meat loaf with gravy, mashed potatoes, apple pie, milk [19%]
Omitted
Correct answer
1
Answered correctly
26% Time: 3 seconds
Updated: 05/06/2017
Explanation:

Clients experiencing a manic episode are often undernourished and dehydrated on hospital admission. They need more calories, protein, and fluids due to their excessive energy and psychomotor activity. Most clients with mania are unable to sit still long enough to consume a meal and they would not be able, on their own, to choose foods that would meet their caloric needs.

Clients will need frequent reminders to eat, and their intake should be monitored. Foods that are readily available and easy to consume should be provided. Foods that can be eaten “on the run” increase the probability that the client will consume them. Items such as sandwiches, smoothies, milkshakes, ice cream bars, fresh fruit, chips, pizza slices, burritos, fruit juices, and granola bars have high nutritional density and are easily consumed.

The items in Option 1 would provide the highest number of calories that could be easily consumed while the client is moving around.

(Option 2) These food items would provide a comparatively low number of calories.

(Option 3) These food items do not contain as many calories as those in Option 1 and would be difficult to eat if not sitting down.

(Option 4) This meal would provide a comparatively high number of calories but would be difficult to consume “on the run.”

Educational objective:
A client with bipolar disorder, manic episode, is at risk for under-nutrition and dehydration due to high energy needs secondary to psychomotor agitation. Because most clients with mania are unable to sit down long enough to consume a meal, foods and fluids that are easily consumed “on the run” must be provided.

Block Time Remaining: 01:34:20
TIMEDTUTOR
Test Id: 80617473
QId: 30333 (921666)
58 of 71
A A A
The nurse is teaching a client with insomnia techniques to improve sleep habits. Which statement by the client indicates a need for further teaching?1. “I will avoid caffeine with dinner.” [3%]
2. “I will avoid naps later in the day.” [5%]
3. “I will keep my bedroom cool.” [25%]
4. “I will read in bed if I can’t fall asleep.” [64%]
Omitted
Correct answer
4
Answered correctly
64% Time: 1 seconds
Updated: 04/26/2017
Explanation:

Clients with trouble sleeping should be encouraged to keep good sleep habits, which include the following:

Reducing stimuli in the bedroom (eg, reading, television). Reading in bed is not recommended. A client wanting to read before bed should do so in a different setting and then go to bed when ready to sleep.
Avoiding naps later in the day.
Keeping the bedroom slightly cool, quiet, and dark for comfort.
Avoiding caffeine, nicotine, and alcohol (stimulants) within 6 hours of sleep.
Avoiding exercise or strenuous activity within 6 hours of going to bed to avoid brain stimulation.
Avoiding going to bed hungry.
Practicing relaxation techniques if stress is causing insomnia.
Educational objective:
Clients with insomnia should be taught good sleep hygiene – using the bed only for sleep (not reading or watching television), avoiding stimulants and exercise before bedtime, and keeping the room cool and dark.

Block Time Remaining: 01:34:19
TIMEDTUTOR
Test Id: 80617473
QId: 31293 (921666)
59 of 71
A A A
An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, “I’ve got to get back home to my things. I have so much to do.” Which is the most likely interpretation of this client’s behavior?1. The client has been admitted to the facility without the client’s consent [4%]
2. The client is becoming delirious and should be assessed for infection [37%]
3. The client is concerned that someone might steal possessions [2%]
4. The client wants to take care of business before imminent death [55%]
Omitted
Correct answer
4
Answered correctly
55% Time: 1 seconds
Updated: 01/29/2017
Explanation:

This client with advanced renal failure who decides not to start dialysis treatments may have only a few weeks to live. Toxins will build up in the body and soon lead to increased weakness and cognitive decline. This client knows there is a limited time left to live and wants to ensure that possessions will be taken care of appropriately after the client’s death (Option 4).

(Option 1) The client has probably been admitted to the facility due to concerns about safe management at home. However, the statement does not indicate that the client has been admitted against the client’s will.

(Option 2) Clients with end-stage renal disease are at risk for delirium due to a buildup of toxins, which may manifest as agitation and statements about needing to go somewhere. However, the nurse should not automatically assume that the client is delirious. Instead, it is important to assess the client’s concern with an open mind so that appropriate interventions can be planned.

(Option 3) The client’s statement about having “so much to do” suggests that this is not the concern prompting the behavior.

Educational objective:
The client with a limited life expectancy will have concerns about completing personal business, such as ensuring that possessions go to the appropriate people. The nurse should assess the client’s needs and ensure that the plan of care will facilitate the client’s life closure activities (eg, legacy building).

Block Time Remaining: 01:34:18
TIMEDTUTOR
Test Id: 80617473
QId: 31152 (921666)
60 of 71
A A A
A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, “I want to get out of here and try living in my own home.” What is the best response by the nurse?1. “Do you have family or friends who could take care of you?” [5%]
2. “I’ll make a referral to the local home care agency in your area.” [4%]
3. “It will be very difficult to manage your care at home.” [1%]
4. “Tell me how you think your life would be different if you moved from here.” [87%]
Omitted
Correct answer
4
Answered correctly
87% Time: 1 seconds
Updated: 12/30/2016
Explanation:

After 2 years of residence, this client has expressed a desire to leave the nursing home and return home. This client with advanced MS will need maximal assistance with basic activities of daily living (bathing, grooming, toileting, transfers, locomotion), meal preparation, laundry, shopping, and other housekeeping chores. Discharging this client to care at home will require much planning and present numerous challenges related to safety, finances, support and informal caregiver system, durable medical equipment, and layout of the home.

Therefore, before any discussion or planning can take place, the nurse needs to determine why the client wants to go home at this point in time. The nurse should also ask the client if something happened in the nursing home. However, asking “why” or “yes/no” questions is non-therapeutic and will not facilitate a meaningful nurse-client interaction. By using the therapeutic communication technique of exploring, the nurse can encourage the client to discuss thoughts, feelings, and reasons for wanting to leave the current residence.

(Option 1) This is important information to obtain when planning the discharge of a client who needs care at home; however, it is not the priority assessment.

(Option 2) This would be an appropriate nursing action after the nurse has discussed and assessed the reasons why the client wants to return home.

(Option 3) This is an appropriate response as it presents the reality of the client’s situation, but it is not the priority response.

Educational objective:
Exploring is a therapeutic communication technique that will facilitate further assessment of a particular subject or experience. It is a technique that is especially helpful when a client makes a statement or presents a topic that alerts the nurse that there could be additional information beyond the surface of the initial communication.

Block Time Remaining: 01:34:17
TIMEDTUTOR
Test Id: 80617473
QId: 30660 (921666)
61 of 71
A A A
The nurse is performing an admission assessment on an elderly client with Alzheimer disease (AD). The nurse should do which of the following when communicating with the client?1. Ask open-ended questions [6%]
2. Speak in a loud voice [0%]
3. Touch the client prior to speaking [3%]
4. Use simple sentences [89%]
Omitted
Correct answer
4
Answered correctly
89% Time: 1 seconds
Updated: 05/09/2017
Explanation:

AD is a progressive neurodegenerative disease that causes dementia (reduced cognitive function) in older individuals (age >60). Conversation becomes progressively more difficult and word-finding difficulties occur. The best way for the nurse to obtain information is to offer a calm environment and use clear and simple explanations.

(Option 1) Asking open-ended questions is often a good way to collect information from clients, but in this case it could confuse the client with AD. This is not the best answer option.

(Option 2) AD results in reduction in cognitive function and is not associated with hearing loss. There would be no need to speak loudly.

(Option 3) Touching the client before speaking would be more appropriate for a client who has hearing loss, not one with AD.

Educational objective:
When speaking with AD clients, use clear and simple explanations. When communicating with clients who have hearing loss, speak loudly, stand close to the person, and touch the person before speaking.

Block Time Remaining: 01:34:16
TIMEDTUTOR
Test Id: 80617473
QId: 34390 (921666)
62 of 71
A A A
The nurse enters a client’s room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse?1. “Do you have any questions about the diagnosis?” [14%]
2. “There are medications available to treat Alzheimer disease.” [0%]
3. “This new diagnosis must be frightening for you.” [80%]
4. “We can help you make decisions about your care.” [4%]
Omitted
Correct answer
3
Answered correctly
80% Time: 1 seconds
Updated: 05/23/2017
Explanation:

Reflecting is a therapeutic communication technique that reiterates the feeling, idea, or message conveyed by the client. Therapeutic communication encourages the client and family to express feelings and thoughts, increases the nurse’s understanding, and conveys support. Emotional expression is an important part of the coping process for the client and family. The nurse provides support by expressing empathy, actively listening, and encouraging open communication. Nontherapeutic responses can block communication by shifting the receiver’s focus away from the expression of feelings and thoughts.

(Option 1) Questions or statements that prevent the client from expressing feelings (eg, changing the subject) when a client and family are trying to cope with a new diagnosis are not therapeutic and can block communication. Once the nurse understands the client’s thoughts and feelings, information can be provided.

(Option 2) Providing false reassurance is not therapeutic and can block communication. A client and family may not fully understand the progression of Alzheimer disease immediately after receiving the diagnosis. Stating that medications are available to treat the disease may lead to a false belief that it can be cured.

(Option 4) A client diagnosed with Alzheimer disease may need assistance with care planning, but the nurse should first support the process of coping when the client receives the life-changing diagnosis.

Educational objective:
When clients and families are faced with significant life changes, the nurse should support the process of coping by encouraging emotional expression. The nurse provides support by expressing empathy, actively listening, and encouraging therapeutic communication.

Block Time Remaining: 01:34:15
TIMEDTUTOR
Test Id: 80617473
QId: 31470 (921666)
63 of 71
A A A
A postoperative client is prescribed IV patient-controlled analgesia (PCA) with morphine. The client tells the nurse, “I am pushing the button, but I’m still having a lot of pain.” What is the priority nursing action?1. Administer a bolus dose [1%]
2. Notify the health care provider (HCP) to request a higher dose [11%]
3. Perform a thorough pain assessment [72%]
4. Reinforce the proper use of the IV PCA pump [14%]
Omitted
Correct answer
3
Answered correctly
72% Time: 1 seconds
Updated: 01/23/2017
Explanation:

When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis. The client’s self-report is considered to be the most reliable indicator of pain, so the priority nursing action is to perform a thorough pain assessment to determine the cause of worsening/continuous pain despite the medication. This includes location, quality, radiation, severity, and associated factors (eg, nausea, diaphoresis) for the severe pain. The assessment data will guide the nurse’s subsequent interventions (Option 3).

(Option 1) An IV PCA bolus is an extra, as-needed dose of analgesia (eg, 1-2 mg) for increased pain (eg, before a painful procedure) that is prescribed by the HCP when the PCA is initiated. If needed, the nurse programs the pump to deliver the bolus dose because no one but the client is permitted to push the button. However, this is not the priority action.

(Option 2) If the client’s attempts are twice the number of doses actually delivered and adequate pain relief is not achieved, the nurse would notify the HCP to request a dose increase or shorter dose interval. However, this is done after the pain assessment.

(Option 4) The client learns how to use the IV PCA pump when it is initiated. The nurse should reassess the client’s knowledge level regarding proper use and reinforce previous teaching. However, it is not the priority intervention.

Educational objective:
When providing care for a client prescribed IV PCA, the nurse assesses pain on a regular and as-needed basis, assesses the client’s knowledge level regarding its use, and reinforces previous teaching.

Block Time Remaining: 01:34:13
TIMEDTUTOR
Test Id: 80617473
QId: 30284 (921666)
64 of 71
A A A
The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct which client to avoid the Valsalva maneuver when defecating? Select all that apply.1. 22-year-old man with a head injury sustained during a college football game
2. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty
3. 56-year-old man 2 weeks post myocardial infarction
4. 68-year-old woman recently diagnosed with pancreatic cancer
5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis
6. 82-year-old woman 1 week post cataract surgery
Omitted
Correct answer
1,3,5,6
Answered correctly
33% Time: 2 seconds
Updated: 04/26/2017
Explanation:

The Valsalva maneuver (straining during defecation) involves holding the breath while bearing down on the perineum to pass a stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased intracranial pressure, stroke, or head injury as straining increases intra-abdominal and intrathoracic pressure, which raises the intracranial pressure (Option 1).

The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease (Option 3).

Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding (Option 5).

The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery (Option 6).

(Option 2) The otherwise healthy client recovering from reconstructive augmentation mammoplasty is not at risk for complications related to the Valsalva maneuver.

(Option 4) The client recently diagnosed with pancreatic cancer is not at risk for complications related to the Valsalva maneuver.

Educational objective:
The Valsalva maneuver is contraindicated in the client diagnosed with increased intracranial pressure, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis.

Block Time Remaining: 01:34:12
TIMEDTUTOR
Test Id: 80617473
QId: 34116 (921666)
65 of 71
A A A
The home health nurse is following up with the parent of a Native American infant recently diagnosed with lactose intolerance. In accordance with principles of culturally competent care, what is the most important question for the nurse to ask the parent?1. Do your other children have this condition? [18%]
2. How long did your infant have diarrhea? [19%]
3. How often are you feeding the infant? [23%]
4. What do you think caused your infant’s illness? [37%]
Omitted
Correct answer
4
Answered correctly
37% Time: 1 seconds
Updated: 12/20/2016
Explanation:

All clients have cultural influences that can affect their beliefs and concerns about causes of medical conditions and expectations for treatment. The nurse should have clients express what caused their medical illnesses or problems to gain knowledge of their beliefs and understandings about the conditions; this is fundamental to developing a culturally sensitive and appropriate teaching and care plan. Culturally competent care requires the nurse to recognize that the client’s interpretation of an illness is more significant than the nurse’s knowledge of the illness.

Clients’ beliefs about health and disease may be complex and tightly rooted in centuries-old traditions. Some clients welcome scientific explanations about their conditions, whereas others ignore a nurse’s teaching that does not align with their personal perspectives. The nurse must never assume that a client knows (or does not know) about a subject; accurate assessment about knowledge and beliefs is necessary.

(Option 1) The nurse may ask about other family members; however, this does not address cultural beliefs and concerns.

(Option 2) Knowing the duration of diarrhea will help determine the infant’s nutritional status and fluid balance but does not address cultural beliefs and concerns.

(Option 3) Although it is important to determine that nutritional intake is adequate for normal growth and development, this does not address cultural beliefs and concerns.

Educational objective:
When providing culturally competent care, it is most important for the nurse to assess the client’s beliefs regarding the cause of current illnesses. This will facilitate development of a culturally sensitive and appropriate teaching and care plan.

Block Time Remaining: 01:34:11
TIMEDTUTOR
Test Id: 80617473
QId: 31738 (921666)
66 of 71
A A A
A client who is 24-hours postoperative bowel resection is receiving IV opioids for severe pain. The nurse reviews the health care provider’s (HCP’s) prescription to discontinue the continuous IV fluids and advance the diet from clear liquids to regular diet as tolerated. What is the nurse’s most appropriate action?1. Apply a saline lock adaptor [52%]
2. Contact the HCP to request a prescription for a saline lock [18%]
3. Remove the IV catheter [7%]
4. Slow the IV fluids to a keep-vein-open rate [20%]
Omitted
Correct answer
1
Answered correctly
52% Time: 1 seconds
Updated: 04/09/2017
Explanation:

The nurse identifies severe pain as a major problem because if it is not controlled adequately, the client is less likely to move or breathe deeply and more likely to develop postoperative complications (eg, venous thrombosis, atelectasis, pneumonia). The nurse should discontinue the IV infusion and apply a saline lock adaptor to maintain IV access (without clotting). The HCP’s prescription to lock the IV catheter is implied, as the client is currently receiving IV opioids.

(Options 2 and 4) The HCP’s prescription specifies that IV fluids should be discontinued; there is no mention of IV catheter removal or about slowing the infusion to a keep-vein-open rate. A saline lock will be sufficient to maintain the line patency and allows greater mobility than a continuous infusion.

(Option 3) The client is only 24-hours postoperative abdominal surgery, and IV access is necessary to administer medications (eg, antibiotics, analgesics, antiemetics). If the client does not tolerate diet advancement, IV fluids may also need to be restarted.

Educational objective:
IV access is necessary to administer intermittent IV opioids to control postoperative pain. Saline lock will be enough to maintain the line patency and allows greater mobility than a continuous infusion.

Block Time Remaining: 01:34:09
TIMEDTUTOR
Test Id: 80617473
QId: 32300 (921666)
67 of 71
A A A
The nurse is preparing to irrigate the ears of a 67-year-old client with impacted cerumen. Place the following steps for ear irrigation in the correct order. All options must be used.Your Response/ Incorrect Response
Correct Response
Assess the client for fever, ear infection, or tympanic membrane injury
Place the client in a sitting position with the head tilted toward the affected ear
Place a towel and an emesis basin under the ear
Straighten the ear canal by pulling the pinna up and back
Gently irrigate the ear canal with a slow, steady flow of solution
Omitted
Correct answer
1,4,3,5,2
Answered correctly
58% Time: 2 seconds
Updated: 03/26/2017
Explanation:

Ear irrigation may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure:

Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies (Option 1).

Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth).

Place the client in a side-lying or sitting position with the head tilted toward the affected ear (Option 4). Place a towel and an emesis basin under the ear (Option 3).

Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort.

Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ≤3 years (Option 5).

Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal (Option 2). Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences severe pain, nausea, or dizziness.

Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled.

Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching.

Educational objective:
To perform ear irrigation, assess for contraindications (fever, ear infection, tympanic membrane injury); tilt the affected ear down; straighten the ear canal; and use a solution at body temperature to irrigate gently, aiming toward the top of the ear canal until it is clear.

Block Time Remaining: 01:34:08
TIMEDTUTOR
Test Id: 80617473
QId: 30731 (921666)
68 of 71
A A A
A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, “Is this disease going to kill me?” What is the best response by the nurse?1. “Hearing this diagnosis must have been difficult for you. What are your thoughts?” [95%]
2. “We will do everything possible to prevent that from happening.” [3%]
3. “Well, we’re all going to die sometime.” [0%]
4. “You should concentrate on getting better rather than thinking about death.” [1%]
Omitted
Correct answer
1
Answered correctly
95% Time: 1 seconds
Updated: 01/22/2017
Explanation:

The stress of receiving a life-threatening diagnosis often causes clients to feel very vulnerable. There is a tendency to keep feelings and concerns closed off; clients may not be able to express how distressed they feel or find the right words to express feelings and concerns. In asking, “Is this disease going to kill me?,” the client is most likely not looking for a direct “yes” or “no” answer. This would immediately close off the conversation and create a missed opportunity for a meaningful engagement and communication with the nurse. It is more likely that this question is being asked to provide an opening for further discussion about the meaning of this devastating diagnosis as well as the client’s thoughts and feelings.

The nurse can facilitate a sense of trust, connection, and collaboration by the following:

Providing empathy – acknowledging the distressing nature of the diagnosis
Providing situations (eg, broad opening for discussion) in which the client can share thoughts and feelings in a safe environment
Active listening – being very attentive to what the client is saying and trying to understand what the client is thinking and feeling
Focusing – going beyond words and explanations to attain new awareness of a client’s concerns
Communicating effectively will assist the client in coping with difficult situations, reducing stress, and developing approaches for making necessary life changes
(Option 2) This response attempts to give reassurance but does not address the client’s thoughts and concerns.

(Option 3) This is a very trite response and will close down any opportunity for further discussion.

(Option 4) This response gives advice to the client and is non-therapeutic; it does not acknowledge the client’s current concerns.

Educational objective:
Clients with devastating conditions or situations may have difficulty expressing their concerns, thoughts, and feelings. A nurse who is skilled in using effective communication techniques such as active listening, providing broad openings for discussion, and focusing can help clients cope with and reduce the stress of difficult situations.

Block Time Remaining: 01:34:07
TIMEDTUTOR
Test Id: 80617473
QId: 31296 (921666)
69 of 71
A A A
An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP’s recommendation that the client stay a few more days. Which is the most appropriate initial response by the nurse?1. “I understand your desire to leave, but it would be very risky.” [2%]
2. “I will ask the palliative care nurse to talk with you to help clarify your care goals.” [3%]
3. “I will let the HCP know that you want to be discharged and do everything I can to make it happen.” [5%]
4. “Tell me more about your need to leave the hospital.” [87%]
Omitted
Correct answer
4
Answered correctly
87% Time: 1 seconds
Updated: 01/05/2017
Explanation:

Knowing that this client has just received bad news with a limited prognosis, the nurse should anticipate that the client’s urgent request for discharge may be due to concerns about needing to complete unfinished business while still functioning. Examples of end-of-life “business” include concerns about family, finances, business responsibilities, and dealing with property and possessions.

To get more information, the nurse should assess the client’s concern and the motivation behind the request by asking an open-ended question, such as “Tell me more about ______.” It is important to gain the client’s trust, to actively listen, and to avoid immediately jumping to problem-solving during this assessment (Option 4).

With the information gained from the assessment, the nurse will be able to problem-solve with the client while intervening and advocating as appropriate.

(Option 1) Although leaving may be risky for the client, the nurse’s warning is not an appropriate initial action.

(Option 2) The nurse is not taking the time to listen but is passing this responsibility to another member of the team. A palliative care nurse referral may be appropriate in this situation, but the nurse needs more information and must take the time to listen to the client now.

(Option 3) This option does not acknowledge the HCP’s concern about the client still needing to be hospitalized. The nurse must first understand the client’s situation and then take this information to the HCP to negotiate for a solution that acknowledges the concerns of both.

Educational objective:
A client facing the end of life often has unfinished business that needs to be completed, which may motivate the client to become anxious or insist on discharge. The nurse should assess the client’s concern and use this information to design a care plan that will allow the client to make necessary preparations while ensuring medical care to control symptoms.
.

Block Time Remaining: 01:34:06
TIMEDTUTOR
Test Id: 80617473
QId: 31079 (921666)
70 of 71
A A A
The unit implemented a quality improvement program to address client pain relief. Which set of criteria is the best determinant that the goal has been met?1. Chart audits found clients’ self-reported pain scores improved by 10% [63%]
2. Number of narcotics used on the unit increased by 20% [2%]
3. Positive comments on returned client satisfaction surveys increased by 30% [28%]
4. Survey found that 90% of the nurses believed clients had better pain control [6%]
Omitted
Correct answer
1
Answered correctly
63% Time: 1 seconds
Updated: 12/12/2016
Explanation:

Measurements should be objective, rather than subjective. Evidence-based criteria should be used, if applicable. These survey results are objective, retrospective measurements of a positive change.

(Option 2) This increase in use could be attributed to many other factors, including difference in the number or type of clients on the unit and theft of the narcotics. In addition, clients may obtain pain relief by alternate means.

(Option 3) These are subjective criteria. It is possible to consider satisfaction as an outcome, but there is no indication in the option that the percentage of returned surveys is a satisfactory amount. There is no indication whether the positive comments are about pain relief or other aspects of care. There is no indication if these clients had pain relief as part of their nursing needs.

(Option 4) This is a subjective perception on the part of the nurses that may or may not be accurate.

Educational objective:
The outcomes of a quality improvement program should be objective and measureable.
.

Block Time Remaining: 01:34:05
TIMEDTUTOR
Test Id: 80617473
QId: 30077 (921666)
71 of 71
A A A
The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?1. Administer the prescribed as-needed milk of magnesia [16%]
2. Ask dietary services to add more fruits and vegetables to the client’s tray [5%]
3. Notify the health care provider (HCP) [4%]
4. Perform a focused abdominal assessment [73%]
Omitted
Correct answer
4
Answered correctly
73% Time: 1 seconds
Updated: 04/26/2017
Explanation:

Constipation may develop as a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse’s first priority is to assess the client. The nurse can administer the as-needed laxative once it has been determined to be safe. The HCP is contacted if the focused abdominal assessment indicates a potential complication, such as postoperative ileus.

(Option 1) The nurse’s first priority is assessment. A laxative would not help if this client had intestinal obstruction (from adhesions).

(Option 2) The client is taught to eat a high-fiber diet and increase fluid intake to promote normal bowel function. The nurse would not change the diet until further assessment of the client is accomplished and the HCP has prescribed a new diet.

(Option 3) The nurse should further assess the client before contacting the HCP.

Educational objective:
Constipation may be a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse’s first priority is to assess the client and then use measures that promote normal bowel function (eg, as-needed laxatives, stool softeners, bulk agents, high-fiber diet, increased fluids).

Block Time Remaining: 00:00:24
TUTOR
Test Id: 80620147
QId: 30907 (921666)
1 of 75
A A A
The nurse is assessing a client’s peripheral pulses. The nurse palpates the top portion of the client’s foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. How should the nurse document these findings?1. Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+. [76%]
2. Bilateral DP pulses palpable. Right DP 3+, left DP 2+. [14%]
3. Bilateral popliteal pulses palpable. Right foot > left foot. [4%]
4. Bilateral posterior tibial (PT) pulses palpable. Right PT 2+, left PT 1+. [4%]
Correct Answered correctly
76% Time: 24 seconds
Updated: 03/16/2017
Explanation:

The DP pulse is located on the top or dorsal part of the foot. The nurse should compare the characteristics of the arteries on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated on the following scale.

0 Absent
1+ Weak
2+ Normal
3+ Increased, full, bounding
(Option 2) DP is the correct artery being assessed, but 3+ would indicate a full, bounding pulse and 2+ would indicate a normal pulse.

(Option 3) The popliteal pulse is assessed just behind the knee area, not on the foot. The description of the right foot being greater than the left foot does not indicate the force of the individual pulse.

(Option 4) Posterior tibial pulses are palpated just behind the medial malleolus bone on the foot. The description of 2+ and 1+ is accurate.

Educational objective:
The nurse should palpate and compare the characteristic and quality of the pulses on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated as 0, absent; 1+, weak; 2+, normal; and 3+, increased, full, bounding. These descriptions should be documented in the client’s record.

SKILLS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Block Time Remaining: 00:01:33
TUTOR
Test Id: 80620147
QId: 30589 (921666)
2 of 75
A A A
The nurse caring for a female client reviews a prescription for insertion of an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks the unlicensed assistive personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used.Unordered Options
Apply sterile gloves
Cleanse labial fold with antiseptic swab
Insert catheter until urine is visualized
Perform hand hygiene
Use nondominant hand to spread the labia
Wipe meatus with antiseptic swab
Your Response/ Correct Response
Perform hand hygiene
Apply sterile gloves
Use nondominant hand to spread the labia
Cleanse labial fold with antiseptic swab
Wipe meatus with antiseptic swab
Insert catheter until urine is visualized
Correct Answered correctly
44% Time: 69 seconds
Updated: 01/15/2017
Explanation:

Critical steps to indwelling catheter insertion for the female client include the following:

Perform hand hygiene
After ensuring privacy, position client in the dorsal recumbent position and drape
Open the catheterization kit on a clean bedside table or between client’s legs
Touching only the outside 1″ border, place sterile drape under the client’s hips
Apply sterile gloves
Apply fenestrated drape over perineum
Organize remaining items in the kit. Place top tray on a sterile field and ensure the clamp on the catheter is closed.
Open antiseptic swabs with stick end up or pour antiseptic solution over cotton balls
Squirt lubricant into tray
Remove protective sheath from catheter and place the tip in lubricant
Using the nondominant hand, spread the labia to expose the urethral meatus
Use the antiseptic swab (or cotton ball with forceps) to cleanse the perineum. Wipe in the direction from clitoris to anus. Always use a new swab or cotton ball with each swipe. Cleanse far labial fold, near labial fold and finally the meatus.
Using the dominant hand, pick up catheter and insert until urine is visualized (usually about 3″), then advance another 1-2″. If obstruction occurs, do not force the catheter.
Let go of the labia but hold the catheter securely in place with the nondominant hand.
Inflate the balloon according to manufacturer instructions (most manufacturers now warn against testing the balloon prior to insertion)
Anchor indwelling catheter and secure drainage bag to the bed frame
Educational objective:
To insert an indwelling urinary catheter on a female client, perform hand hygiene; position; open the urinary catheter kit; place sterile drape under the hips; apply sterile gloves; empty lubricant into tray and place tip of catheter in lubricant; spread labia with the nondominant hand and cleanse front to back, outer to inner with meatus last using a new swab each time; insert catheter until urine is visualized and then advance 1-2″; and inflate balloon. Maintaining sterile technique throughout the procedure is imperative.

In aortic stenosis, there is a narrowing of the valve opening between the left ventricle and aorta. On auscultation, a loud, systolic ejection murmur (heard following the S1) is heard over the aortic area found at the right sternal border, second intercostal space.

Valvular disorders (eg, stenosis, regurgitation, prolapse) are best heard over their respective areas. These include:

The pulmonic area – auscultated over the left sternal border at the second intercostal space
Erb’s point (where S2 is best heard) – auscultated at the left sternal border in the 3rd intercostal space
The tricuspid area – located at the left lower sternal border (at the 4th or 5th intercostal space)
The mitral area – auscultated at the left mid-clavicular line at the 5th intercostal space
Educational objective:
Disorders of the aortic valve are best auscultated over the aortic area (right sternal border, second intercostal space).

Block Time Remaining: 00:03:11
TUTOR
Test Id: 80620147
QId: 30079 (921666)
5 of 75
A A A
While preparing to insert a peripheral IV line, the nurse notices scarring near the client’s left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply.1. Advance the entire stylet into the vein upon venipuncture
2. Insert the IV line into the most distal site of the right arm
3. Place an appropriate precaution sign above the bed
4. Review the medical record for history of mastectomy
5. Teach the client to keep the left arm in a dependent position
Incorrect
Correct answer
2,3,4
Answered correctly
33% Time: 39 seconds
Updated: 01/17/2017
Explanation:

A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated.

The nurse should insert the IV line into the most distal site of the unaffected side (Option 2). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client’s bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) (Options 3 and 4).

In general, venipuncture is contraindicated in upper extremities affected by:

Weakness
Paralysis
Infection
Arteriovenous fistula or graft (used for hemodialysis)
Impaired lymphatic drainage (prior mastectomy)
(Option 1) The stylet should be advanced until blood return is seen (approximately ¼ inch). If advanced fully, the stylet may penetrate the posterior wall of the vein and cause a hematoma.

(Option 5) Keeping the affected arm in a dependent position for a long time can increase lymphedema. The client should be reminded that raising the limb helps drainage.

Educational objective:
IV line insertion is contraindicated on the operative side of clients with a prior mastectomy. Additional contraindications for IV line insertion include weakness, paralysis, or infection of the arm; or presence of an arteriovenous fistula.

Block Time Remaining: 00:03:57
TUTOR
Test Id: 80620147
QId: 31001 (921666)
6 of 75
A A A
ExhibitThe nurse is assessing urine dipstick results in a client with right flank area pain for the past 24 hours. According to the dipstick results, what is the nurse’s best action? Click on the exhibit button for additional information.

1. Ask the client about any recent illnesses [61%]
2. Consult the diabetes educator [2%]
3. Notify the health care provider (HCP) immediately [22%]
4. Repeat the test to verify the findings [14%]
Correct Answered correctly
61% Time: 46 seconds
Updated: 01/01/2017
Explanation:

The protein test pad measures the amount of albumin in the urine. Normally, there will not be detectable quantities. Albumin is smaller than most other proteins and is typically the first protein that is seen in the urine when kidney dysfunction begins to develop. Proteinuria is characterized by elevated urine protein and can be an early sign of kidney disease. Occasional loss of up to 150 mg/day of protein in the urine, which may reflect as negative or trace protein on a dipstick, is typically considered normal and usually does not require further evaluation. Common benign causes of transient proteinuria include fever, strenuous exercise, and prolonged standing.

(Option 2) Glucose in the urine is suspicious for diabetes mellitus. This client’s glucose test strip result is negative.

(Option 3) Nurse should obtain more information and assess before reporting to the HCP.

(Option 4) There is no indication for the test to be repeated.

Educational objective:
The results of point-of-care testing, such as using urine test strips, are often interpreted by the nurse. Occasional loss of up to 150 mg/day of protein in the urine is typically considered normal and usually does not require further evaluation. Common benign causes of transient proteinuria include fever, strenuous exercise, and prolonged standing.

.

The nurse should position the client with the head of the bed at a 30- to 45-degree angle to assess for the presence of JVD.
When administering oral medications to children, flavorings can be added to mask the taste or the medication can be mixed with jam or pudding. The child is held in the semi-reclining position to prevent aspiration. An infant nipple may be used to administer medication, but a plastic disposable medication syringe or plastic medicine spoon are preferred for accuracy.

Leakage of more than 500 mL of air into a central venous catheter is potentially fatal. An air embolism in the small pulmonary capillaries obstructs blood circulation. A central venous catheter leaks air rapidly at 100 mL/sec. This client requires immediate intervention to prevent further complications (eg, cardiac arrest, death). The nurse should not delay emergency treatment, not even to stop and contact the HCP or the rapid response team (RRT).

Priority interventions for active or suspected air embolism are as follows:

Clamp the catheter to prevent more air from embolizing into the venous circulation.
Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium.
Administer oxygen if necessary to relieve dyspnea.
Notify the HCP or call an RRT to provide further resuscitation measures.
Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.
Educational objective:
Any delay in treatment of an air embolism could prove fatal. There is no time to call the HCP. Seal off the source of the leak, and ensure stabilization of the air bubble via left lateral positioning.

Proper airway suctioning technique includes preoxygenation, limiting a suction pass to 10 seconds, and allowing 1-2 minutes between passes to prevent hypoxia. Medium suction pressure should be set at 100-120 mm Hg for adults, with the catheter inserted without suction.
The Heimlich maneuver (ie, upward abdominal thrusts under the rib cage) is the primary rescue intervention for children over age 1 with a foreign body airway obstruction causing respiratory distress. Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Blind sweeping of a child’s mouth should not be attempted.
Block Time Remaining: 00:06:45
TUTOR
Test Id: 80620147
QId: 31358 (921666)
15 of 75
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Which interventions should the nurse perform when assisting the health care provider with removal of a client’s chest tube? Select all that apply.1. Ensure the client is given an analgesic 30-60 minutes before tube removal
2. Instruct the client to breathe in, hold it, and bear down while the tube is being removed
3. Place the client in the Trendelenburg position
4. Prepare a sterile airtight petroleum jelly gauze dressing
5. Provide the health care provider with sterile suture removal equipment
Incorrect
Correct answer
1,2,4,5
Answered correctly
34% Time: 32 seconds
Updated: 01/19/2017
Explanation:

A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include:

Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal (Option 1).
Provide the health care provider (HCP) with sterile suture removal equipment (Option 5).
Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option 2).
Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space (Option 4).
Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame.
(Option 3) The client should be placed in semi-Fowler’s position or on the unaffected side to promote comfort and facilitate access for tube removal.

Educational objective:
Before chest tube removal, the client is given an analgesic and then asked to perform Valsalva during the procedure. The nurse should also bring sterile suture removal equipment and a sterile airtight occlusive dressing. Post-procedure chest x-ray is necessary within 2-24 hours.

Block Time Remaining: 00:07:08
TUTOR
Test Id: 80620147
QId: 31054 (921666)
16 of 75
A A A
The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen. The nurse intervenes when the student performs which action?1. Instills ear drops at room temperature [1%]
2. Instills ear drops with dropper by occluding the ear canal [69%]
3. Places a cotton ball loosely in outermost auditory canal after the instillation [14%]
4. Pulls pinna up and back and instills drops [14%]
Correct Answered correctly
69% Time: 23 seconds
Updated: 03/25/2017
Explanation:

Otic medications are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect trapped in the ear canal. They are contraindicated in a client with a perforated eardrum.

The general procedure for instilling ear drops includes the following steps:

Perform hand hygiene and don clean gloves. The ear canal is not sterile, but aseptic technique is used

Position the client side-lying with the affected ear up (if not contraindicated). This facilitates administration and prevents drops from leaking out of the ear

Warm ear drops to room temperature (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal ear is sensitive to temperature extremes (Option 1)

Pull the pinna up and back to straighten the ear canal in clients >4 years old and adults. Pull the pinna down and back in clients <3 years old (Option 4)

Support hand on the client’s head and instill the prescribed number of drops by holding the dropper 1 cm (1/2 in) above the ear canal. This avoids damaging the ear canal with the dropper (Option 2)

Apply gentle pressure to the tragus (fleshy part of external ear canal) if it does not cause pain, which facilitates the flow of medication into the ear canal

Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage

Place a cotton ball loosely in the client’s outermost ear canal for 15 minutes, only if needed, to absorb excess medication. Perform this with caution and avoid in infants or very young clients as it is a choking hazard (Option 3)

Educational objective:
To administer otic medications in an adult client, follow these steps: (1) Perform hand hygiene, (2) position the client side-lying with the affected ear up, (3) pull pinna up and back, (4) administer prescribed number of ear drops, (5) instruct the client to remain side-lying for 2-3 minutes, and (6) place cotton ball loosely in the outer ear canal for 15 minutes (if needed).

A urine specimen is collected aseptically from the specimen port in an indwelling urinary catheter. Urine that has been collected from the collection bag does not yield accurate urinalysis and culture results.
A DNR order requires the nurse to withhold resuscitation in the event of a cardiac or respiratory arrest. If an event occurs, the nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the HCP to confirm the death.
Block Time Remaining: 00:08:30
TUTOR
Test Id: 80620147
QId: 30327 (921666)
19 of 75
A A A
An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client with a right subclavian triple-lumen central venous catheter (CVC). Which statement by the graduate nurse indicates understanding of the CVC?1. “All 3 lumens come together, so all drugs infused through the CVC must be compatible.” [14%]
2. “It is used to provide enteral nutrition to the client who cannot eat.” [5%]
3. “Sterile gloves must be worn when administering drugs through the CVC.” [11%]
4. “The lumen hub should be cleaned thoroughly with antiseptic prior to drug administration.” [67%]
Correct Answered correctly
67% Time: 30 seconds
Updated: 05/30/2017
Explanation:

A central line or central venous catheter (CVC) is inserted by the health care provider in a “central” vein (eg, subclavian, internal jugular, femoral) and is used to administer fluids, medications, and parenteral nutrition and for hemodynamic monitoring.

Proper hand hygiene should be performed when caring for a CVC to prevent infection, and nonsterile gloves should be worn to protect the nurse from blood or body fluids at the port site as one or more lumens are often used to draw blood (Option 3).

The Centers for Disease Control and Prevention recommend that catheter hubs always be handled aseptically to prevent catheter-associated infections. The hubs should be disinfected with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5% chlorhexidine with alcohol; 10% povidone-iodine). Always allow the antiseptic to dry before using the hub/port (Option 4).

(Option 1) CVCs may have multiple lumens. These are used to administer incompatible drugs simultaneously, for blood draws, and for hemodynamic monitoring.

(Option 2) Enteral nutrition is given only through the GI tract (orally or through a feeding tube). Parenteral nutrition is administered through the IV route via a central vein.

Educational objective:
A central venous catheter is used to administer fluids, for simultaneous infusion of incompatible drugs, for parenteral nutrition, and for hemodynamic monitoring. The nurse should always handle the lumen ports and hubs aseptically with facility-approved antiseptics to prevent catheter-associated infections.

The nurse’s role in informed consent is to witness a client’s signature and ascertain that the client signed voluntarily, was competent to provide consent at the time of signature, received the necessary information, and has no further questions.
The nurse can teach a client or caregiver to inject subcutaneous enoxaparin. The appropriate site of injection is on the right or left side of the abdomen at least 2 in from the umbilicus.

he steps below should be performed to calculate the amount of heparin that needs to be administered.

Convert pounds to kilograms (standard conversion is 1 kg = 2.2 lb):

108 lb ÷ 2.2 lb = 49.09 kg

Calculate prescribed bolus dose in units:

70 units x 49.09 kg = 3,436 units

Convert prescribed bolus dose from units to mL:

Desired x Quantity
Available

3436 units x 1 mL = 3.436 mL (round down to 3.4 mL)
1000 units

The nurse is to administer a 3.4 mL bolus of heparin IV push.

Educational objective:
The nurse calculates the amount of heparin to be administered by converting pounds to kilograms, calculating the prescribed bolus dose in units, and then converting the prescribed dose from units to mL.

The general steps for administering a continuous enteral feeding include identifying the client, elevating the head of bed at least 30 degrees, validating tube placement, flushing the tube with 30 mL of water, and administering the prescribed enteral feeding solution.
Block Time Remaining: 00:10:25
TUTOR
Test Id: 80620147
QId: 30869 (921666)
24 of 75
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A client receives intermittent bolus enteral feedings through a nasogastric tube. Which are appropriate nursing actions prior to starting the feeding? Select all that apply.1. Discard aspirated residual volume in a biohazard container
2. Flush the tube before and after the feeding
3. Place the client in the semi-Fowler position
4. Start the feeding after obtaining a gastric residual volume <100 mL 5. Start the feeding when the residual volume has pH of 6 Correct Answered correctly 46% Time: 30 seconds Updated: 01/03/2017 Explanation: The head of the bed should be elevated to a minimum of 30 degrees (semi-Fowler position) during enteral feedings and for 30-60 minutes afterward, thereby decreasing aspiration risk. Many institutions have policies that require the nurse to hold the feeding if the client must be supine (eg, diagnostic tests). Gastric residual volumes are checked every 4 hours with continuous feeding or before each intermittent feeding and medication administration. Continuing feedings despite a large volume residual increases the client’s risk for emesis and aspiration. Recent evidence suggests that holding the feeding for a residual volume >100 mL is not necessary, and some institutional policies allow a residual volume of up to >500 mL as long as the client is asymptomatic.

Flush the tube before and after bolus feedings to keep the tube patent and avoid contamination of the stagnant feeding solution. Sterile fluid is used to help prevent infection in vulnerable clients.

(Option 1) Aspirated residual volume should be returned to the stomach. If acidic gastric juices are repeatedly discarded (2,500 mL secreted daily), there is risk for metabolic alkalosis and hypokalemia.

(Option 5) Gastric pH should be acidic (pH ≤5). A pH ≥6 requires x-ray confirmation of tube placement. In addition, any newly inserted nasogastric tube requires x-ray confirmation of tube location.

Educational objective:
Care of a client receiving enteral feedings requires elevating the head of the bed, monitoring for acidic pH ≤5, assessing for excessive residual volume, returning aspirated residual volume to the stomach, and flushing the tubing before and after bolus intermittent feeding.

A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results.

Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a hematoma.

(Option 2) Skin preparation involves cleaning using an antiseptic solution and friction and allowing the skin to air dry. Remaining solution may hemolyze and/or dilute the blood sample. Traditionally, alcohol (alone or with povidone iodine) is applied in a circular motion, from insertion site outward (clean to dirty). Current research suggests that the most effective method is applying chlorhexidine (2%) in a back and forth motion, followed by adequate drying time.

(Option 4) The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided.

(Option 5) The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results.

Educational objective:
When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

teach client the following steps for self-administration of ophthalmic ointments:

Perform hand hygiene
Tilt the head back, pull the lower lid down, and look upward
Squeeze a thin strip of ointment onto the lower eyelid, from the inner to the outer edge
Close the eyes gently for 2-3 minutes after applying the ointment

Explanation:

Albumin may be given after paracentesis to prevent volume depletion in a client with ascitic cirrhosis. Calculation of the amount of medication in mL to be infused requires two calculations: 1) the total amount of medication prescribed in grams and 2) the volume of the infusion containing this correct amount of medication.

Step 1: Calculate the total amount of albumin prescribed in grams.

1000 X = 43200
X = 43.2 g
Step 2: Calculate the volume of albumin that will deliver the total prescribed amount:
(Remember: 25 g in a 100 mL bottle)

25 X = 4320
X = 172.8 mL
Educational objective:
Albumin may be given after paracentesis to prevent volume depletion. To calculate how many milliliters to administer when the prescribed medication is provided in grams/milliliter, the nurse should first determine the total dose of medication prescribed in grams. Then, the prescribed dose should be converted from grams to milliliters using the volume of the supplied medication (eg, 25 g in 100 mL).

Instructions when injecting a prefilled enoxaparin syringe include to choose an injection site on the right or left side of abdomen, 2 inches from umbilicus, do not expel the air bubble in the syringe, insert the needle at a 90-degree angle into a pinched-up area of skin, and discourage the client from rubbing the site.

Urine output would be expected as this client has not voided for 6 hours (obligatory amount is at least 30 mL x 6 = 180 mL). The most common explanation is that the catheter was unintentionally inserted into the vagina. The nurse should leave that catheter as a landmark and insert a new sterile catheter into the urethra which is located above the vagina.

(Option 2) There sometimes can be a brief (15 second) delay from the water-based lubricant partially blocking the opening before quickly “melting.” 30 minutes is too long a delay without an additional intervention. There is no reason to wait that long.

(Option 3) There is no sign that there is an obstruction; the catheter was not adequately inserted.

(Option 4) A urinary catheter should never be reused as it is no longer sterile and may introduce bacteria in the urinary tract; a new one should always be obtained. By removing the first catheter, the nurse will be more likely to re-insert it into the same (wrong) opening.

Educational objective:
If no urine is returned from Foley catheter insertion in a female client after a short time, the nurse has probably not inserted it into the correct opening. The nurse should leave the original catheter in place and reinsert a new sterile catheter above the original position.

Educational objective:
A feeding tube is marked with indelible ink at the exit site (nare). If the external length of the tube changes, the nurse should contact the health care provider and request a prescription for a repeat x-ray to determine tube location before resuming administration of enteral feedings and medications.

The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host’s antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs.

Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body’s physiological processes after the blood transfusion has started

An acute hemolytic transfusion reaction is a life-threatening reaction caused primarily by blood incompatibility. If it occurs, the transfusion should be stopped and a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. Asking the client to void prior to starting the transfusion helps ensure that any urine specimen collected after a reaction is reflective of the body’s physiological processes after the blood transfusion.
Coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx. When this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube.
In clients with HIV, who have had an organ transplant, are immunocompromised, or have been exposed to active TB, even a ≥5 mm of induration is considered positive.
Clients who do not belong to either the ≥5 mm group or the ≥15 mm group (healthy individuals) likely are in the ≥10 mm positive group. Erythema is not considered in the interpretation of TST results.

The TST result depends on the size of the indurated area and on the client’s risk for becoming infected with tuberculosis (TB) bacteria and developing TB disease. The nurse determines the presence or absence of a visible raised and palpable area of induration (hardness) or swelling; if present, this is measured with a flexible ruler calibrated in mm or with calipers. The nurse documents the reaction objectively by recording the size of the reaction in mm (eg, 0-15 mm).

Immunocompromised clients cannot elicit a good inflammatory response, and so even 5 mm of induration is considered positive; these clients include all HIV and organ transplant recipients (who are usually on immunosuppressant medications). An individual exposed to active TB is at very high risk of developing TB infection; therefore, even 5 mm is considered positive in these clients as well.

In all normal healthy individuals, ≥15 mm induration is considered abnormal (Option 4). Clients who do not belong to either the ≥5 mm group (HIV, organ transplant, immunocompromised, or exposure to active TB) or the ≥15 mm group (healthy individuals) are likely to be in the ≥10 mm positive group.

Block Time Remaining: 00:15:39
TUTOR
Test Id: 80620147
QId: 30995 (921666)
34 of 75
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A client with hypokalemia is prescribed intravenous (IV) potassium chloride (KCL) to infuse at 10 mEq/hr. The pharmacy sends 20 mEq in 250 mL D5W. To deliver the prescribed dose, the nurse sets the infusion pump at how many milliliters per hour? Record your answer using a whole number.Answer:
1
(mL/hr)

Incorrect
Correct answer
125
Answered correctly
82% Time: 12 seconds
Updated: 12/09/2016
Explanation:

Calculate the infusion rate:

20 mEq = 10 mEq
250 mL X mL
20 X = 2500
X = 125 mL/hour
The nurse programs the infusion pump at 125 mL/hr to deliver the prescribed dose of 10 mEq/hr.

Educational objective:
IV KCL is a high-alert drug and is administered using an infusion pump at no more than 10 mEq/hr for adults.

Block Time Remaining: 00:16:15
TUTOR
Test Id: 80620147
QId: 34319 (921666)
35 of 75
A A A
The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply.1. Arrange for health care workers of the same sex to provide care for the client
2. Coordinate with the registered dietician to provide halal meals
3. Reposition the immobile client to face the city of Mecca during daily prayer times
4. Restrict the number of visitors from the family to preserve the client’s privacy
5. Upon death, provide the family with supplies for postmortem care
Correct Answered correctly
42% Time: 36 seconds
Updated: 12/21/2016
Explanation:

Spirituality, religious beliefs, and traditions are important to include in client care. Aspects of care for Muslim clients include:

Facilitating client to face Kaaba in the holy city of Mecca, generally northeastward from North America, during prayer (Option 3) – Ritual daily prayers occur 5 times a day, and dying clients may pray more often.
Modesty – Care providers should be the same sex as the client whenever possible (Option 1). The female client may require a hijab (traditional head covering) and/or gown to cover most of the body.
Providing foods that are halal (lawful), or acceptable for consumption (eg, no pork) – Kosher and vegetarian meals are acceptable if a specific halal menu is unavailable (Option 2). During Ramadan, the sick and dying are not required to fast with other Muslims from dawn until sunset. If the client chooses to fast, meals and medications should be rescheduled accordingly.
Postmortem care of the Muslim client involves ritual washing, usually performed by family members, in preparation for burial. Burial occurs quickly after death, sometimes the same day (Option 5).

(Option 4) In Islam, the family is the most important unit, and family presence brings strength to the individual. Multiple visitors should be accommodated unless they interfere with care.

Educational objective:
Important aspects of care for Muslim clients include accommodating the following client needs: Facing Kaaba in the holy city of Mecca for prayer, modesty considerations, adherence to dietary practices (halal or kosher meals and possibly fasting during Ramadan), and involvement of family.

If a client reports cramping or pain during instillation of an enema, the infusion should be stopped for 30 seconds and then resumed at a slower rate.

A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. The nurse’s role when assisting with a lumbar puncture includes the following:

Verify informed consent
Gather the lumbar puncture tray and needed supplies
Explain the procedure to older child and adult
Have client empty the bladder
Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table)
Assist the client in maintaining the proper position (hold the client if necessary)
Provide a distraction and reassure the client throughout the procedure
Label specimen containers as they are collected
Apply a bandage to the insertion site
Deliver specimens to the laboratory

When assisting with a lumbar puncture, the nurse verifies informed consent, gathers supplies, explains the procedure, has the client void, and then assists the client into position. During the procedure, the nurse provides a distraction, helps the client stay in position (if needed), and labels specimens as they are collected. Afterward, the nurse applies a bandage and ensures that the specimens are delivered to the laboratory.
Block Time Remaining: 00:19:06
TUTOR
Test Id: 80620147
QId: 31495 (921666)
38 of 75
A A A
A student nurse has prepared instructions for the caregiver of an 8-month-old who weighs 16.5 lb. The health care provider (HCP) has prescribed oral amoxicillin 25 mg/kg/day in 2 divided doses for 5 days as treatment for acute otitis media. Amoxicillin for oral suspension comes packaged as 125 mg/5 mL. Which instruction by the student nurse needs an intervention by the RN?1. “Give the medicine right before feeding your baby.” [18%]
2. “Give your baby 7.5 mL of the medicine at 8 AM and 8 PM.” [62%]
3. “Give your baby the medicine for the full 5 days even if the baby seems better before then.” [13%]
4. “Stroke your baby’s cheek gently before administering the medicine.” [4%]
Correct Answered correctly
62% Time: 71 seconds
Updated: 12/13/2016
Explanation:

The dose of amoxicillin that the infant should receive is 3.75 mL at 8 AM and 3.75 mL at 8 PM. Instruction by the student nurse to administer 7.5 mL twice daily is incorrect and requires intervention by the RN.

Calculation

Determine infant’s weight in kg:
16.5 lb/2.2 kg = 7.5 kg

Calculate total daily dose:
25 mg x 7.5 kg = 187.5 mg

Calculate each dose:
187.5 mg/2 = 93.75 mg

Calculate amount in mL to administer:
5 mL : 125 mg = X mL : 93.75 mg
(5 mL/125 mg) x 93.75 mg = 3.75 mL

(Option 1) Amoxicillin may be given with or without food. Giving the medicine when the infant is hungry will make it more likely that the infant will swallow it.

(Option 3) The caregiver may notice that the infant seems better in 24-48 hours on the medication as evidenced by less or no pulling on the affected ear, increased appetite, and overall decreased fussiness. The caregiver should be instructed that the full course of the antibiotic needs to be administered for optimal effectiveness.

(Option 4) The infant will usually open his/her mouth when stroked on the cheek, allowing the caregiver to administer the medicine.

Educational objective:
Pediatric dosages are calculated by body weight measured in kg. The nurse needs to convert body weight in pounds to kilograms (1 kg = 2.2 lb) and then calculate each dose based on the HCP prescription and amount of the drug in a specified quantity (x mg in x mL).

Block Time Remaining: 00:20:03
TUTOR
Test Id: 80620147
QId: 31743 (921666)
39 of 75
A A A
A blood transfusion is prescribed for a client with sickle cell exacerbation and a hemoglobin level of 6 g/dL (60 g/L). Which are appropriate actions by the registered nurse? Select all that apply.1. Administer O negative (O-) blood to the AB positive (AB+) client
2. Delegate the fourth set of vital signs to the unlicensed assistive personnel
3. Prime line with normal saline prior to hanging the blood
4. Time the blood infusion to occur over a 6-hour period
5. Validate the client’s name and room number with a licensed practical nurse
Incorrect
Correct answer
1,2,3
Answered correctly
20% Time: 57 seconds
Updated: 04/14/2017
Explanation:

The blood type O- is the “universal donor” as it has no anti-A or anti-B antigens; AB+ is the “universal recipient” as the lack of antibodies allows any blood type to be transfused (Option 1).

Blood is always transfused with normal saline, not dextrose. The line should be established prior to obtaining the blood. Most facilities have a policy to start the blood within 30 minutes of obtaining it to prevent bacterial growth (Option 3).

The most likely time for a serious ABO incompatibility/transfusion reaction is when the infused blood first enters the client’s body. The registered nurse (RN) should remain in the room for the first 15 minutes/50 mL of the transfusion. However, the fourth set of vital signs would be taken after 1 hour of infusion; it would be safe to delegate this data collection to the unlicensed assistive personnel (the RN will analyze the vital signs) (Option 2).

(Option 4) Most facilities want the transfusion completed in 2-4 hours. “Old” blood is more likely to break apart and cause hyperkalemia from the intracellular potassium leak.

(Option 5) Most policies have the RN checking with another RN or qualified health care professional prior to blood administration. At least 2 identifiers such as name, medical record number, or date of birth can be used. Client identifiers never include a room number.

Educational objective:
Safe blood transfusion protocol includes checking of at least 2 client identifiers by 2 qualified health professionals, using normal saline to prime, and giving the infusion in 2-4 hours. The unlicensed assistive personnel can take vital signs during the later part of the transfusion. O- is the universal donor blood type and AB+ is the universal recipient.

During circumcision, the newborn is restrained in a wrapped blanket or placed on a special board to prevent injury. Non-nutritive sucking of a concentrated sucrose solution is offered for pain management.
Essential nursing actions related to a needle liver biopsy include checking coagulation, blood type, and crossmatch beforehand, positioning the client on the right side for hours afterward, and monitoring vital signs and for potential signs of shock.
Block Time Remaining: 00:21:58
TUTOR
Test Id: 80620147
QId: 31970 (921666)
41 of 75
A A A
The nurse is assisting a client who has a bedside needle liver biopsy scheduled. Which are the essential actions? Select all that apply.1. Assess for rising pulse and respirations afterward
2. Check PT/INR and PTT values before the procedure
3. Ensure that the client’s blood is typed and crossmatched
4. Have the client void to ensure an empty bladder
5. Position the client flat or on the left side after the procedure
Incorrect
Correct answer
1,2,3
Answered correctly
16% Time: 66 seconds
Updated: 03/14/2017
Explanation:

The client’s coagulation status is checked before the liver biopsy using PT/INR and PTT. The liver ordinarily produces many coagulation factors and is a highly vascular organ. Therefore, bleeding risk should be assessed and corrected prior to the biopsy (Option 2). Blood should be typed and crossmatched in case hemorrhage occurs (Option 3).

After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and respirations, with hypotension occurring later (Option 1).

(Option 4) The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety.

(Option 5) The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a “heavy” organ and can “fall on itself” to tamponade any bleeding. The client stays on bed rest for 12-14 hours.

Educational objective:
Essential nursing actions related to a needle liver biopsy include checking coagulation, blood type, and crossmatch beforehand, positioning the client on the right side for hours afterward, and monitoring vital signs and for potential signs of shock.

Block Time Remaining: 00:22:11
TUTOR
Test Id: 80620147
QId: 30623 (921666)
42 of 75
A A A
The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next?1. Further insert the catheter 1-2 in (2.5-5.1 cm) [82%]
2. Have the client hold his breath [1%]
3. Immediately inflate the 5 mL balloon [14%]
4. Secure the tubing to the client’s leg [1%]
Correct Answered correctly
82% Time: 16 seconds
Updated: 02/06/2017
Explanation:

Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to further insert the catheter before inflating the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma).

In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5 cm) or until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation.

(Option 2) The client should be told to take slow, deep breaths to help relax the external sphincter and provide a distraction.

(Option 3) The catheter needs to be inserted further before inflating the balloon to prevent urethral trauma.

(Option 4) Securing the catheter to the leg occurs after the balloon is inflated and placement is assured.

Educational objective:
Insert the Foley urinary catheter further if drops appear in the tubing to ensure that the tip with the balloon is in the bladder. Inflating the balloon before advancing the catheter could result in urethral trauma.

Block Time Remaining: 00:22:15
TUTOR
Test Id: 80620147
QId: 30508 (921666)
43 of 75
A A A
ExhibitThe nurse is caring for a client with a fluid volume deficit. Prescribed interventions include inserting a urinary catheter, collecting urine for urinalysis, and maintaining a strict record of intake and output. What is the client’s net intake and output? Click the exhibit button for additional information. Record your answer as a whole number.

Answer:
1
(mL)

Incorrect
Correct answer
1530
Answered correctly
22% Time: 4 seconds
Updated: 01/16/2017
Explanation:

Net intake and output is calculated by subtracting total output from total intake. The nurse should record all occurrences of intake and output.

Clients with a significant discrepancy in fluid intake and output are at risk for a fluid volume imbalance; however, daily weights are always the best indicator of fluid balance.

Net intake and output can be calculated by performing these steps:

Convert oral intake to mL using the following equivalents:
1 cup = 8 oz 1 oz = 30 mL 1 cup = 240 mL
Calculate total intake and total output:

Total intake = 1380 mL + 1500 mL = 2880 mL

Total output = 50 mL + 1300 mL = 1350 mL

Subtract total output from total intake:
Net intake and output = 2880 mL − 1350 mL = 1530 mL

Educational objective:
Net intake and output is calculated by subtracting total output from total intake. To calculate a client’s net intake and output, all values must be converted to milliliters (mL). Key conversions include 1 cup = 8 ounces, 1 ounce = 30 mL, and 1 cup = 240 mL.

Block Time Remaining: 00:23:09
TUTOR
Test Id: 80620147
QId: 31576 (921666)
44 of 75
A A A
Which client finding is most important for the nurse to follow up?1. Client with distinct liver edge even with right costal margin [13%]
2. Client with pyelonephritis who has costovertebral angle tenderness [12%]
3. Client with rash that has purplish blotches that do not blanch [31%]
4. Client with spinal injury whose toes point downward with the Babinski test [42%]
Correct Answered correctly
31% Time: 54 seconds
Updated: 01/07/2017
Explanation:

Purpura refers to reddish-purple blotches on the skin that do not blanch with pressure due to bleeding underneath the skin. Further assessment must be done to evaluate for a potentially serious etiology, such as blood dyscrasia.

(Option 1) The normal finding is a soft, distinct liver edge that is even with the bottom of the right rib cage or right costal margin. An abnormal finding would be a boggy liver edge below the rib cage (hepatomegaly).

(Option 2) Kidney inflammation (pyelonephritis) results in positive costovertebral angle (CVA) tenderness tenderness in the back/flank. It is an expected finding that is elicited when the examiner places the hand over the client’s lower back and places the other hand on top and makes a fist to gently “thump” or tap the area.

(Option 4) The Babinski sign can indicate an upper motor neuron lesion from damage to the corticospinal tract. A normal finding for an adult is for the toes to point downward.

Educational objective:
Purpura refers to purplish blotches indicating bleeding underneath the skin; it is a significant finding that requires further assessment.

Block Time Remaining: 00:23:26
TUTOR
Test Id: 80620147
QId: 33561 (921666)
45 of 75
A A A
The nurse receives report on 4 clients. Which client should the nurse assess first?1. Client with end-stage renal disease receiving hemodialysis who reports fever with chills and nausea [18%]
2. Client taking ibuprofen for ankylosing spondylitis who reports black-colored stools [11%]
3. Client with altered mental status who is not following commands starts vomiting [61%]
4. Client with acute diverticulitis receiving antibiotics who reports increasing abdominal pain [8%]
Correct Answered correctly
61% Time: 17 seconds
Updated: 12/10/2016
Explanation:

This client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting. This client should be assessed first; the client needs to be placed in the lateral position with head elevated and may need emergent intubation if airway cannot be protected.

(Option 1) Clients receiving hemodialysis are at risk for bloodstream infections. Blood cultures need to be obtained from a client with a bloodstream infection, and antibiotics would then be administered. This is not a priority over airway compromise.

(Option 2) Clients with ankylosing spondylitis often take nonsteroidal anti-inflammatory drugs to control back pain and are at risk of developing gastric ulcers. They can cause melena (black stools). The client needs further assessment of orthostatic vital signs and hemoglobin level. This is not a priority over airway compromise.

(Option 4) Clients with acute diverticulitis (inflammation of the diverticula) are at risk for perforation, which can be manifested by increasing abdominal pain, rigidity, guarding, and rebound tenderness (peritoneal signs). This client needs further assessment, but this is not a priority over airway compromise.

Educational objective:
A client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting.
.

Coughing is an important lung defense mechanism. Clients with chronic obstructive pulmonary disease (COPD) have weakened muscles and narrowed airways that are prone to collapse when under increased pressure. They are therefore unable to generate the high pressure needed to create the explosive rush of air to cough effectively.

The low-pressure “huff” cough, which uses a series of mini-coughs, is more effective in mobilizing and expectorating secretions in clients with COPD. When this technique is done correctly, there is less airway collapse, less energy and oxygen consumption, and greater secretion removal. The steps are as follows:

Educational objective:
The normal cough reflex creates high pressure in the airways. Because the airways of clients with chronic obstructive pulmonary disease are prone to collapse with increased airway pressure, clients are taught the low-pressure cough technique (huff) to expectorate mucus.

Position upright – maximizes lung expansion and gas exchange
Inhale through the nose using abdominal breathing and prolong the exhalation through pursed lips for 3 breaths – deflates excess air from lungs
Hold breath for 2-3 seconds following an inhalation, keeping the throat open – opens glottic structures and prevents a high-pressure cough
Deeply inhale and, while leaning forward, force the breath out gently using the abdominal muscles while making a “ha” sound (huff cough); repeat 2 more times (eg, “ha, ha, ha”) – keeps airways open while moving secretions up and out of the lungs.
Inhale deeply using abdominal breathing and give one forced huff cough – the last, increased force (“ha”) usually results in mucus being expectorated from the larger airways.
When working with a medical interpreter, the nurse should apply best practices to maximize communication and understanding with the client. Key practices include speaking to the client directly; using short, simple sentences; avoiding the use of family members as interpreters; and being mindful of cultural, gender, or age preferences.
Maintenance of sterile technique is a key outcome for indwelling urinary catheterization. A sterile field should be maintained during the entire procedure through proper placement of the kit and application of sterile gloves. The nondominant hand should be used for cleansing and kept in place to prevent contamination. The sterile dominant hand should be used for insertion.
Block Time Remaining: 00:25:42
TUTOR
Test Id: 80620147
QId: 30140 (921666)
49 of 75
A A A
A client with heart failure is prescribed a continuous IV infusion of dobutamine at 10 mcg/kg/min. He weighs 70 kg. The concentration of dobutamine is 250 mg in 500 mL D5W. For how many milliliters per hour should the nurse program the IV pump? Record your answer as a whole number.Answer:
1
(mL/hr)

Incorrect
Correct answer
84
Answered correctly
42% Time: 4 seconds
Updated: 12/21/2016
Explanation:

Dobutamine hydrochloride (Dobutrex) is a positive inotropic drug that increases cardiac muscle contractility. The dosage is weight-based and is prescribed in micrograms per kilogram per minute (mcg/kg/min) and administered with an IV pump. Because IV pumps are set by milliliters per hour (mL/hr), the nurse must be able to calculate the drug dose and the infusion rate in mL/hr.

Dobutrex can be diluted in dextrose or normal saline, and concentrations usually range from 500-2,000 micrograms per milliliter (mcg/mL) depending on client status. This medication may be administered in acute or long-term facilities or in the home. It is most often administered in the emergency department, intensive care unit, and step-down units. The nurse must always follow institution policy and procedure in relation to its dilution, dosage, administration, and titration.

The Joint Commission and Institute for Safe Medical Practices discourage the use of abbreviations for medication prescriptions and dosage calculations. They are used here to conserve space.

Convert mg to micrograms:

250 mg = 250,000 mcg
Calculate concentration:

250,000 mcg = 500 mcg/mL
500 mL
Calculate weight-based dose:

10 mcg x 70 kg/min = 700 mcg/min
Calculate the dose (10 mcg/kg/min) in mcg/mL:

500 mcg = 700 mcg = 1.4 mL/min
1 mL X mL
Calculate how many milliliters are to be infused over one hour:

1.4 mL x 60 minutes = 84 mL/h
Set the pump at 84 mL/h
The following formula may also be used to calculate the pump setting in mL/hr if a given dose is prescribed:

_______ mcg/kg/min x________ kg x 60 min/h ÷ ___________ mcg/mL = ____________mL/h
dosage client weight concentration pump setting
10 mcg/kg/min x 70 kg x 60 min = 84 mL/h
500 mcg/mL
Educational objective:
The nurse must be able to calculate weight-based titrated drug dosages and flow rates accurately because the administration of an incorrect dose or infusion rate can be life-threatening.

A 10 mL syringe is generally preferred for administering medications through a CVC. The smaller the syringe, the greater the amount of pressure per square inch (PSI) exerted during injection. If the pressure produced by the IV push is too high, it can damage the CVC. A damaged CVC may result in complications for the client, including embolism or malfunction. A 1 mL or 3 mL syringe may cause too much pressure (Options 1 and 2). The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC.

(Option 4) The nurse would have difficulty accurately drawing up precisely 3 mL of medication in a 30 mL syringe, which is too big for most IV pushes.

Educational objective:
When administering IV medications through a CVC, the nurse should use the safest syringe possible to avoid exerting too much pressure, which may damage the CVC. The smaller the syringe, the greater the amount of pressure exerted during the flush. A 10 mL syringe is generally recommended; however, it is important to consult the manufacturer guidelines.

Block Time Remaining: 00:25:59
TUTOR
Test Id: 80620147
QId: 30746 (921666)
51 of 75
A A A
The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus?1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip [7%]
2. Compare apical and radial pulses for any deficit [48%]
3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle [26%]
4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3 [17%]
Incorrect
Correct answer
3
Answered correctly
26% Time: 10 seconds
Updated: 01/26/2017
Explanation:

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:

Place client in semirecumbent position
Have client breathe normally
Determine the SBP using a manual BP cuff
Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP
Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure
Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure
Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox
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.

Block Time Remaining: 00:26:03
TUTOR
Test Id: 80620147
QId: 31394 (921666)
52 of 75
A A A
The health care provider prescribes a continuous IV insulin infusion for a client. The insulin drip is initiated with 50 units of regular insulin in 100 mL of normal saline solution at 5 units/hr. At what rate in milliliters per hour does the nurse set the IV pump? Record your answer using a whole number.Answer:
1
(mL/hr)

Incorrect
Correct answer
10
Answered correctly
65% Time: 4 seconds
Updated: 01/16/2017
Explanation:

The steps below should be performed to calculate the infusion pump rate in milliliters per hour:

Calculate the concentration of the insulin solution:
50 units ÷ 100 mL = 0.5 units/mL

Calculate the dose in mL/hr:
Desired x Quantity method
Available

5 units x 1 mL = 10 mL/hr
0.5 units

OR
Ratio/proportion method

0.5 units = 5 units
1 mL X mL

0.5X = 5

X = 10 = 10 mL/hr

Educational objective:
To set the IV pump in mL/hr for a prescribed dose of insulin in units/hr, the nurse first calculates the concentration of the insulin infusion, and then calculates the dose in mL/hr.

Neutral protamine Hagedorn (NPH) insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to decrease the risk of cross-contaminating multidose vials (mnemonic – RN: Regular comes before NPH).
Block Time Remaining: 00:27:25
TUTOR
Test Id: 80620147
QId: 34077 (921666)
54 of 75
A A A
A child with congenital heart disease weighing 44 lb is prescribed furosemide 1 mg/kg by mouth every 8 hours. It is available as a 10 mg/mL pediatric oral solution. How many milliliters (mL) of this medication should be given to the client per dose? Record your answer using a whole number.Answer:
1
(mL)

Incorrect
Correct answer
2
Answered correctly
83% Time: 4 seconds
Updated: 02/21/2017
Explanation:

Furosemide is the primary diuretic used in children, particularly in those with congenital heart disease when fluid overload is a frequent problem. Pediatric drug dosages are usually prescribed based on age and weight (unit per kilogram), either per 24 hours or per dose. A pediatric drug reference should be available, and medication prescriptions for the pediatric client must be checked by the nurse prior to administration.

Step 1: Convert pounds (lb) to kilograms (kg).

2.2 lb = 1 kg
44 lb/2.2 = 20 kg
Step 2: Calculate dosage.

1 mg/kg per dose
1 mg × 20 kg = 20 mg per dose
Step 3: Calculate drug volume based on concentration to achieve desired dose.

10 mg/mL for the furosemide oral solution
20 mg ÷ 10 mg = 2 (Amount needed per dose ÷ Amount available)
20 mg = 2 mL
Educational objective:
Pediatric drug dosages are usually prescribed based on age and weight (unit per kilogram), either per 24 hours or per dose. The nurse calculates the amount of furosemide to be administered by converting pounds to kilograms, calculating the prescribed dose in milligrams, and then converting the prescribed dose from milligrams to milliliters.

Block Time Remaining: 00:27:28
TUTOR
Test Id: 80620147
QId: 30120 (921666)
55 of 75
A A A
An IV infusion of norepinephrine at 8 mcg/min is prescribed for a client in shock. The concentration of norepinephrine is 4 mg in 250 mL D5W. For how many mL per hour should the nurse program the IV pump?Record your answer using a whole number.

Answer:
1
(mL/hr)

Incorrect
Correct answer
30
Answered correctly
56% Time: 3 seconds
Updated: 03/17/2017
Explanation:

Many IV drugs for critically ill clients are prescribed using units per hour, micrograms per minute (mcg/min), milligrams per minute (mg/min), and micrograms per kilogram per minute (mcg/kg/min). Intravenous pumps are set by milliliters per hour (mL/hr). As a result, the nurse must be able to calculate the drug dose and infusion rate in mL/hr. Due to the potency of these drugs and the hemodynamic instability of critically ill clients, it is imperative that the nurse be able to calculate the appropriate dosages and infusion rates.

Convert the prescribed dose to milligrams:

1000 mcg = 1 mg

8 mcg/min × 1 mg/1000 mcg = 0.008 mg/min

Convert the prescribed dose from milligrams to milliliters:

Norepinephrine concentration is 4 mg per 250 mL

0.008 mg/min × 250 mL/4 mg = 0.5 mL/min

Convert the time from minutes to hours:

60 min = 1 hour

0.5 mL/min x 60 min/hr = 30 mL/hr

As an alternative, the following formula can be used to calculate pump setting in mL/hr if a given dose is prescribed:

Dosage (mg/min) × 60 min/hr ÷ concentration (mg/mL) = pump setting (mL/hr)

Concentration = 4 mg/250 mL= 0.016 mg/mL

0.008 mg/min × 60 min/hr ÷ 0.016 mg/mL = 30 mL/hr

Educational objective:
The nurse must be able to accurately calculate titrated medication drug dosages and flow rates as administration of an incorrect dose or infusion rate can be catastrophic.

Block Time Remaining: 00:28:13
TUTOR
Test Id: 80620147
QId: 31311 (921666)
56 of 75
A A A
The nurse observes a client self-administering nasal fluticasone. Which observation would require the nurse to intervene and provide further teaching?1. A sitting position is assumed as the head is bowed slightly forward [37%]
2. The client points the spray tip toward the nasal septum during instillation [39%]
3. The nasal spray tip is inserted into the nostril as the other nostril is occluded [13%]
4. While administering the medication, the client inhales deeply through the nose [9%]
Incorrect
Correct answer
2
Answered correctly
39% Time: 45 seconds
Updated: 03/19/2017
Explanation:

The proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When educating a client on how to self-administer nasal sprays, the nurse teaches the client to:

Assume a high Fowler’s position with head slightly tilted forward (Option 1)
Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger (Option 3)
Point the nasal spray tip toward the side and away from the center of the nose (Option 2)
Spray the medication into the nose while inhaling deeply (Option 4)
Remove the nozzle from the nose and breathe through the mouth
Repeat the above steps for the other nostril
Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation
Educational objective:
The correct administration of nasal medication includes pointing the nasal spray tip toward the side and away from the center of the nose.

Block Time Remaining: 00:28:16
TUTOR
Test Id: 80620147
QId: 31145 (921666)
57 of 75
A A A
ExhibitThe nurse is caring for a client with a deep vein thrombosis. The client is prescribed a continuous IV heparin infusion of a standard concentration: heparin 25,000 units in 500 mL D5W. After receiving heparin for 6 hours at the prescribed rate of 1300 units/hr, the client’s partial thromboplastin time (PTT) is 44 seconds. The nurse must adjust the infusion rate according to the heparin drip protocol, shown in the exhibit. According to the protocol, at what rate in milliliters per hour should the nurse set the IV infusion pump? Record your answer using a whole number. Click on the exhibit button for additional information.

Answer:
1
(mL/hr)

Incorrect
Correct answer
28
Answered correctly
34% Time: 3 seconds
Updated: 05/14/2017
Explanation:

Heparin is a high-alert medication that requires an additional double check on all boluses and when a new bag is hung or the rate is changed. The nurse should always follow institution policy regarding high-alert medications.

The current dose is 1300 units/hr. This client’s PTT is 44 seconds. This is below the therapeutic range of 55-70 seconds as shown in the exhibit, indicating that the client requires a higher dose of heparin for adequate anticoagulation. According to the Heparin Anticoagulation Dose Adjustments Protocol (institutions protocols vary), the rate should be increased by 100 units/hr, or to an infusion rate of 1400 units/hr.

The following steps should be performed to calculate the rate at which the IV infusion pump should be set to deliver 1400 units/hr (current dose 1300 units/hr + increase by 100 units/hr per protocol):

1. Calculate the concentration of the heparin solution:
25,000 units ÷ 500 mL = 50 units/mL
2. Calculate the adjusted dose in mL/hr:
Desired x Quantity
Available
1400 units x 1 mL = 28 mL/hr
50 units
or
1 mL =
50 units X mL
1400 units
X = 28 mL/hr
Educational objective:
To calculate the IV infusion pump rate to infuse heparin at 1400 units/hr, the nurse should calculate the concentration of the heparin solution (eg, 25,000 units in 500 mL D5W). The nurse must then convert the dose from units/hr to mL/hr.

Block Time Remaining: 00:28:27
TUTOR
Test Id: 80620147
QId: 31393 (921666)
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A A A
The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client who practices traditional Islamic customs. Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity to this client?1. “Ask the client’s wife if she would like to give the bed bath.” [49%]
2. “Do not make eye contact with the client during the bath.” [15%]
3. “The client may prefer for you not to talk to him during the bath.” [5%]
4. “Touching the head is a sign of disrespect; let the client wash his own face.” [29%]
Correct Answered correctly
49% Time: 11 seconds
Updated: 02/14/2017
Explanation:

To provide culturally competent care, it is important for the nurse to realize that in many Arab cultures, a man is not allowed to be alone with a woman other than his wife. It may also be inappropriate for a female health care worker to physically care for him; however, in some instances, direct physical care from the opposite sex is allowed if a third party is present.

(Option 2) Eye contact varies greatly among cultural groups. Some cultures (eg, Arab, Asian, Native American) view eye contact as a sign of disrespect or aggressiveness. This could be a concern with this client, but it is not as high a priority as respecting the client’s cultural beliefs of not being alone in the same room with a member of the opposite sex.

(Option 3) Some cultures (eg, Native American, Asian) are comfortable with silence and see it as a sign of respect, privacy, or respect for elders.

(Option 4) In some Asian and Hispanic cultures, the head is thought to be the basis of one’s strength or soul, and touching a person’s head is considered disrespectful.

Educational objective:
The nurse should be aware that in many Arab cultures a man is not allowed to be alone with a woman other than his wife. In addition, cultural customs may not allow physical care by a member of the opposite sex. The nurse needs to plan accordingly to provide culturally sensitive care.

Obstruction (eg, clots, sediment), kinking/compression of catheter tubing, bladder spasms, and improper catheter size can cause leakage of urine from the insertion site of an indwelling urinary catheter.

The nurse’s first action should be to assess for a mechanical obstruction by inspecting the catheter tubing (Option 1). These interventions may alleviate obstruction:

Remove kinking or compression of the catheter or tubing.
Attempt to dislodge a visible obstruction by milking the tubing. This involves squeezing and releasing the full length of the tubing, starting from a point close to the client and ending at the drainage bag.
If these interventions fail, the nurse should then notify the health care provider (HCP) (Option 3).

(Option 2) Irrigation is usually avoided as pus or sediment can be washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to urine flow. If there is a discrepancy in expected urine output compared with fluid intake, a blockage is suspected and a bladder scan is then performed to confirm the presence of urine in the bladder.

(Option 4) The client has the recommended size of catheter and balloon for an adult male. The HCP may prescribe removal and reinsertion of a different-size catheter if other measures fail to relieve obstruction.

Educational objective:
If leakage of urine is observed from the insertion site of an indwelling urinary catheter, the nurse should assess for obstruction, kinking, or compression of the catheter or drainage tubing; bladder spasms; and improper catheter size.

Block Time Remaining: 00:28:52
TUTOR
Test Id: 80620147
QId: 31327 (921666)
60 of 75
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The nurse is drawing a blood specimen from the client’s right basilic vein. The client cries out and reports a shooting, severe “pins and needles” sensation in the arm. The nurse should take what action next?1. Apply ice locally [2%]
2. Apply lidocaine/prilocaine cream [1%]
3. Reassure the client [7%]
4. Withdraw the needle [88%]
Correct Answered correctly
88% Time: 9 seconds
Updated: 01/14/2017
Explanation:

The preferred site for venipuncture when collecting blood specimens is the antecubital fossa’s median cubital vein. The basilica vein lies close to the brachial nerve and artery. Nerve injury may be occurring when a client has severe, shooting pain radiating down the arm during venipuncture. If a client reports shooting pain, withdraw the needle and avoid probing.

(Option 1) Local ice can cause numbing/pain relief. It is not applied beforehand due to the vasoconstriction. It could be applied after the procedure. However, due to this client’s symptoms, the needle must be withdrawn. Cold is used with extravasations of IV fluids.

(Option 2) Lidocaine/prilocaine cream (EMLA) is a 5% emulsion preparation, containing 2.5% of each substance. It is used to provide dermal anesthesia (eg, for phlebotomy, IV insertion). It is applied for 60 minutes under an occlusive dressing to achieve its effect and therefore must be applied prior to the procedure. When there is a sign of potential nerve injury, the needle must be removed.

(Option 3) Reassurance and deep breathing can help to relax an anxious client, but due to this client’s symptoms, the nurse must suspect possible nerve injury and withdraw the needle. Withdrawing the needle will lessen nerve injury and the risk for chronic regional pain syndrome.

Educational objective:
Withdraw the needle immediately when the client reports shooting pain down the arm during venipuncture to lessen the risk for nerve injury.

Which of these are correct nursing actions related to client positioning? Select all that apply.

1. Position client in high Fowler’s for a paracentesis related to end-stage cirrhosis
2. Position client on left side after liver biopsy
3. Position client on side with head, back, and knees flexed after lumbar puncture
4. Position client Trendelenburg on left side if air embolism is suspected
5. Position client with arm raised above head for chest tube placement
Correct Answered correctly
28% Time: 33 seconds
Updated: 02/15/2017
Explanation:

Abdominal paracentesis is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis). The client should be positioned in high Fowler’s or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture (Option 1).

In the event of an air embolus, the head of the bed should be lowered (Trendelenburg) and the client positioned on the left side; this will cause the air to rise to the right atrium. The health care provider should be notified immediately and the nurse should remain with the client (Option 4).

Chest tube insertion should be performed with the client’s arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm (Option 5).

(Option 2) After a liver biopsy, the client should lie on the right side for a minimum of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours. The risk for bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk.

(Option 3) During a lumbar puncture, the client is positioned side-lying, with the head, back, and knees flexed. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position. Following the procedure, the client will be positioned according to the health care provider’s prescription (usually supine or with head of the bed elevated 30 degrees).

Educational objective:
For medical procedures, the nurse should ensure that the client:

Has an empty bladder and is in high Fowler’s or a sitting position for paracentesis
Is Trendelenburg on the left side for suspected air embolism
Has the arm raised above the head on the affected side for chest tube insertion
Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy
Is side-lying with the head, back, and knees flexed for lumbar puncture

The nurse is assessing the abdomen of a client experiencing gastrointestinal distress. Place the answer choices in the correct order of assessment.

Correct Response
Stand on the client’s right side
Inspection
Auscultation
Percussion
Palpation

Explanation:

Nursing assessments are generally performed in order of least invasive to most invasive.

To perform an abdominal assessment, the nurse always stands on the client’s right side when beginning an abdominal examination. Before touching anything, the nurse makes a visual inspection of the abdomen.

After inspection, the nurse proceeds by auscultating the abdomen. Auscultation is performed next because percussion and palpation can increase peristalsis, potentially leading the nurse to make an erroneous interpretation of bowel sounds. The nurse should lightly place the diaphragm of the stethoscope in the right lower quadrant, as high-pitched bowel sounds are normally present in this region.

After auscultation, the nurse proceeds to percussion and then palpation. Palpation is performed last because it may induce pain, resulting in abdominal rigidity, guarding, and a change in respirations. This rigidity may affect tone heard upon percussion. Percussion is also intended to identify borders of organs that move with respiration (eg, liver, spleen). A client in pain from abdominal tenderness will likely take quick, shallow breaths, which will change how far organs are displaced and make it more difficult for the examiner to identify true borders of organs.

Educational objective:
Abdominal examination is done in the following sequence – stand on right side, inspect, auscultate, percuss, then palpate.

When administering otic medication to children age 3 and older, the pinna is pulled upward and back to straighten the ear canal. The child is placed in a prone or supine position with the head turned to the appropriate side, and the medication is allowed to drop against the wall of the canal.
Block Time Remaining: 00:31:03
TUTOR
Test Id: 80620147
QId: 31698 (921666)
64 of 75
A A A
A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for further instruction?1. Faces forward when going up and down the stairs [2%]
2. Holds the cane with the right hand [9%]
3. Leads with left leg, follows next with cane, and finally right leg when going up the stairs [46%]
4. Places full weight on left leg when going down the stairs [40%]
Incorrect
Correct answer
3
Answered correctly
46% Time: 51 seconds
Updated: 03/07/2017
Explanation:

To provide full support when climbing stairs, clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction of the stairs (Option 2). They should also keep 2 points of support on the floor at all times (eg, both feet, cane and foot) and face forward when going up or down the stairs, especially if there is no handrail (Option 1). The nurse should instruct the client on the following:

When ascending stairs:

Step up with the stronger leg first (in this client, the right leg)
Move the cane next while bearing weight on the stronger leg
Finally, move the weaker leg (in this client, the left leg)
When descending stairs:

Lead with the cane
Bring the weaker leg down next
Finally, step down with the stronger leg
The nurse may use the mnemonic “up with the good and down with the bad.” The cane always moves before the weaker leg.

(Option 4) Clients are usually hospitalized for 3-4 days following a total knee replacement and can bear full weight by the time of discharge. Early ambulation and weight-bearing helps to hasten recovery and prevent complications (eg, thromboembolism).

Educational objective:
Clients who have had total knee replacement surgery can typically bear full weight by the time of discharge. To reduce the risk of falls, the client should hold the cane on the stronger side and face forward when going up and down the stairs. To ascend the stairs, the client should first step up with the stronger leg, next bear weight on that leg and move the cane, and finally step up with the weaker leg.

Block Time Remaining: 00:31:47
TUTOR
Test Id: 80620147
QId: 32152 (921666)
65 of 75
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A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client’s vital signs and most current serum laboratory results. Which finding is most important to report to the health care provider (HCP)?1. Blood pressure of 180/100 mm Hg [27%]
2. Creatinine of 2 mg/dL (176.8 µmol/L) [14%]
3. Hemoglobin of 9.8 g/dL (98 g/L) [13%]
4. Platelet count of 120,000/mm3 (120 x 109/L) [43%]
Correct Answered correctly
27% Time: 44 seconds
Updated: 02/26/2017
Explanation:

Percutaneous kidney biopsy is an invasive diagnostic procedure. It involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy (Option 1). (Option 2) An elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L) can be expected in a client with probable renal disease. This is not the most important finding to report to the HCP. (Option 3) A decreased hemoglobin level (normal adult male: 13.2-17.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL [117-155 g/L]) can be expected in a client with probable renal disease due to decreased erythropoietin production. The nurse should continue to monitor the client’s hemoglobin post-procedure as it can decrease further (within 6 hours) if bleeding occurs. (Option 4) Only neurosurgery and ocular surgery require a platelet count >100,000/mm3 (100 x 109/L). Most other surgeries can be performed when the platelet count is >50,000/mm3 (50 x 109/L). Although the platelet count is low (normal 150,000-400,000/mm3 [150-400 x109/L]), it is not the most important finding to report to the HCP.

Educational objective:
The kidney is a highly vascular organ and the risk of bleeding is a major complication after a percutaneous biopsy. The client should have normal coagulation studies, an adequate platelet count, and well-controlled blood pressure prior to the procedure to reduce bleeding risk.

Block Time Remaining: 00:32:22
TUTOR
Test Id: 80620147
QId: 32149 (921666)
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The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply.1. Area around the insertion site feels cool to the touch
2. Client reports mild arm discomfort since the infusion was started
3. Edema is observed on the dependent side of the involved arm
4. Intraoperative peripheral IV catheter is placed in the left antecubital region
5. Serous fluid leaks from the site despite secure connections
Correct Answered correctly
47% Time: 35 seconds
Updated: 04/17/2017
Explanation:

Peripheral IV (PIV) catheter sites should be changed usually no more frequently than every 72-96 hours unless signs of complications develop. Signs of phlebitis include erythema, edema, warmth, pain, and palpable venous cord. Manifestations of infiltration include edema and coolness to the touch around the insertion site (Option 1). The nurse should also monitor for edema related to infiltration under the involved limb. Infiltrated fluid may leak into loose skin, causing edema in dependent areas without obvious signs of infiltration at the PIV site, particularly in the elderly (Option 3).

If a PIV site is leaking fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible problems include infiltration/extravasation, a thrombus at the catheter tip, or damage to the catheter; all of these issues require a site change (Option 5).

(Option 2) Potassium is a known irritant to veins. Discomfort is not a sign of infiltration, although the site should be regularly monitored for complications.

(Option 4) Locations where flexion occurs (eg, antecubital region) are generally avoided; however, these sites may be required for certain medications or situations. Unless a problem develops, PIV sites are not changed based solely on location.

Educational objective:
Peripheral IV catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications develop. The nurse should check for signs of infiltration by assessing the insertion site and areas dependent from it (ie, edema, cool skin).

The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order. All options must be used.

Correct Response
Gather supplies and position client
Don mask, goggles, and clean gloves
Remove soiled dressing
Don sterile gloves; remove old disposable cannula and replace with a new one
Clean around stoma with sterile water or saline; dry and replace sterile gauze pad

Correct answer

Explanation:

When performing tracheostomy care, the nurse follows institution policy and observes principles of infection control and client safety. Sterile technique is used to prevent infection of the lower airway. The steps for performing the procedure for a client with a disposable inner cannula include the following:

Gather supplies to the bedside, then place client in semi-Fowler’s position, if not contraindicated, to promote lung expansion and oxygenation and prevent aspiration of secretions.
Don personal protective equipment (mask, goggles, and clean gloves) to maintain universal precautions. Auscultate lungs and suction secretions if necessary.
Remove soiled dressing and also remove clean gloves.
Don sterile gloves; remove old disposable cannula and replace with a new one. While stabilizing the back plate with the nondominant hand, unlock (unclip) the old cannula with the dominant hand; remove gently by pulling it out in line with its curvature; pick up the new cannula, touching only the outer locking portion (to prevent contamination and maintain asepsis); insert; and lock (clip) into place.
Clean around stoma with sterile water or saline, dry and replace sterile gauze pad to remove dried secretions, and dry around stoma well to limit the growth of microorganisms. Some tracheostomy tubes are sutured in place and do not require a dressing. If secretions are copious, apply a dressing.

The nurse admits a client who fell off a 20-ft (6-m) ladder. On arrival in the emergency department, the client is arousable but lethargic. What is the nurse’s priority action?

1. Ask about client’s chronic medical conditions [
2. Assess for level and duration of pain
3. Obtain a Glasgow Coma Scale score
4. Perform a head-to-toe assessment

Explanation:

After trauma to a client (eg, fall), the nurse performs an emergency or trauma assessment that includes a primary and secondary survey (assessment). The primary assessment determines the status of the airway, breathing, and circulation (ABCs). Next, the nurse evaluates disability (D) of neurological function using the Glasgow Coma Scale (GCS).

The GCS measures the client’s level of consciousness by assessing the best eye opening response, best verbal response, and best motor response. The lower the GCS score, the higher the risk for the client to develop complications (eg, loss of airway patency, increased intracranial pressure).

(Options 1, 2, and 4) Although a health history, head-to-toe assessment, and notation of the client’s level of pain are essential for the overall assessment, they are considered part of the secondary survey. This survey’s purpose is to get a complete picture of the injuries, but only after the client’s priority needs have been addressed.

Educational objective:
After trauma to a client (eg, fall), the nurse performs a primary survey to determine status of airway, breathing, circulation, disability (eg, Glasgow Coma Scale to assess neurological impairment), and exposure. Health history, head-to-toe assessment, and level of pain are part of the secondary survey.

The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regard to medication administration? Select all that apply.

* 1. Avoid salt substitutes when taking valsartan for hypertension
2. Take levofloxacin with an aluminum antacid to avoid gastric irritation
3. Take sucralfate after meals to minimize gastric irritation associated with a gastric ulcer
*4. When taking ethambutol, notify the health care provider (HCP) of any changes in vision
5. When taking rifampin, notify the HCP if the urine turns red-orange
Incorrect
Correct answer
1,4

Both ACE inhibitors (“prils” – captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers (“sartans” – valsartan, losartan, telmisartan) cause hyperkalemia. Salt substitutes contain high potassium and must not be consumed unless approved by the health care provider (HCP) (Option 1).

Ethambutol (Myambutol) is used to treat tuberculosis but can cause ocular toxicity, resulting in vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly (Option 4).

(Option 2) Levofloxacin (Levaquin) is a quinolone antibiotic. For this class of antibiotics, 2 hours should pass between drug ingestion and consumption of aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate. These substances can bind up to 98% of the drug and make it ineffective.

(Option 3) Sucralfate (Carafate, Sulcrate), prescribed to treat gastric ulcers, should be administered before meals to coat the mucosa and prevent irritation of the ulcer during meals. It should also be given at least 2 hours before or after other medications to prevent interactions that reduce drug efficacy.

(Option 5) Rifampin (Rifadin), used to treat tuberculosis, normally causes red-orange discoloration of all body fluids. The client should be alerted to expect this change but does not need to notify the HCP.

Educational objective:
The nurse should watch for vision changes with ethambutol. Potassium supplements or salt substitutes should not be given to a client taking an ACE inhibitor or angiotensin receptor blocker. Sucralfate must be given before meals to prevent irritation of the ulcer. Quinolone antibiotics should not be given with antacids or supplements that reduce drug efficacy. Rifampin commonly causes red-orange discoloration of body fluids.

Block Time Remaining: 00:34:47
TUTOR
Test Id: 80620147
QId: 30282 (921666)
70 of 75
A A A
The nurse educates a client with obstructive lung disease in the correct use of a short-acting beta agonist metered-dose inhaler without the use of a spacer. Place the steps in the correct order.Unordered Options
Compress canister while inhaling slowly through the mouth for about 3-5 seconds
Hold breath for 10 seconds, if possible, before exhaling
Place mouthpiece between teeth and wrap lips around mouthpiece
Shake canister well for 3-5 seconds
Tilt head back slightly and exhale slowly for 3-5 seconds
Wait at least 1-2 minutes before taking a second puff, if prescribed
Your Response/ Correct Response
Shake canister well for 3-5 seconds
Tilt head back slightly and exhale slowly for 3-5 seconds
Place mouthpiece between teeth and wrap lips around mouthpiece
Compress canister while inhaling slowly through the mouth for about 3-5 seconds
Hold breath for 10 seconds, if possible, before exhaling
Wait at least 1-2 minutes before taking a second puff, if prescribed
Correct Answered correctly

Explanation:

Inhalation devices include metered-dose inhalers (MDIs), dry powder inhalers, and nebulizers. The devices deliver a measured dose of medication with each actuation. They are primarily used to treat respiratory disorders but may also be used for some nonrespiratory conditions (eg, diabetes, analgesia). The inhaled route is preferred for beta agonist, anticholinergic, and steroid medications as it causes fewer side effects than the PO route.

Correct use of the MDI is necessary to receive the full benefit from inhaled medication. The steps are as follows:

Shake canister well for about 3-5 seconds.
Tilt head back slightly and exhale slowly for 3-5 seconds.
Hold canister mouthpiece about 1½ inches in front of open mouth; as an alternative, place the mouthpiece in the mouth with lips sealed around it. Holding it in front of the open mouth prevents impaction of the particles into the tongue and sides of mouth.
Compress canister while inhaling slowly for about 3-5 seconds.
Hold breath for 10 seconds, if possible, before exhaling.
Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchioles and allows easy passage of the second puff.
Educational objective:
Correct use of the metered-dose inhaler is necessary to receive the full benefit of the inhaled medication. Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchioles and allows easy passage of the second puff.

The nurse takes on the role of anesthetist when assisting with bedside procedural moderate sedation and cannot leave the client during the procedure.
Magnetic resonance cholangiopancreatography (MRCP) uses MRI technology to visualize the biliary and hepatic ductal system. Contraindications should be assessed prior to the procedure and include pregnancy, presence of certain metal implants, and an allergy to gadolinium (a noniodine contrast agent).

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic test used to visualize the biliary and hepatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP) to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction.

The nurse must assess for contraindications prior to the procedure, including presence of certain metal implants (eg, pacemaker, aneurysm clip, cochlear implant), pregnancy, or any previous allergy or reaction to gadolinium (Options 3 and 4). Most orthopedic implants (eg, rods, pins, artificial joints) are considered safe for MRI imaging.

Postmortem care can be delegated to unlicensed assistive personnel at the nurse’s discretion (5 rights of delegation). It includes client preparation (eg, hygiene, positioning) and transportation of the body to the appropriate facility.

A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revising the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see? Select all that apply.

1. A client who fell and hit the head but refuses to go to the emergency department
2. A client who is due for a maintenance dose of cyanocobalamin
3. A client who needs pre-filled insulin syringes
4. A client who was discharged from the hospital yesterday after heart failure treatment
5. A client with a stage 3 pressure ulcer in need of a dressing change
Correct Answered correctly
31% Time: 30 seconds
Updated: 02/16/2017
Explanation:

In this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure ulcer has a scheduled dressing change for a serious wound and this should not be postponed.

(Option 2) Maintenance doses of cyanocobalamin for vitamin B12 deficiency are usually administered every 4 weeks. Although this client should receive the injection as soon as possible, postponing the home care visit for 1 or 2 days will not harm the client.

(Option 4) This client can be provided with telephonic care management; the nurse can perform medication reconciliation over the phone and provide instructions regarding care.

Educational objective:
During a weather-related emergency, home care visits are classified as:

High priority – unstable clients who need care and are at risk for hospitalization if not seen.
Moderate priority – clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care management can be provided to these clients.
Low priority – clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care.

Steps to promote safety and reduce infection risk when initiating IV therapy include the following:

Perform hand hygiene using Centers for Disease Control and Prevention guidelines
Prepare equipment: Open IV tray, prime tubing with prescribed IV solution for infusion, set IV pump if indicated, prepare tape, and open the over-the-needle catheter (ONC) with safety device
Don clean (non-sterile) gloves
Identify a possible venipuncture site
Apply a tourniquet, ensuring it is tight enough to impede venous return but not tight enough to occlude the artery
Select a venipuncture site after palpating the vein. Ask the client to open and close the hand several times to promote vein distension. The tourniquet may need to be released temporarily to restore blood flow and prevent trauma from extended application.
Clean the site with chlorhexidine, alcohol, or povidone iodine. Use friction and clean per facility protocol, either back and forth or in a circular motion from insertion site to outward area (clean to dirty direction).
Stretch the skin taut using the nondominant hand to stabilize the vein
Insert the IV ONC bevel up at a 10- to 30-degree angle and watch for blood backflow as the catheter enters the vein lumen, advancing ¼ inch into the vein to release the stylet. On visualization of blood return, lower the ONC almost parallel with the skin and thread the plastic cannula completely into the vein to the insertion site. Never reinsert the stylet after it is loosened. Use the push-tab safety device to advance the catheter.
Apply firm but gentle pressure about 1¼ inch above the catheter tip, release the tourniquet, and retract the stylet from the ONC
On removal, guide the protective guard over the stylet for safety and feel for a click as the device is locked. Never try to recap a stylet.
Attach a sterile connection of primed IV tubing to the hub of the catheter and stabilize the catheter with tape and dressing using sterile technique. Dispose of the stylet in the sharps container.
Educational objective:
When initiating IV therapy, the nurse should wash hands thoroughly and don clean gloves, identify the appropriate venipuncture site, apply the tourniquet, select the venipuncture site after palpating the vein, clean the site, stretch skin taut, insert the IV ONC until blood returns, thread the cannula, apply firm pressure above the catheter tip, release the tourniquet, and retract the stylet safely.

Collection of a sputum specimen by expectoration is a sterile procedure that requires the client to be able to breathe deeply and cough effectively. The client should be instructed to rinse the mouth with water, sit upright, inhale deeply several times, and cough prior to expectorating.

Sputum collection is prescribed to identify respiratory pathogens (eg, in the setting of bacterial pneumonias or tuberculosis). Collection should be done in the morning, as secretions accumulate overnight. A nebulizer treatment may be prescribed to help mobilize secretions.

To collect a sputum specimen, the nurse should instruct the client to:

Rinse the mouth with water to reduce specimen contamination by oral flora
Sit on the side of the bed, if possible, or in a high or semi-Fowler position to allow maximum lung ventilation and expansion
Inhale deeply several times to provide enough air to force secretions from the lower airways to the pharynx
Cough deeply to raise enough sputum (4-10 mL), and expectorate into the sterile specimen container
The nurse should immediately close and label the specimen container as this will prevent contamination or transmission of microorganisms and assure proper client information. The specimen and requisition are transported to the laboratory per policy; some specimens must be sent immediately, and others may be refrigerated. The nurse should then provide oral care for the client and document pertinent information (eg, sputum characteristics, tolerance of procedure).

Incentive spirometry is recommended in postoperative clients to prevent atelectasis associated with
incisional pain, especially in upper abdominal incisions (close to the diaphragm)
Incentive spirometry Guidelines recommend.
Volume-oriented or flow-oriented sustained maximal inspiration (SMI) devices can be used.
5-10 breaths per session every hour while awake
TEACH PT. instructions for using a volume-oriented SMI device include:
-Assume a sitting or high Fowler position, which optimizes lung expansion, and exhale normally
-While holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage of air around it
-Inhale deeply through the mouth until the piston is elevated to the predetermined level of tidal volume.
-The piston is visible on the device and helps provide motivation.
-Hold the breath for at least 2-3 seconds (up to 6 seconds) as this maintains maximal inhalation
-Exhale slowly to prevent hyperventilation
-Breathe normally for several breaths before repeating the process
-Cough at the end of the session to help with secretion expectoration
Educational objective:
Incentive spirometry is recommended to prevent atelectasis in postoperative clients. Clients with incisional pain should receive adequate pain medication prior to the inhalations. The client is instructed to use the device while sitting upright, seal the lips tightly around the mouthpiece, inhale deeply, sustain the maximal inspiration for at least 2-3 seconds, exhale slowly before repeating the procedure, and cough at the end of the session.
Crushing an enteric-coated, slow-release, extended-release, or sustained-release drug disrupts its designed time of release and is contraindicated. The nurse should contact the PHCP for an alternate prescription if such a drug is prescribed via NG route.

Enteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the small intestine) to protect the stomach from irritant effects. Crushing enteric-coated medications (eg, ibuprofen) disrupts the barrier coating and may cause stomach irritation. In addition, the particles from the coating may clog the NG tube, particularly small-bore NG tubes.

Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly within a specific time frame. Crushing these medications alters this property and introduces the risk of adverse effects from toxic blood levels due to more rapid drug absorption. Therefore, the nurse should first contact the PHCP for clarification.

Double- and extra-strength drugs such as sulfamethoxazole and acetaminophen may be
crushed and administered separately through an NG tube as long as they are not enteric-coated. The nurse should flush the tube with water before and after each drug administration.
What size IV catheter size is best for children and some older adults with small, fragile veins
24-gauge catheter
When would you want to use a 14 gauge catheter
A 14-gauge (large-bore) catheter may be used for administering fluids and drugs in an emergency or prehospital setting, or for hypovolemic shock
what IV catheter size is preferred in STABLE adult clients who require large amounts of fluids or blood,
an 18-gauge catheter is preferred.
What and Why is the universally recommended for the administration of IM injections
The Z-track technique prevents tracking (leakage) of the medication into the subcutaneous tissue
The procedure for administering an IM injection using the Z-track technique includes these steps

:

1. Pull the skin 1-1 ½” (2.5-3.5 cm) laterally away from the injection site

2.Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree angle – taut skin facilitates entry of the needle and this angle ensures that the needle will reach the muscle

3. Inject the medication slowly into the muscle while maintaining traction – slow injection promotes comfort and allows time for tissue expansion to facilitate absorption of the medication

4. Wait 10 seconds after injecting the medication and withdraw the needle while maintaining traction on the skin; this allows the medication to diffuse before needle removal and helps to prevent tracking

5.Release the hold on the skin – this allows the tissue layers to slide back to their original position, sealing off the needle track

Apply gentle pressure at the injection site, but do not massage as this can cause the medication to seep back up to the skin surface and cause local tissue irritation

Where is the preferred areas for IM injection

ventrogluteal site in adults

vastus lateralis site in children.

What is WRONG? DX?
Pt has decreased C/O=
s/s hypotension
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.
signs and symptoms of tamponade
How will RN measure for Pulsus Paradoxus?
1-Place client in semirecumbent (semi fowlers) -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
The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.
Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3
formula for calculating mean arterial pressure

The nurse is preparing to administer an antibiotic to a child with a severe respiratory infection. The prescription reads: 7.5 mg/kg every 24 hours divided into 2 doses, to be given by mouth in liquid form. Recommended dosage is 250-500 mg every 24 hours. The client weighs 78 lb. The pharmacy has supplied the drug in 125 mg/5 mL. How many mL should the client receive for each dose? Record your answer using one decimal place.

Correct answer
5.3

Explanation:

1. Calculate weight in kg 78 lb ÷ 2.2 = 35.4545 kg
2. Calculate the total dose in mg the client should receive in 24 hr 35.4545 kg x 7.5 mg/kg = 265.9088 mg
3. Determine if the ordered dosage is safe 265.9088 mg falls in the safe range of 250-500 mg/24 hr
4. Calculate the 2 individual dosages to be given in a 24-hr period 265.9088 mg ÷ 2 doses = 132.9544 mg
5. Calculate the amount of medication the client will receive in mL for each dose 132.9544 mg x 5 mL ÷ 125 mg = 5.3182 mL (round down 5.3 mL)
Educational objective:
Correct dosage calculations are very important for all age groups. However, due to lower body weight and immaturity of body systems, an incorrect drug calculation could be more harmful in a child than in an older person.

MATH

The health care provider prescribes a continuous IV insulin infusion for a client. The insulin drip is initiated with 50 units of regular insulin in 100 mL of normal saline solution at 5 units/hr. At what rate in milliliters per hour does the nurse set the IV pump? Record your answer using a whole number.

Answer:

Correct answer
10
Answered correctly
65% Time: 47 seconds
Updated: 01/16/2017
Explanation:

The steps below should be performed to calculate the infusion pump rate in milliliters per hour:

Calculate the concentration of the insulin solution:
50 units ÷ 100 mL = 0.5 units/mL

Calculate the dose in mL/hr:
Desired x Quantity method
Available

5 units x 1 mL = 10 mL/hr
0.5 units

OR
Ratio/proportion method

0.5 units = 5 units
1 mL X mL

0.5X = 5

X = 10 = 10 mL/hr

Educational objective:
To set the IV pump in mL/hr for a prescribed dose of insulin in units/hr, the nurse first calculates the concentration of the insulin infusion, and then calculates the dose in mL/hr.

MATH

While preparing to insert a peripheral IV line, the nurse notices scarring near the client’s left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply.

1. Advance the entire stylet into the vein upon venipuncture
2. Insert the IV line into the most distal site of the right arm
3. Place an appropriate precaution sign above the bed
4. Review the medical record for history of mastectomy
5. Teach the client to keep the left arm in a dependent position
Incorrect
Correct answer
2,3,4
Answered correctly
33% Time: 52 seconds
Updated: 01/17/2017
Explanation:

A modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated.

The nurse should insert the IV line into the most distal site of the unaffected side (Option 2). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client’s bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) (Options 3 and 4).

In general, venipuncture is contraindicated in upper extremities affected by:

Weakness
Paralysis
Infection
Arteriovenous fistula or graft (used for hemodialysis)
Impaired lymphatic drainage (prior mastectomy)
(Option 1) The stylet should be advanced until blood return is seen (approximately ¼ inch). If advanced fully, the stylet may penetrate the posterior wall of the vein and cause a hematoma.

(Option 5) Keeping the affected arm in a dependent position for a long time can increase lymphedema. The client should be reminded that raising the limb helps drainage.

Educational objective:
IV line insertion is contraindicated on the operative side of clients with a prior mastectomy. Additional contraindications for IV line insertion include weakness, paralysis, or infection of the arm; or presence of an arteriovenous fistula.

PERIPHERAL KNOWLEDGE

signs of traumatic injury are present, the nurse should follow steps to remove the catheter before further complications such as obstruction occur.

Steps for removing an indwelling catheter include the following:

Perform hand hygiene
Ensure privacy and explain the procedure to the client
Apply clean gloves
Place a waterproof pad underneath the client
Remove any adhesive tape or device anchoring the catheter
Follow specific manufacturer instructions for balloon deflation
Loosen the syringe plunger and connect the empty syringe hub into the inflation port
Deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration.
Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client.
If any resistance is met, stop the removal procedure and consult with the urologist for removal
Empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy
Remove gloves and perform hand hygiene

A client with heart failure is prescribed a continuous IV infusion of dobutamine at 10 mcg/kg/min. He weighs 70 kg. The concentration of dobutamine is 250 mg in 500 mL D5W. For how many milliliters per hour should the nurse program the IV pump? Record your answer as a whole number.

Answer:
(mL/hr)

Correct answer
84
Answered correctly

Explanation:

Dobutamine hydrochloride (Dobutrex) is a positive inotropic drug that increases cardiac muscle contractility. The dosage is weight-based and is prescribed in micrograms per kilogram per minute (mcg/kg/min) and administered with an IV pump. Because IV pumps are set by milliliters per hour (mL/hr), the nurse must be able to calculate the drug dose and the infusion rate in mL/hr.

Dobutrex can be diluted in dextrose or normal saline, and concentrations usually range from 500-2,000 micrograms per milliliter (mcg/mL) depending on client status. This medication may be administered in acute or long-term facilities or in the home. It is most often administered in the emergency department, intensive care unit, and step-down units. The nurse must always follow institution policy and procedure in relation to its dilution, dosage, administration, and titration.

The Joint Commission and Institute for Safe Medical Practices discourage the use of abbreviations for medication prescriptions and dosage calculations. They are used here to conserve space.

Convert mg to micrograms:

250 mg = 250,000 mcg
Calculate concentration:

250,000 mcg = 500 mcg/mL
500 mL
Calculate weight-based dose:

10 mcg x 70 kg/min = 700 mcg/min
Calculate the dose (10 mcg/kg/min) in mcg/mL:

500 mcg = 700 mcg = 1.4 mL/min
1 mL X mL
Calculate how many milliliters are to be infused over one hour:

1.4 mL x 60 minutes = 84 mL/h
Set the pump at 84 mL/h
The following formula may also be used to calculate the pump setting in mL/hr if a given dose is prescribed:

_______ mcg/kg/min x________ kg x 60 min/h ÷ ___________ mcg/mL = ____________mL/h
dosage client weight concentration pump setting
10 mcg/kg/min x 70 kg x 60 min = 84 mL/h
500 mcg/mL
Educational objective:
The nurse must be able to calculate weight-based titrated drug dosages and flow rates accurately because the administration of an incorrect dose or infusion rate can be life-threatening.

MATH

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse intervenes when the student performs which action?

1. Advances tip of needle through epidermis until the bevel is no longer visible under the skin [65%]
2. Chooses a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle; dons clean gloves [19%]
3. Injects medication slowly while raising a small wheal (bleb) on the skin [3%]
4. Inserts needle at a 10-degree angle almost parallel to skin with the bevel up [12%]
Correct Answered correctly 1

Explanation:

Intradermal dermal injections deliver a small amount of medication (0.1 mL) into the dermal layer of the skin, just under the epidermis. This parenteral route is used to perform allergy testing and tuberculosis (TB) screening.

The correct procedure for administering a TB intradermal injection is as follows:

Choose a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle then don clean gloves – the syringe is calibrated in hundredths of a millimeter and the intradermal needle is short enough to remain in the dermis with length range of 1/4-5/8 inch (Option 2).

Position the left forearm to face upward, and cleanse site that is a hands width above the wrist – the left arm is commonly used for TB testing; the forearm has little hair and subcutaneous tissue and is readily accessible to observe a skin reaction.

Place non-dominant hand 1 inch below the insertion site and pull skin downward so that it is taut – taut skin makes it easier to insert the needle and promotes comfort.

Insert the needle almost parallel to skin at a 10-degree angle with bevel up – this is important as the medication can enter the subcutaneous tissue if the angle is >15 degrees (Option 4).

Advance the tip of the needle through epidermis into dermis; outline of bevel should be visible under the skin – verify that the medication will be injected into dermis (Option 1).

Inject medication slowly while raising a small wheal (bleb) on the skin – verify that the medication is being deposited into the dermis (Option 3).

Remove needle and do not rub the area – rubbing promotes leakage through the insertion site and medication deposition into the tissue.

Circle the area with a pen to assess for redness and induration (according to institution policy) – this delineates the border for measurement of reaction.

Educational objective:
For TB skin testing:

Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe
Administer injection on inner forearm at a 10-degree angle with bevel up
Make a wheal (bleb)
Avoid rubbing site after injection

Block Time Remaining: 00:05:20
TUTOR
Test Id: 80629987
QId: 30824 (921666)
22 of 75
A A A
A client postoperative from a transurethral prostatectomy has a triple-lumen Foley catheter and is receiving continuous bladder irrigation of sterile normal saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of 2300 mL at the end of the 8-hour shift. How many milliliters does the nurse document as the total amount of urine output for the shift? Record your answer as a whole number.Answer:

Correct answer
900

Explanation:

Calculate the total amount of irrigating solution infused into the bladder in milliliters:

175 mL X 8 hr = 1400 mL
Calculate the total amount of urine output in milliliters:

Total amount of drainage in bag – total amount of irrigating solution infused:

2300 mL – 1400 mL = 900 mL
Educational objective:
To calculate urine output in a client with continuous bladder irrigation, subtract the total amount of irrigating solution infused from the total amount in the urine drainage bag. Urine output approximates input minus insensible losses.

To ensure proper shoulder sling fit, the nurse should assess for the following:
Elbow is flexed at 90 degrees
Hand is held slightly above the level of the elbow
Bottom of the sling ends in the middle of the palm with the fingers visible
Sling supports the wrist joint
Suction PRESSURE FOR airway suctioning technique
100-120 mm Hg ADULTS
50-75 mm Hg for children
as excess pressure will traumatize the mucosa and can cause hypoxia.
Block Time Remaining: 00:08:52
TUTOR
Test Id: 80629987
QId: 30282 (921666)
28 of 75
A A A
The nurse educates a client with obstructive lung disease in the correct use of a short-acting beta agonist metered-dose inhaler without the use of a spacer. Place the steps in the correct order.Your Response/ Incorrect Response
Correct Response
Shake canister well for 3-5 seconds
Tilt head back slightly and exhale slowly for 3-5 seconds
Place mouthpiece between teeth and wrap lips around mouthpiece
Compress canister while inhaling slowly through the mouth for about 3-5 seconds
Hold breath for 10 seconds, if possible, before exhaling
Wait at least 1-2 minutes before taking a second puff, if prescribed
Omitted
Correct answer
4,5,3,1,2,6
Answered correctly
25% Time: 8 seconds
Updated: 02/27/2017
Explanation:

Inhalation devices include metered-dose inhalers (MDIs), dry powder inhalers, and nebulizers. The devices deliver a measured dose of medication with each actuation. They are primarily used to treat respiratory disorders but may also be used for some nonrespiratory conditions (eg, diabetes, analgesia). The inhaled route is preferred for beta agonist, anticholinergic, and steroid medications as it causes fewer side effects than the PO route.

Correct use of the MDI is necessary to receive the full benefit from inhaled medication. The steps are as follows:

Shake canister well for about 3-5 seconds.
Tilt head back slightly and exhale slowly for 3-5 seconds.
Hold canister mouthpiece about 1½ inches in front of open mouth; as an alternative, place the mouthpiece in the mouth with lips sealed around it. Holding it in front of the open mouth prevents impaction of the particles into the tongue and sides of mouth.
Compress canister while inhaling slowly for about 3-5 seconds.
Hold breath for 10 seconds, if possible, before exhaling.
Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchioles and allows easy passage of the second puff.
Educational objective:
Correct use of the metered-dose inhaler is necessary to receive the full benefit of the inhaled medication. Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchioles and allows easy passage of the second puff.

Block Time Remaining: 00:09:18
TUTOR
Test Id: 80629987
QId: 31329 (921666)
29 of 75
A A A
Which procedures are appropriate for the nurse to use when obtaining an adult client’s blood for a laboratory test? Select all that apply.1. Avoid the arm on the affected side after a mastectomy
2. Do not make further attempts to draw blood if unsuccessful on first 2 attempts
3. If necessary to use an arm with IV infusing, draw proximal to infusion point
4. Insert the needle bevel up at a 15-degree angle to the skin
5. Obtain a finger capillary specimen from the middle of the finger pad
Correct Answered correctly
40% Time: 26 seconds
Updated: 12/13/2016
Explanation:

When performing phlebotomy, clean the site, “fix” or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely.

The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw.

The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema.

(Option 3) An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between.

(Option 5) The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges tends to make the blood run down the ridges and will hamper collection. A heel stick collection on an infant should be done on the plantar surface.

Educational objective:
When obtaining blood from a client, insert the needle at 15-degree angle, limit attempts to 2, and avoid the side of a mastectomy. A capillary specimen should be obtained at the side of the finger pad. Never draw a specimen above an IV infusion.

.

Block Time Remaining: 00:09:41
TUTOR
Test Id: 80629987
QId: 32061 (921666)
30 of 75
A A A
A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?1. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning [7%]
2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning [61%]
3. Discard urine and container, have client void, add urine to new container, and then restart test [22%]
4. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM [8%]
Incorrect
Correct answer
2
Answered correctly
61% Time: 23 seconds
Updated: 12/24/2016
Explanation:

Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine.

Not all of the client’s urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client’s first morning voiding and to end it at the same hour the next morning after the morning voiding (Option 2).

(Option 1) Adding 250 mL to the total output when the test is completed is not an appropriate action as the actual urine output from the 24-hour period is needed for accurate results.

(Option 3) To start the collection period, the nurse asks the client to void and discards this specimen (it is not added to the collection container). The 24-hour period starts at the time of the client’s first voiding.

(Option 4) Relabeling the same container and changing the start time from 6:00 AM to 10:00 AM is not an appropriate action. The container would include part of the urine produced in a 28-hour period, and the test results would be inaccurate.

Educational objective:
It is common practice to start a 24-hour urine collection test at the time of the client’s first voiding in the morning. If any urine is discarded by accident during the test period, the procedure must be restarted. All produced urine should be placed in the same container and kept cool (on ice).

Block Time Remaining: 00:09:47
TUTOR
Test Id: 80629987
QId: 30857 (921666)
31 of 75
A A A
Place the nursing actions for performing a renal system physical assessment in the correct order. All options must be used.Your Response/ Incorrect Response
Correct Response
Advise client to empty the bladder completely
Observe skin and contour of abdomen and lower back
Auscultate the renal arteries in right and left upper quadrants
Percuss and palpate both the right and left kidneys
Document the assessment of renal system function
Omitted
Correct answer
1,4,2,5,3
Answered correctly
75% Time: 6 seconds
Updated: 03/26/2017
Explanation:

Examination of the urinary system requires an abdominal assessment. Therefore, assessment techniques must be reordered to optimize the examination. The steps for a renal system assessment are:

Empty the bladder to avoid discomfort during percussion and palpation and to provide a clean-catch sample (if prescribed) (Option 1)

Inspect the abdomen and lower back for color, contour, symmetry, distension, and movements (eg, visible peristalsis). Inspection is always done first during physical examination (Option 4).

The nurse should auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Listen for renal artery bruits in the right and left upper abdominal quadrants (Option 2).

Percuss for kidney borders, costovertebral angle tenderness, and bladder distension. A dull percussion sound indicates solid structures or fluid-filled cavities (eg, distended bladder). Palpate for bladder distension, masses, and tenderness. A distended bladder may be palpated at any point from the symphysis pubis to the umbilicus and is felt as a firm, rounded organ. A normal kidney is not usually palpable; a palpable kidney may indicate hydronephrosis or polycystic kidney disease (Option 5).

Document all renal assessment findings immediately after the examination (Option 3).

Educational objective:
Physical assessment of the renal system includes the techniques of inspection, auscultation, percussion, and palpation, in that order. Allow the client to empty the bladder before beginning the assessment and auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Always document the findings.

Block Time Remaining: 00:10:55
TUTOR
Test Id: 80629987
QId: 30323 (921666)
34 of 75
A A A
The nurse plans to start an IV line on a female client hospitalized with pneumonia. The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for the client’s IV line?1. Basilic vein of the left forearm [4%]
2. Cephalic vein in the right antecubital space [28%]
3. Median vein of the right forearm [63%]
4. Radial vein of the left wrist [4%]
Correct Answered correctly
63% Time: 48 seconds
Updated: 04/26/2017
Explanation:

The client’s medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected arm. The nurse must avoid any needlesticks, IV insertions, or blood pressure measurements in the affected arm (Options 1 and 4).

The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best because the client had a left-sided mastectomy (Option 3). Other considerations when selecting IV sites include avoidance of areas that have obstructed blood flow, dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection.

(Option 2) The antecubital space should be avoided when possible (except for emergency insertion) as it inhibits mobility and may be positional.

Educational objective:
The nurse should review the client’s medical record and assess for contraindications to IV sites, including impaired lymphatic drainage (prior mastectomy), arteriovenous fistula or graft (used for hemodialysis), and areas distal to old puncture sites.

Steps for inserting a nasogastric tube for gastric decompression include the following:

Perform hand hygiene and apply clean gloves (no need for sterile gloves)
Place client in high Fowler’s position
Assess nares and oral cavity and select naris
Measure and mark the tube
Curve 4-6″ tube around index finger and release
Lubricate end of tube with water-soluble jelly
Instruct client to extend neck back slightly
Gently insert tube just past nasopharynx, aiming tip downward
Rotate tube slightly if resistance is met, allowing rest periods for client
Continue insertion until just above oropharynx
Ask client to flex head forward and swallow small sips of water (or dry if NPO)
Advance tube to marked point
Verify tube placement and anchor – use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method. Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration

Key steps when inserting a large-bore nasogastric tube include using clean gloves; inspecting nares; measuring, marking, and lubricating tube; instructing client to extend the neck back slightly; inserting tube past the nasopharynx and continuing advancement until just above oropharynx; asking the client to flex the head forward and swallow; advancing tube to marked point; and verifying tube placement using abdominal x-ray and anchoring.
How will the nurse collect a urine sample for urinalysis and culture from a pt. with an indwelling urinary catheter
Urine specimens must be collected aseptically from the port located on the catheter tubing of an indwelling urinary catheter
A urine specimen is collected aseptically from the specimen port in an indwelling urinary catheter. Urine that has been collected from the collection bag does not yield accurate urinalysis and culture results
During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an
upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort.

The nurse assesses a client during the dwell time of a peritoneal dialysis cycle. Which assessment would require immediate intervention?

1. Blood pressure of 168/88 mm Hg and pulse of 72/min
2. Client experiencing intermittent nausea
3. Crackles present in the left and right lung bases [76
4. Presence of 1+ pitting edema in ankles and feet bilaterally

Explanation:

During peritoneal dialysis, dialysate is infused into the abdominal cavity and the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid drains out via gravity. During the instillation and dwell portions of the cycle, clients are monitored closely for indications of respiratory distress (eg, difficulty breathing, rapid respirations, crackles) that can result from instilling the dialysate too rapidly, overfilling of the abdomen, or fluid entering the thoracic cavity (Option 3). Crackles can also occur if over time there is more dialysate infused than is removed (fluid gain).

(Option 1) Clients receive peritoneal dialysis due to chronic kidney failure. The client’s blood pressure is likely elevated secondary to the renal failure. This assessment is important to monitor, but crackles in the lungs are the priority.

(Option 2) Clients with renal failure typically have electrolyte abnormalities (eg, acidosis) that lead to nausea. This is not a priority.

(Option 4) Edema in the extremities can also indicate volume overload. However, this could be due to many other factors (eg, blood pressure medications such as amlodipine) or fluid overload from kidney disease. It is not a priority over crackles, which indicate direct seeping of excess peritoneal cavity fluid into the thorax through diaphragmatic channels.

Educational objective:
Clients receiving peritoneal dialysis should be monitored carefully for signs and symptoms of respiratory compromise, including difficulty breathing, rapid respirations, and crackles.

A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. The nurse’s role when assisting with a lumbar puncture includes the following:
Verify informed consent
Gather the lumbar puncture tray and needed supplies
Explain the procedure to older child and adult
Have client empty the bladder
Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table)
Assist the client in maintaining the proper position (hold the client if necessary)
Provide a distraction and reassure the client throughout the procedure
Label specimen containers as they are collected
Apply a bandage to the insertion site
Deliver specimens to the laboratory
Educational objective:
When assisting with a lumbar puncture, the nurse verifies informed consent, gathers supplies, explains the procedure, has the client void, and then assists the client into position. During the procedure, the nurse provides a distraction, helps the client stay in position (if needed), and labels specimens as they are collected. Afterward, the nurse applies a bandage and ensures that the specimens are delivered to the laboratory.

Nursing assessments are generally performed in order of least invasive to most invasive.

To perform an abdominal assessment, the nurse always stands on the client’s right side when beginning an abdominal examination. Before touching anything, the nurse makes a visual inspection of the abdomen.

After inspection, the nurse proceeds by auscultating the abdomen. Auscultation is performed next because percussion and palpation can increase peristalsis, potentially leading the nurse to make an erroneous interpretation of bowel sounds. The nurse should lightly place the diaphragm of the stethoscope in the right lower quadrant, as high-pitched bowel sounds are normally present in this region.

After auscultation, the nurse proceeds to percussion and then palpation. Palpation is performed last because it may induce pain, resulting in abdominal rigidity, guarding, and a change in respirations. This rigidity may affect tone heard upon percussion. Percussion is also intended to identify borders of organs that move with respiration (eg, liver, spleen). A client in pain from abdominal tenderness will likely take quick, shallow breaths, which will change how far organs are displaced and make it more difficult for the examiner to identify true borders of organs.

Abdominal examination is done in the following sequence – stand on
right side, inspect, auscultate, percuss, then palpate.
Abdominal paracentesis is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis). The client should be positioned in high Fowler’s or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture
high Fowler’s or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture

in the event of an air embolus, the TX:

this will cause the air to rise to the right atrium. The health care provider should be notified immediately and the nurse should remain with the client

head of the bed should be lowered (Trendelenburg) and the client positioned on the left side;
Chest tube insertion should be performed with the client’s arm raised above the head on the affected side. If possible, the head of the bed should be
raised 30-60 degrees to reduce risk of injury to the diaphrag
After a liver biopsy, the client should lie on the right side for a minimum
of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours.
The risk for bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk.
During a lumbar puncture, the client is positioned side-lying, with the head, back, and knees flexed. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position. Following the procedure,
the client will be positioned according to the health care provider’s prescription (usually supine or with head of the bed elevated 30 degrees).
Educational objective:
For medical procedures, the nurse should ensure that the client:Has an empty bladder and is in high Fowler’s or a sitting position for paracentesis
Is Trendelenburg on the left side for suspected air embolism
Has the arm raised above the head on the affected side for chest tube insertion
Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy
Is side-lying with the head, back, and knees flexed for lumbar puncture

he steps below should be used to calculate the amount of cefuroxime that needs to be administered per dose:

1. Convert pounds to kilograms (1 kg = 2.2 lb) 32 lb ÷ 2.2 lb = 14.545454 kg
2. Calculate prescribed amount per day in milligrams 30 mg/kg x 14.545454 kg = 436.36362 mg
3. Calculate prescribed amount per dose in milligrams 436.36362 mg ÷ 2 daily doses = 218.1818 mg
4. Convert prescribed dose from milligrams to milliliters:

Desired x Quantity
Available

OR

Ratio/proportion

218.1818 mg x 5 mL ÷ 250 mg = 4.3636 mL

250 mg ÷ 5 mL = 218.1818 mg ÷ X mL

X = 4.3636 mL

5. Round answer based on directions Rounding rules are applied after all calculations have been made.

4.3636 mL recorded using one decimal place is 4.4 mL.

MATH
To calculate pediatric doses that are prescribed in mg/kg/day format, the nurse should convert pounds to kilograms, calculate the prescribed amount per day in milligrams, calculate the prescribed dose in milligrams, and then convert the prescribed dose from milligrams to milliliters.
Epistaxis,
nosebleed, is rarely serious and is usually due to
Epistaxis CAUSES
mucosal irritation from dryness, local injury (eg, nose-picking), a foreign body, or rhinitis. Most bleeding arises from a highly vascular network on the anterior nasal septum. Epistaxis generally resolves spontaneously or with simple home management.
Epistaxis can often be prevented by avoiding
local trauma and maintaining hydration of the mucosa with saline nasal spray or a humidifier.
Epistaxis tx:
Initial management of epistaxis includes tilting the client’s head forward; applying direct, continuous pressure to the nose for 5-10 minutes; and holding a cold cloth to the nasal bridge.

The health care provider prescribes a therapeutic heparin protocol for a client who weighs 198 lb and has a pulmonary embolus. The nurse initiates the infusion with 25,000 units of heparin in 500 mL dextrose 5% in water at 18 units/kg/hr. At what rate per hour does the nurse set the intravenous (IV) pump? Record your answer as a whole number.

Answer:
Correct answer
32

Explanation:

Convert pounds to kilograms:
198 ÷ 2.2 = 90 kg
Calculate concentration of heparin solution:
25,000 units ÷ 500 mL = 50/mL
Calculate dose in units/hour:
18 units X 90 kg = 1620 units/hr
Calculate dose in mL/hour:
1620 units X 1 mL = 32.4 mL/hr
50 Units
or
X mL =
1620 units 1 mL
50 units
50 X = 1620
X = 32.4 = 32 mL/hr
Educational objective:
To set the IV pump in milliliters per hour, the nurse calculates the amount of heparin to be administered by converting the client’s weight in pounds to kilograms, calculates concentration of the heparin infusion, calculates total dose in units per kilograms per hour, and calculates the dose in milliliters per hour.

MATH
What is the nurse’s role in informed consent is to
-witness that the client signed the consent voluntarily and was competent at the time of signing
– The nurse should ensure that the client received necessary information and has no remaining questions about the procedure.
– After obtaining the signature, the nurse should document in the client’s medical record that the informed consent was given and the date/time of the signature
Educational objective:
The nurse’s role in informed consent is to witness a client’s signature and ascertain that the client signed voluntarily, was competent to provide consent at the time of signature, received the necessary information, and has no further questions
If the client’s condition allows, the nurse should avoid suctioning or changing activity or oxygenation levels prior to drawing of ABGs. These actions can result in inaccurate ABG results.
Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure
ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client’s activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client’s condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client’s oxygen level and cause inaccurate test results.
When cleaning a trach, When will RN put on sterile gloves?
Remove soiled dressing and also remove clean gloves.
Can a clean catch urine specimen be delegated to a UAP
Yes
Can a specimen collection from a Foley catheter Be delegated to a UAP
NO B/c is considered a sterile procedure and should not be assigned to a UAP.
Can a emptying or recharging a Hemovac or Jackson-Pratt wound drain Be delegated to a UAP
NO
needs to be assessed to ensure it is working properly.
Can a UAP measure the drainage of a Hemovac or Jackson-Pratt?
YES
measure the drainage is ok but
assessing the functioning of the drain and the drainage, as well as recharging the drain, should be performed by a nurse.
When descending stairs with a cane ( after hip replacement), the client should:
Lead with the cane
Bring the weaker leg down next (in this client, it is the right leg)
Finally, step down with the stronger leg
When ascending stairs with a cane, the client should:
Step up with the stronger leg first
Move the cane next while bearing weight on the stronger leg
Finally, move the weaker leg
******************The nurse may use the mnemonic “up with the good and down with the bad.” Cane always moves before the weaker leg.*********************
Following thoracentesis, the nurse should monitor for signs of pneumothorax
Which could turn into a Tension pneumothorax
increased respiratory rate,
increased respiratory effort,
respiratory distress,
low oxygen saturation, and
absent breath sounds on the side where the procedure was done (where the lung is collapsed).Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. Altered level of consciousness may occur due to decreased oxygenation and blood flow to the brain . A tension pneumothorax may be prevented by early detection of pneumothorax through appropriate monitoring..

what is a complication of thoracentesis
pneumothorax
complication of thoracentesis days later ?
infection

During a weather-related emergency, home care visits are classified as:

.

High priority – unstable clients who need care and are at risk for hospitalization if not seen.

Moderate priority – clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care management can be provided to these clients.

Low priority – clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care.

The nurse should teach a client receiving a clonidine patch to:
-Apply patch to a dry hairless area on the upper arm or chest
-Wash hands before and after application
-Rotate sites with each new patch application
-Discard patch away from children or pets with sticky sides folded together
-Never wear more than 1 patch at a time
-Never stop using the patch abruptly
Clonidine is a potent
antihypertensive agent and is available as a transdermal patch. The patches should be replaced every 7 days and can be left in place during bathing.

Heparin is a high-alert medication that requires an additional double check on all boluses and when a new bag is hung or the rate is changed. The nurse should always follow institution policy regarding high-alert medications.

The current dose is 1300 units/hr. This client’s PTT is 44 seconds. This is below the therapeutic range of 55-70 seconds as shown in the exhibit, indicating that the client requires a higher dose of heparin for adequate anticoagulation. According to the Heparin Anticoagulation Dose Adjustments Protocol (institutions protocols vary), the rate should be increased by 100 units/hr, or to an infusion rate of 1400 units/hr.

The following steps should be performed to calculate the rate at which the IV infusion pump should be set to deliver 1400 units/hr (current dose 1300 units/hr + increase by 100 units/hr per protocol):

1. Calculate the concentration of the heparin solution:
25,000 units ÷ 500 mL = 50 units/mL
2. Calculate the adjusted dose in mL/hr:
Desired x Quantity
Available
1400 units x 1 mL = 28 mL/hr
50 units
or
1 mL =
50 units X mL
1400 units
X = 28 mL/hr
Educational objective:
To calculate the IV infusion pump rate to infuse heparin at 1400 units/hr, the nurse should calculate the concentration of the heparin solution (eg, 25,000 units in 500 mL D5W). The nurse must then convert the dose from units/hr to mL/hr.

___________________ is a high-alert medication that requires an additional double check on all boluses and when a new bag is hung or the rate is changed.
Heparin
Block Time Remaining: 00:22:20
TUTOR
Test Id: 80629987A client with hypokalemia is prescribed intravenous (IV) potassium chloride (KCL) to infuse at 10 mEq/hr. The pharmacy sends 20 mEq in 250 mL D5W. To deliver the prescribed dose, the nurse sets the infusion pump at how many milliliters per hour? Record your answer using a whole number.

Correct answer
125

Explanation:

Calculate the infusion rate:

20 mEq = 10 mEq
250 mL X mL
20 X = 2500
X = 125 mL/hour
The nurse programs the infusion pump at 125 mL/hr to deliver the prescribed dose of 10 mEq/hr.

Educational objective:
IV KCL is a high-alert drug and is administered using an infusion pump at no more than 10 mEq/hr for adults.

nurse teaches the client how to use the most advanced gait, the 4-point crutch gait.
**advance right crutch, then left foot, and advance left crutch, then right foot.
Emergency self-injection of epinephrine (EpiPen) can be done through clothing into the mid-outer thigh when the client first notices any anaphylactic symptoms.
Can epipen be given through cloths
yes
Sjögren’s syndrome (SjS, SS) is a
long-term autoimmune disease in which the moisture-producing glands of the body are affected.[4] This results primarily in the development of a dry mouth and dry eyes
Scleroderma is a
long term autoimmune disease that results in hardening of the skin. In the more severe form, it also affects internal organs
Somogyi rebound AKA Somogyi effect and posthypoglycemic hyperglycemia,
contested explanation of phenomena of elevated blood sugars in the morning
it is a rebounding high blood sugar that is a response to low blood sugar
The dawn phenomenon, sometimes called the dawn effect, is an early-morning (usually between 2 a.m. and 8 a.m.) increase in blood sugar (glucose)
managed in many patients by avoiding carbohydrate intake at bedtime, adjusting the dosage of medication or insulin, switching to a different medication, or by using an insulin pump to administer extra insulin during early-morning hours.

An IV infusion of norepinephrine at 8 mcg/min is prescribed for a client in shock. The concentration of norepinephrine is 4 mg in 250 mL D5W. For how many mL per hour should the nurse program the IV pump?

Record your answer using a whole number.

Answer:
1
(mL/hr)

Incorrect
Correct answer
30
Answered correctly
56% Time: 5 seconds
Updated: 03/17/2017
Explanation:

Many IV drugs for critically ill clients are prescribed using units per hour, micrograms per minute (mcg/min), milligrams per minute (mg/min), and micrograms per kilogram per minute (mcg/kg/min). Intravenous pumps are set by milliliters per hour (mL/hr). As a result, the nurse must be able to calculate the drug dose and infusion rate in mL/hr. Due to the potency of these drugs and the hemodynamic instability of critically ill clients, it is imperative that the nurse be able to calculate the appropriate dosages and infusion rates.

Convert the prescribed dose to milligrams:

1000 mcg = 1 mg

8 mcg/min × 1 mg/1000 mcg = 0.008 mg/min

Convert the prescribed dose from milligrams to milliliters:

Norepinephrine concentration is 4 mg per 250 mL

0.008 mg/min × 250 mL/4 mg = 0.5 mL/min

Convert the time from minutes to hours:

60 min = 1 hour

0.5 mL/min x 60 min/hr = 30 mL/hr

As an alternative, the following formula can be used to calculate pump setting in mL/hr if a given dose is prescribed:

Dosage (mg/min) × 60 min/hr ÷ concentration (mg/mL) = pump setting (mL/hr)

Concentration = 4 mg/250 mL= 0.016 mg/mL

0.008 mg/min × 60 min/hr ÷ 0.016 mg/mL = 30 mL/hr

Educational objective:
The nurse must be able to accurately calculate titrated medication drug dosages and flow rates as administration of an incorrect dose or infusion rate can be catastrophic.

MATH

The nurse is to administer prescribed heparin 70 units/kg IV bolus before initiating the continuous infusion per institution protocol. Heparin 1,000 units/mL is available. The client weighs 108 lb. How many milliliters of heparin bolus should the nurse administer? Record your answer using one decimal place.

Answer:
1
(mL)

Incorrect
Correct answer
3.4
Answered correctly
77% Time: 3 seconds
Updated: 04/28/2017
Explanation:

The steps below should be performed to calculate the amount of heparin that needs to be administered.

Convert pounds to kilograms (standard conversion is 1 kg = 2.2 lb):

108 lb ÷ 2.2 lb = 49.09 kg

Calculate prescribed bolus dose in units:

70 units x 49.09 kg = 3,436 units

Convert prescribed bolus dose from units to mL:

Desired x Quantity
Available

3436 units x 1 mL = 3.436 mL (round down to 3.4 mL)
1000 units

The nurse is to administer a 3.4 mL bolus of heparin IV push.

Educational objective:
The nurse calculates the amount of heparin to be administered by converting pounds to kilograms, calculating the prescribed bolus dose in units, and then converting the prescribed dose from units to mL.
d.

A continuous regular insulin IV infusion of 0.2 units/kg/hr is prescribed for a 10-year-old weighing 48 lb with new-onset diabetes mellitus. How many units would the nurse administer to this client per hour? Record your answer using one decimal place.

Answer:
1
(units/hr)

Incorrect
Correct answer
4.4
Answered correctly
70% Time: 4 seconds
Updated: 02/15/2017
Explanation:

It is critical for the nurse to calculate insulin correctly due to its being a high-risk medication (eg, can cause severe hypoglycemia).

Step 1: Convert weight from pounds to kilograms:

2.2 lb = 1 kg

Child weighs 48 lb; divide 48 lb by 2.2 = 21.8182 kg
Step 2: Calculate amount of medication needed:

0.2 units/kg/hr

Child weighs 21.8182 kg; multiply 21.8182 kg by 0.2 units/hr = 4.3636 units/hr
Then, round this answer to the nearest tenth to get 4.4 units/hr.

Educational objective:
Insulin is a high-risk medication (eg, can cause severe hypoglycemia), and exact dosages are critical. To calculate a weight-based insulin infusion rate, the nurse should first convert the client’s weight from pounds to kilograms. Next, the nurse should multiply the weight in kilograms by the amount of insulin prescribed per kilogram.

MATH
The incidence of cervical cancer is higher among
Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women
TRUE OR FALSE
The mortality rate for hypertension among African American women is higher than that for white American women
TRUE
African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among the women than men in this ethnic group.
TRUE OR FALSE
African Americans have a higher incidence of ischemic stroke than whites or Hispanics.
TRUE
Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia
TRUE OR FALSE
African Americans have a higher incidence of osteoporosis
FALSE White and Asian women higher incidence of osteoporosis BUT disease affects all ethnic groups
TRUE OR FALSE
Melanoma of the skin is more common in people who are of white ancestry, light-skinned, and over age 60 with frequent sun exposure.
TRUE
The incidence of melanoma is 10 times higher in white Americans than African Americans.
The RN know that the proper intervention should be to Slow down the rate of administration of total enteral nutrition when giving hypertonic formulas when pt has N/V/D bc?
because of their higher osmolality, hypertonic formulas sometimes cause nausea, vomiting, or diarrhea, especially during the initiation of total enteral nutrition.
The gastrointestinal tract will pull fluid from the surrounding intra- and extravascular compartments to dilute the formula, making it similar to body fluid osmolality.
This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, nausea, and vomiting.
What type of solution would be infused in clients with ICP.
A hypertonic
What type of solution would be infused in clients severe hyponatremia and neurologic manifestation
rapid correction of hyponatremia with hypertonic saline (3% saline).
How long before a dairy product can be consumed When meat or poultry is consumed Individuals who practice Orthodox Judaism follow Kosher laws
3-6 hours must pass before a dairy product can be consumed
A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include

Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these instructions are as follows:

Wash incisions daily with soap and water in the shower. Gently pat dry

Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves

Tub baths should be avoided due to risk of introducing infection

Do not apply powders or lotions on incisions as these trap the bacteria at the incision

Report any redness, swelling, and increase in drainage or if the incision has opened

Wear a supportive elastic hose on the legs. Elevate legs when sitting to decrease swelling

The nursing goals in end-of-life care are to comfort and support the client and family when death is imminent. Morphine is commonly used to manage the dyspnea, tachycardia, and restlessness associated with withdrawing mechanical ventilator support. Intravenous benzodiazepines, (eg, midazolam, lorazepam) may be administered for additional comfort.
The Valsalva maneuver is contraindicated in the client diagnosed with
increased intracranial pressure, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis.
Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped immediately and tube placement checked if the client develop
signs of aspiration.
Palliative care focuses on quality of life and symptom management (eg, pain, dyspnea, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, depression). It can be given concurrently with life-prolonging treatment in the setting of terminal disease. Palliative care is provided by a multidisciplinary care team with a focus on the clients and their families
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.
Beneficence is the ethical principle of
doing good. It involves helping to meet the client’s (including the family) emotional needs through understanding. This can involve withholding information at times.
RN must consider what when initiating IV therapy and caring for an older adult receiving IV therapy?

Important considerations include the following:

-The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia.

Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance

Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours.

Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure.

Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the client when speaking.

Use the smallest gauge catheter (24-26 gauge) indicated for the client’s therapy as veins are more fragile.

Consider vein sites to promote client independence (non-dominant arm, avoiding back of the hand).

Use a 5-15-degree angle on insertion as veins of the elderly are usually more superficial

RN will use this technique when ?
(24-26 gauge) IV catheters and correct technique (5-15-degree angle) for insertion of an IV into fragile veins.
Older adults IV therpy
When teaching clients and caregivers, the nurse must keep in mind several principles of adult learning. These include the learner’s:
Need to know
Readiness to learn
Prior experiences
Motivation to learn
Orientation to learning
Self-concept
The nurse should actively engage the client in teachings that the client is ready to receive and perceives as an immediate need.
When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex individual rather than a family member or personal friend. The nurse should speak slowly and directly to the client, not the interpreter; provide infor

Which client is at the greatest risk for development of hospital-acquired pressure ulcers?

1. 25-year-old client with quadriplegia, urosepsis, temperature of 101 F (38.3 C), and white blood cell count of 18,000/mm3 (18.0 x 109/L) [46%]
2. 50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg [26%]
3. 80-year-old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L) [23%]
4. 87-year-old client 2 days post open cholecystectomy
Correct answer
2

Explanation:

Pressure ulcers are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk.

This client (Option 2) has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 g/dL (<160 mg/L), indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving norepinephrine (Levophed), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and the ability to provide adequate nutrition to the cells. (Option 1) This client has 4 risk factors: a deficit in independent mobility and activity, spinal cord injury with quadriplegia, decreased sensation, and fever and infection. (Option 3) This client has 3 risk factors: advanced age, surgery, and dementia. Hemoglobin is within the normal range. (Option 4) This client has 2 risk factors: advanced age and surgery. Surgery can be associated with deep-tissue injury ulcers. Positioning and immobility during the surgical procedures (>2½ hours) and receiving anesthetic and vasoactive drugs (to treat hypotension) present a special risk for the development of deep-tissue injury in postoperative clients.

Educational objective:
Although pressure ulcers can develop in any client with limited mobility and activity, those at most risk include older adults; those with quadriplegia; the critically ill; and those with fracture of a long bone or hip, incontinence, nutritional deficits, chronic illness, renal failure, anemia, oxygenation and circulation problems, infection, or fever.

The most reliable indicator for the client’s pain is the client’s
The most reliable indicator for the client’s pain is the client’s self-report of symptoms.
When there is new, sudden onset of restlessness/agitation, the nurse should first think about
oxygenation (or blood glucose).
The outcomes of a quality improvement program should be .
objective and measureable
The electronic record is a legal document and should contain
factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It must include direct observation and measurement.
Clients with sickle cell crisis often have excruciating pain and need large doses of narcotics. The most effective method
is PCA of morphine or hydromorphone (Dilaudid).
When speaking with AD clients,
use clear and simple explanations. .
When communicating with clients who have hearing loss,
speak loudly, stand close to the person, and touch the person before speaking
Rest from activities that aggravate pain and inflammation is a
nonpharmacologic comfort intervention to decrease the inflammation due to acute pain.
interventions to prevent wound dehiscence include use of
stool softeners and antiemetics, application of an abdominal binder, and tight blood glucose control.
When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client’s
general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.
IV site has redness, edema, discomfort, drainage, hardness, warmth, or coolness. What will RN do?
infiltration occurs, discontinue the IV line immediately and restart it in another site.
how will rn perform a thorough pain assessment
location, quality, radiation, severity, and associated factors (eg, nausea, diaphoresis) for the severe pain. The assessment data will guide the nurse’s subsequent interventions
Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah’s Witnesses is that transfusions containing blood in any form are not acceptable.
Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma)
Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer’s, dextran, and hetastarch.
These can be administered safely to clients who refuse blood productsRecombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah’s Witnesses. These medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and hemoglobin levels

Jehovah’s Witnesses will not take any 4 components of blood = RBC WBC Platlets Plasma.
RN TX: for Jehovah’s Witnessess who is lossing blood will be givein?
saline, lactated Ringer’s, dextran, and hetastarch
Recombinant human erythropoietin (eg, epoetin alfa) and IV iron
A STAT order indicates that a medication is to be given
immediately and only once.
What to meds cannot be given together b/c Risk for serotonin syndrome.
Selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram) cannot be combined with monoamine oxidase inhibitors (MAOIs) (eg, phenelzine)
What S/S pt have serotonin syndrome?
Mydriasis ( dilated pupils) high body temperature Body temperature can increase to greater than (106.0 °F).
agitation
increased reflexes
tremor
sweating
diarrhea
Complications may include seizures and extensive muscle breakdown.
An MAOI should be withdrawn at least
14 days before starting an SSRI.
PHARM SECTION~~~~~~~~~~~~~~~~~~~~~~~~~~“
PHARM~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~`
isosorbide has actions identical to nitroglycerin and can cause hypotension from vasodilation
Isosorbide mononitrate is a nitrate-class drug used for the prophylactic treatment
of angina pectoris; that is, it is taken in order to prevent or at least reduce the occurrence of angina
When should Isosorbide be held?

systolic blood pressure is <90 mm Hg.

Perfusion to the kidneys is inadequate if the systolic blood pressure is <80 mm Hg. Because the pressure is so low, the nurse does not want to lower it further by giving the drug.

A “normal” fasting glucose level (
70-99 mg/dL
warfarin (Coumadin) is monitored
by the INR. The therapeutic range of INR is 2-3
minimum of how many days before the administration of MAOIs and SSRIs
14 days ;
to avoid serotonin syndrome; these medications cannot be administered concurrently
What may not be prescribed to a premenopausal client without a formal agreement to participate in the iPledge prescription tracking program. A commitment to always use at least 2 forms of birth control to prevent pregnancy is required.
Isotretinoin (Accutane)
What Med will NOT be safe for a PREGNANT pt. with Hypertension to be prescribed?
Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril (Prinivil)
as they can affect kidney development in the fetus.

Fluticasone propionate (belongs to a class of drugs known as corticosteroids, specifically glucocorticoids).

This drug is a C and WILL be prescribed to PREGNANT pt. with severe asthma.

used to treat asthma, allergic rhinitis, nasal polyps, various skin disorders and Crohn’s disease and ulcerative colitis. It is also used to treat eosinophilic esophagitis.
thyroxine (Synthroid) in pregnancy should be
monitored carefully to provide an appropriate dose for the physiological changes of maternity, but it is not teratogenic
Doxycycline (Doryx) should NOT be used
during PREGNANCY as it can impair bone mineralization in the fetus
doxycycline, isotretinoin, and ACE inhibitors.
absolutely contraindicated in pregnancy
Naproxen indomethacin, ibuprofen
nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation.
NSAIDs (eg, indomethacin, ibuprofen) are associated with the following:

Gastrointestinal (GI) toxicity – symptoms of GI bleeding such as black tarry stools

Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food.

Kidney injury – long-term use is associated
with kidney injury

Hypertension and heart failure – NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension

Bleeding risk – clients should notify the HCP if taking concurrently with aspirin, other NSAIDs, or anticoagulant or antiplatelet drugs as they can increase the risk of GI bleeding

Clients should not drive when taking
sedating medications
eg, antihistamines, benzodiazepine.
Orthostatic hypotension is common with
blood pressure medications (eg, ACE inhibitors, alpha blockers)
Suicidal thoughts are commonly associated with
selective serotonin reuptake inhibitors (antidepressants) and varenicline (Chantix), a smoking cessation medication.

escitalopram systemic

citalopram systemic

fluoxetine systemic

sertraline systemic

paroxetine systemic

fluvoxamine systemic

priority over the daily need to increased fluids for the nurse to educate the client taking allopurinol
drinking a full glass of water with each dose and increasing overall fluid intake. Increased fluids help to prevent renal stones and promote diuresis and uric acid excretion.
Methotrexate (Rheumatrex) Adverse
bone marrow suppression, hepatotoxicity, and gastrointestinal irritation (eg, nausea, vomiting, diarrhea)
Methotrexate (Rheumatrex) treat
rheumatoid arthritis (RA)
What S/S would RN know are adverse effects pt. on Methotrexate?

marrow suppression can lead to anemia, leukopenia, and thrombocytopenia.

Anemia manifests as fatigue, dyspnea on exertion, and pallor.

Leukopenia increases the risk for infection.

Thrombocytopenia presents as petechiae, purpura, or bleeding.

Petechiae are small, purplish hemorrhagic skin spots that occur when the platelet count is <150,000/mm3

Bone marrow suppression is managed with dose reduction or discontinuation of the medication.

Stomatitis (inflammation of the mouth, oral ulcers) is a common side effect associated with methotrexate.
with folic acid supplementation. Although the condition is uncomfortable, it would not require immediate intervention and is not the most important finding to report.
Educational objective:
Methotrexate (Rheumatrex) is a nonbiologic DMARD prescribed to treat RA. Major adverse effects include bone marrow suppression and hepatotoxicity. Most common side effects can be prevented by folic acid supplementation.
Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for
muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury.
Pt on cyclobenaprine Rn will monitor

Liver Function

In the presence of hepatic impairment (eg, hepatitis), drug metabolism is reduced and results in the accumulation of medication in the body, which leads to toxicity

increased CNS depression (eg, weakness, confusion, drowsiness, lethargy)and serious adverse effects.

muscle relaxants are metabolized by the
liver
What med treats Trichomonas infection
Metronidazole (Flagyl) is an antibiotic
what is is an important treatment in early acetylsalicylic acid (ASA) toxicity
FIRST: activated charcoal
2ND: IV sodium bicarbonate is an appropriate treatment for aspirin toxicity
Educational objective:
Activated charcoal is used as the initial treatment for aspirin overdose in clients with clinical signs of salicylate toxicity as well as in those who are asymptomatic. Activated charcoal binds with salicylate and therefore inhibits absorption by the small intestine. IV sodium bicarbonate is also used for treating aspirin overdose after treatment with activated charcoal has been initiated.
The nurse should encourage the client with osteoporosis to take supplemental calcium with food to increase its absorption. Vitamin D will also enhance absorption. Multiple daily doses are recommended as calcium absorption is impaired when taken in excess of 500 mg per dose. Constipation is a frequent side effect of calcium supplementation.
Any rash in a client taking allopurinol, even if mild, should be reported immediately to the HCP.
The nurse should direct the client to stop taking the medication immediately, schedule an appointment, and notify the HCP. A rash caused by allopurinol may be followed by more severe hypersensitivity reactions that can be fatal, including Stevens-Johnson syndrome and toxic epidermal necrolysis
Educational objective:
The nurse should direct the client taking allopurinol for gout to immediately discontinue the medication and report to the HCP if any rash develops. Allopurinol-induced rashes can develop into severe and sometimes fatal hypersensitivity reactions, such as Stevens-Johnson syndrome. Similar instructions should be given to clients taking anticonvulsants (eg, carbamazepine, phenytoin, lamotrigine) and sulfa antibiotics.
Educational objective:
The topical analgesic capsaicin relieves minor peripheral pain (eg, osteoarthritis, neuralgia) with regular use. Local irritation (burning, stinging, erythema) is quite common. The client should
wait at least 30 minutes before washing the affected area to ensure adequate absorption.
~~~~~~~~~~~~~~~~~~Pharm Basic CARE~~~~~~~~~~~~~~““
~~~~~~~~~~~~~~~~~CARE~~~~~~~~~~~~~~““
Educational objective:
Constipation is an expected long-term side effect of opioid use; clients will not develop tolerance to this side effect. It is important to teach aggressive preventive measures (eg, defecate when the urge is felt, drink 2-3 L of fluid/day, high-fiber diet, exercise) and simultaneous use of a stool softener and a stimulant.
Clients will not develop tolerance to this side effect. Although clients with idiopathic chronic constipation are not commonly advised to take laxatives, opioid-induced constipation is treated with simultaneous use of senna (stimulant) and docusate (stool softener).
Educational objective:
Opioid analgesics are effective for managing postoperative pain, which encourages participation in deep breathing exercises. Side effects of opioid analgesics include sedation, respiratory depression, hypotension, and constipation. The nurse should administer IV hydromorphone slowly over 2-3 minutes, monitor sedation level, instruct the client not to get out of bed unassisted, and administer PRN stool softeners.
Factors that increase risk for respiratory depression related to opioid use for pain control include
advanced age, underlying pulmonary disease, snoring, obesity, smoking, opiate naïve, and surgery.
he Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of drug-induced toxicity, cognitive dysfunction, and falls. Some commonly used medications in this list include
antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales.
a tricyclic antidepressant used to treat depression and neuropathic pain;
its anticholinergic properties may cause dry mouth, constipation, blurred vision, and dysrhythmias
RN will caution in elderly Pt.
Amitriptyline (Elavil)
Chlorpheniramine (ChlorTrimeton) is a sedating histamine H1 antagonist used to treat allergy symptoms. RN will caution in elderly Pt.
Increased central nervous system effects
(eg, drowsiness, dizziness)
may occur due to its reduced clearance in the elderly
Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include
drowsiness, dizziness, ataxia, and confusion
caution in elderly or pt. decrease excretion function.
Donepezil (Aricept) is an acetylcholinesterase inhibitor used to treat Alzheimer dementia.
It does not place the elderly at increased risk of adverse effects.
The nurse should closely monitor the medication administration record of clients receiving acetaminophen to ensure that the total 24-hour dose from all sources does not exceed 4 g. Why?
Hepatotoxicity may develop with >4 g/day.
Morphine administration can cause respiratory depression. The nurse should hold a dose of morphine for a client whose respiratory rate is
<12/min
What meds can cause urinary retention;
by increasing the bladder sphincter tone and/or relax bladder muscle.What is RN NI?

Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants

The nurse should assess the client’s suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions.

The half-life of naloxone (Narcan) is shorter than most narcotics. When naloxone is used to reverse the effects of narcotics, the nurse must
monitor the client to ensure that the client does not fall again into excessive sedation and/or respiratory depression.
Aspirin and other NSAIDs inhibit platelet aggregation, resulting in GI bleeding complications. They also promote development of gastric ulcers with long-term use. Tinnitus (ringing in the ears) is the earliest sign of
aspirin toxicity.
What is the primary form of treatment for individuals with hyperthyroidism
radioactive iodine (RAI)
How does radioactive iodine (RAI) treat Hyperthyroidism?
it destroys or damages the thyroid gland (or a part of it).
RAI has a delayed response and may take up to
3 months to have a maximum effect. For this reason, other medications should be maintained to lower thyroid hormone synthesis and treat symptoms of hyperthyroidism until RAI begins to have maximum effect
RAI should be taught to use the following precautions for up to 1 week:

Avoid close proximity to pregnant women or children

Do not breastfeed as RAI may be excreted through breast milk and could harm the infant

Do not share utensils with others or use bare hands to handle food that is to be served to others

Isolate personal laundry (eg, bed linens, towels, daily clothes) and wash it separately

Use a separate toilet from the rest of the family and flush 2-3 times after each use

Wash hands frequently and thoroughly, especially after restroom use

Drink plenty of fluids

Sleep in a separate bed from others and do not sit near others in an enclosed area for a prolonged period of time (eg, train or flight travel)

Isotretinoin is a vitamin A derivative prescribed to treat severe and/or cystic acne. Side effects include birth defects, skin changes (eg, dry skin, skin fragility, cutaneous atrophy), and risk for increased intracranial pressure. Clients need to be instructed
to avoid tetracycline, excess sun and tanning, and vitamin A supplements. Women of child-bearing age should use 2 forms of contraception to prevent pregnancy.
Educational objective:
A client prescribed CSII is taught how to self-manage the insulin pump. Key points include the importance of checking blood glucose levels at least
4 times a day, how to administer a bolus dose at mealtime to cover carbohydrate intake, how to administer a supplemental bolus dose to correct pre- and postprandial hyperglycemia, and the importance of balancing diet and exercise to avoid excess weight gain.
insulin glargine should not be mixed
in a single syringe with any other insulin as the mixture may alter the pharmacodynamics of the drug.
How long is Blood donation discourage when pt. stops taking isotrentinion?
1 month afterward to ensure that pregnant women do not receive any donated blood

Which insulin is an intermediate-acting insulin with a duration of 12-18 hours; it is generally prescribed 2 times daily (morning and evening).

These are generally taken before meals and at bedtime.

Educational objective:
NPH is an intermediate-acting insulin with a duration of 12-18 hours and typically prescribed twice a day.

NPH
HumliN
NovliN
rapid-acting insulins (lispro, aspart, glulisine) are typically used with a sliding scale for tighter control of blood glucose throughout the day.
Regular insulin = also the ONLY insulin goes in IV
Humlin R
Novlin R
What is the only insulin that can be administered IV push
Regular insulin
Pt with hypothyroidism should be take _____________ empty stomach, preferably in the morning, separately from other medications.
Levothyroxine
The expected therapeutic response to levothyroxine (Synthroid) includes an increased sense of well-being with elevated mood, greater energy levels, and a heart rate within normal limits. It takes up to 8 weeks to see the full effect of pharmacological therapy.
Regular insulin is short-acting and peaks
2-5 hours after administration.
The onset of regular insulin is
30 minutes-1 hour
with duration of 5-8 hours.
Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) increase the risk of cardiovascular events (eg, mycoardial infarction, heart failure) and bladder cancer. Thiazolidinedione use increase insulin sensitivity but carries a low risk for hypoglycemia (similar to metformin).
What medications are commonly associated with constipation, urinary retention, flushing, dry mouth, and heat intolerance.
Anticholinergic medications
RN Will teach pt on anitchloinergic to
to prevent these side effects
increasing intake of fluids
bulk-forming foods (prevents dry mouth and constipation)
avoiding locations or activities that may lead to hyperthermia.
Levetiracetam (Keppra) is an a
nticonvulsant prescribed for seizure disorders
levetiracetam has a depressing effect on the central nervous system (CNS), which may cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is common and typically improves within 4-6 weeks
4-6 weeks
Levetiracetam is an anticonvulsant prescribed for seizure disorders. It may have depressing effects on the central nervous system (eg, drowsiness) as the body adjusts to therapy. Serious adverse effects include
suicidal ideation and Stevens-Johnson syndrome. Clients with seizure disorders must meet the guidelines of their department of transportation and receive permission from their health care provider prior to legally operating a motor vehicle.
Educational objective:
Anticoagulants stop thrombus formation by interfering with the coagulation cascade. Parenteral heparin and oral warfarin affect the clotting cascade differently; therefore, a 5-day overlap for the 2 drugs is required. This allows warfarin to reach a therapeutic level before the continuous heparin infusion is stopped.
Epoetin (Procrit) is a synthetic hormone that stimulates the production of erythropoietin and is used to treat
anemia associated with chronic kidney disease
Sodium polystyrene sulfonate (Kayexalate) is a sodium exchange resin administered to
reduce elevated serum potassium levels in clients with chronic kidney disease and hyperkalemia
Vitamin K (phytonadione) is a fat-soluble vitamin that is administered as an antidote for
warfarin-related bleeding.
Black cohosh is used by some clients for
menopausal hot flashes
Black cohosh main side effects are
thickening of the uterine lining and potential liver toxicity.
Herbal therapy is usually stopped – any surgery.
2-3 weeks before
Educational objective:
A transdermal fentanyl patch is indicated to treat moderate to severe chronic pain. It is not recommended for treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied.

The nurse is reviewing prescriptions for the assigned clients. Which prescriptions should the nurse question? Select all that apply.

1. Allopurinol for a client who developed tumor lysis syndrome from chemotherapy for acute leukemia
2. Dicyclomine for a client with a history of irritable bowel syndrome who develops a postoperative paralytic ileus
3. IV morphine for a client with severe acute renal colic pain who is scheduled for a percutaneous nephrolithotripsy
4. Levofloxacin for a client with a urinary tract infection who has a history of anaphylaxis to penicillin drugs
5. Simvastatin for a client with hypercholesterolemia who is reporting generalized muscle aches and weakness
Incorrect
Correct answer
2,5

Explanation:

The nurse should question these prescriptions and contact the health care provider:

Dicyclomine, an anticholinergic/antispasmodic drug prescribed to manage irritable bowel syndrome, is contraindicated with paralytic ileus, as it decreases intestinal motility and would exacerbate the condition (Option 2).
Statins (eg, atorvastatin, simvastatin) lower LDL cholesterol. Myopathy, a possible adverse effect, may lead to life-threatening rhabdomyolysis (Option 5).
(Option 1) Tumor lysis syndrome is due to rapid lysis of cells and the resulting release of intracellular ions potassium and phosphorous into serum. Phosphorus binds calcium and causes hypocalcemia. Metabolism (catabolism) of released cellular nucleic acids leads to severe hyperuricemia. IV hydration and hypouricemic medications (eg, allopurinol) are usually prescribed to promote excretion of purines and prevent acute kidney injury.

(Option 3) IV opioids (eg, morphine) or nonsteroidal anti-inflammatory agents (eg, ketorolac) are used to treat severe renal colic pain. Percutaneous nephrolithotripsy breaks and removes stones and can lead to severe pain. Therefore, pain medications are appropriate.

(Option 4) Levofloxacin, a fluoroquinolone antibiotic prescribed to treat urinary tract infections, has no known cross-sensitivity to penicillin. However, cross-sensitivity with other fluoroquinolones can occur.

Educational objective:
Dicyclomine is an antispasmodic drug that decreases intestinal motility and is contraindicated with paralytic ileus. For clients with myopathy, statins should be withheld and the health care provider called. Prior to and during chemotherapy, allopurinol helps prevent hyperuricemia in clients at risk for tumor lysis syndrome.

The nurse reviews the serum laboratory results and medication administration records for assigned clients. Which prescriptions should the nurse question and validate with the health care provider before administering? Select all that apply.

1. Bumetanide in the client with heart failure who has hypokalemia
2. Calcium acetate in the client with chronic kidney disease who has hyperphosphatemia
3. Carvedilol in the client with heart failure who has an elevated B-type natriuretic peptide level
4. Isoniazid in the client with latent tuberculosis who has elevated liver enzymes
5. Metronidazole in the client with Clostridium difficile infection who has leukocytosis
Omitted
Correct answer
1,4

Explanation:

Bumetanide is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance (Option 1).

Isoniazid is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis (Option 4).

(Option 2) Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia (normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney disease. Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate and excreting it in feces.

(Option 3) Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the progression of heart failure. B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch. Elevated BNP is expected in a client with heart failure; the nurse need not question this prescription.

(Option 5) Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious diarrhea caused by Clostridium difficile. Leukocytosis is expected with this bacterial infection.

Educational objective:
Loop diuretics (eg, bumetanide, furosemide, torsemide) can cause hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]). Elevated liver enzymes in clients receiving the antitubercular drug isoniazid can indicate development of drug-induced hepatitis.

Educational objective:
A client with signs of a potential allergic reaction should be assessed quickly, including allergy history and physical assessment (face, trunk, and limbs) with attention to signs of anaphylaxis. The health care provider should then be notified to assess the client, and the client’s allergies should be updated in the medical record.

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to provide which instruction to the client?

4. Report excessive urination and increased thirst [62%]

Explanation:

Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics).

Chronic toxicity can result in:

Neurologic manifestations – ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks)
Nephrogenic diabetes insipidus – polyuria and polydipsia (increased thirst) (Option 4)
Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals.

(Option 1) Dietary potassium should be avoided when taking drugs such as potassium-sparing diuretics (eg, spironolactone, triamterene, amiloride) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

(Option 2) Regular exercise and a high-fiber diet can prevent constipation, which is not a known side effect of lithium. Opioids, anticholinergics, and iron supplements are medications that cause constipation.

(Option 3) Good oral hygiene is ideal for every client but is not specially indicated for those taking lithium. Clients taking phenytoin should maintain oral hygiene to prevent gingival hyperplasia.

Educational objective:
Risk factors for lithium toxicity include dehydration, decreased renal function, low-sodium diet, and drug-drug interactions (eg, NSAIDs and thiazide diuretics). Chronic toxicity manifests with neurologic symptoms (ataxia, confusion or agitation, and neuromuscular excitability) and/or diabetes insipidus (polyuria and polydipsia).

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply.

1. Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L)
2. Client on newly prescribed lisinopril and is at 8 weeks gestation
3. Client on nitroglycerine patch for heart failure and blood pressure is 84/56 mm Hg
4. Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia
5. Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value
Incorrect
Correct answer
1,2,3

Explanation:

Heparin is a natural anticoagulant. Its risk is heparin-induced thrombocytopenia (HIT), also known as heparin-associated thrombocytopenia. Normal platelet range is 150,000-400,000/mm3 (150-400 x 109/L). A mild lowering of platelets may occur and resolve spontaneously around the 4th day of administration. The danger is type II HIT, a more severe form in which there is an acute drop in the number of platelets (more than 50% from baseline), which requires discontinuing heparin (Option 1).

Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril are teratogenic. Lisinopril can cause embryonic/fetal developmental abnormalities (cardiovascular and central nervous system) if taken during pregnancy, especially during the first 13 weeks of gestation. During the 2nd and 3rd trimesters, ACE inhibitors interfere with fetal renal hemodynamics, resulting in low fetal urine output (oligohydramnios) and fetal growth restriction (Option 2).

Nitroglycerine causes vasodilation and can lower blood pressure. Systolic blood pressure should be >90 mm Hg to ensure renal perfusion (Option 3).

(Option 4) Gingival hyperplasia or hypertrophy is a known side effect of phenytoin (Dilantin) and is not a reason to stop the drug. Vigorous dental hygiene beginning within 10 days of initiation of phenytoin therapy can help control it. Signs and symptoms that require discontinuation include toxic levels or phenytoin hypersensitivity syndrome (fever, skin rash, and lymphadenopathy).

(Option 5) Warfarin (Coumadin) is used to prolong clotting so that the desired result is a “therapeutic” range rather than the client’s “normal” control value when not on the drug. Therapeutic range is considered roughly 1.5-2.5 times the control (International Normalized Ratio [INR] of 2-3), but up to 3-4 times the control (INR of 2.5-3.5) in high-risk situations such as an artificial heart valve.

Educational objective:
Heparin should be held when there is significant thrombocytopenia. Angiotensin-converting enzyme inhibitors are not administered to pregnant women, and nitrates are not administered when a client is hypotensive. Prothrombin time/International Normalized Ratio is expected to be 1.5-2.5 (up to 4) times the control value when therapeutic effects are reached. Gingival hyperplasia is a side effect of phenytoin (Dilantin) administration and is not a reason to stop the drug.

The emergency department nurse is caring for a client who has recently been prescribed methadone for chronic severe back pain. The client ingested extra tablets tonight because the pain returned. Which assessment findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply.

1. Client falls asleep while the nurse is talking
2. Client frequently scratches due to pruritus
3. Client has third emesis since taking medication
4. Monitor reveals one premature ventricular contraction
5. Pulse oximeter shows oxygen saturation is 90%

Correct answer
1,3,5

Explanation:

Methadone is a potent narcotic with a longer half-life than its duration of action due to its lipophilic properties. The risk for overdose exists as clients can inadvertently take too many tablets for additional pain relief even though fat cells will continue to release high amounts of the drug into circulation.

Early signs of toxicity include nausea/vomiting and lethargy. A client who falls asleep with stimulation (ie, is obtunded) requires additional observation/monitoring. Sedation precedes respiratory depression, a life-threatening complication of severe toxicity (Options 1 and 3).

An acceptable pulse oximetry reading for a normal, healthy nonsmoking adult is considered 95%-100%. A reading of 90% is low and indicates inadequate depth or rate of respiration with possible respiratory depression (Option 5).

(Option 2) Itching sensation (pruritus) is an expected finding with narcotic use, especially in opioid-naïve clients. It can be managed with an antihistamine.

(Option 4) Occasional premature ventricular contractions are a common, insignificant finding in most adults. The client should have cardiac monitoring in the setting of methadone use/overdose as there is a risk of QT interval prolongation (normal 0.34-0.43 sec, or less than half the RR interval), which can lead to cardiac arrhythmias (eg, torsades de pointes).

Educational objective:
Methadone is a potent narcotic with a long half-life. Early signs of toxicity include nausea/vomiting and lethargy. The nurse should monitor the client’s respiratory rate, pulse oximetry, and electrocardiogram tracing. Respiratory depression and QT interval prolongation can lead to life-threatening complications.

The nurse reviews assigned clients’ medical and medication administration records. Which prescription should the nurse validate with the health care provider before administering?

1. Acetaminophen IV for a postoperative client with temperature of 101 F (38.3 C) who reports incisional pain of 6 on a 0-10 scale [21%]
2. Azathioprine for a client with Crohn disease who reports fatigue and nausea and has leukopenia [47%]
3. Baclofen for a client with multiple sclerosis and muscle spasms who reports dizziness when changing positions [15%]
4. Colchicine for a client with an acute gout attack who reports burning pain in the great toe of 10 on a 0-10 scale [14%]
Omitted
Correct answer
2

Explanation:

Azathioprine (Imuran) is an immunosuppressant drug that can cause bone marrow depression and increase the risk for infection. It is prescribed to treat autoimmune conditions such as inflammatory bowel disease and to prevent organ transplant rejection. Fatigue and nausea can be expected as minor adverse effects or may be associated with the disease. Leukopenia (white blood cell count <4,000/mm3 [4.0 × 109/L]) can be a severe adverse effect of the drug and should be reported to the health care provider before administering the medication.

(Option 1) Acetaminophen IV (Ofirmev) blocks the production of prostaglandins and has both antipyretic and analgesic properties. It is effective in relieving mild to moderate pain and can be prescribed in combination with opioid analgesia to relieve moderate to severe pain.

(Option 3) Baclofen (Lioresal) is an antispasmodic drug that promotes skeletal muscle relaxation by interfering with the transmission of impulses that cause muscle spasticity. It is effective in decreasing pain and cramping associated with muscle tightness and spasticity in clients with multiple sclerosis and in those with spinal cord injury. Orthostatic hypotension is an expected adverse effect.

(Option 4) Colchicine is prescribed for clients with an acute attack of gout as it decreases the inflammation and pain associated with deposition of uric acid crystals in the joints.

Educational objective:
Azathioprine (Imuran) is an immunosuppressant drug that can cause bone marrow suppression and increase the risk for infection. Leukopenia, a severe adverse effect of azathioprine, should be reported to the health care provider before the medication is administered.

The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider?

1. Clopidogrel for client with history of stroke and platelet count of 154,000/mm3 (154 × 109/L) [12%]
2. Losartan for client with hypertension who is 8 weeks pregnant [61%]
3. Prednisone for client with herpes simplex lesions and Bell palsy [17%]
4. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease [8%]
Omitted
Correct answer
2

Losartan is an angiotensin II receptor blocker (ARB) prescribed to treat hypertension. ACE inhibitors (eg, lisinopril, enalapril) and ARBs are teratogenic, causing renal and cardiac defects or death of the fetus. ARBs and ACE inhibitors have black box warnings that indicate contraindication in pregnancy.

The nurse should not give an ARB to a pregnant client (Option 2). The health care provider should be notified so that an alternate antihypertensive may be prescribed that is safe to take during pregnancy (eg, labetalol, methyldopa).

(Option 1) Antiplatelet agents (eg, clopidogrel) are prescribed to prevent thromboembolic events in clients with increased risk for stroke or myocardial infarction. Laboratory values are monitored periodically as these drugs increase bleeding time (normal, 2-7 minutes [120-420 seconds]) and, rarely, may lower platelet count (normal, 150,000-400,000/mm3 [150-400 × 109/L])

(Option 3) Bell palsy presents as acute onset of unilateral facial paralysis related to inflammation of the facial nerve (ie, cranial nerve VII) that may be triggered by a viral illness (eg, herpes simplex virus). Standard treatment includes corticosteroids (eg, prednisone) within 72 hours of symptom onset.

(Option 4) Tiotropium is an inhaled anticholinergic drug that inhibits receptors in the smooth muscles of the airways. It is prescribed daily for the long-term management of bronchospasm in clients with chronic obstructive pulmonary disease.

Educational objective:
Angiotensin II receptor blockers and ACE inhibitors are teratogenic, causing fetal injury or death, and are contraindicated in pregnancy.

.

The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply.

1. Client with iron deficiency anemia takes iron supplements with milk
2. Client takes levothyroxine early in the morning on an empty stomach
3. Client taking phenazopyridine for urine infection states that the urine has turned orange
4. Client taking metronidazole mentions going to a wine-tasting party tonight
5. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold
Omitted
Correct answer
1,4,5

Explanation:

Iron is absorbed better on an empty stomach; ascorbic acid (vitamin C), such as found in citrus fruits and juices, increases the absorption of iron. However, milk products decrease iron absorption and should be avoided (Option 1).

Metronidazole (Flagyl) is used to treat trichomoniasis and amebiasis. Consuming alcohol while taking the medication may elicit a disulfiram (Antabuse)-like reaction. Alcohol should be avoided for at least 48 hours after treatment is completed (Option 4).

Many antihistamines also have anticholinergic effects. Anticholinergics have an antimuscarinic effect that can increase intraocular pressure and are therefore contraindicated in closed-angle glaucoma. Other contraindications include urinary retention (benign prostatic hyperplasia) and bowel obstruction related to the anticholinergic drug’s effect on the smooth muscle in the urinary and gastrointestinal tract (Option 5).

(Option 2) Enteral nutrition decreases levothyroxine absorption; as a result, it should be taken early in the morning on an empty stomach (at least 30 minutes before food intake).

(Option 3) Phenazopyridine (Pyridium) is used as a local anesthetic in the treatment of urinary tract infection. The azo dye turns the urine an orange-red color. The client needs to be reassured that this is an expected result and could stain clothing.

Educational objective:
Clients taking metronidazole (Flagyl) should avoid alcohol. Those with glaucoma or urinary retention should avoid anticholinergic drugs. Oral iron is better absorbed on an empty stomach and with vitamin C. Phenazopyridine (Pyridium) will turn urine an orange-red color.

The community health nurse prepares a teaching plan for a client with latent tuberculosis who is prescribed oral isoniazid (INH). Which instructions should the nurse include? Select all that apply.

1. Avoid drinking alcohol
2. Expect body fluids to change color to red
3. Report yellowing of skin or sclera
4. Report numbness and tingling of extremities
5. Take with aluminum hydroxide to prevent gastric irritation
Omitted
Correct answer
1,3,4

Explanation:

Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy.

A teaching plan for a client prescribed INH includes the following:

Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity (Option 1)
Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy
Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH
Report changes in vision (eg, blurred vision, vision loss)
Report signs/symptoms of severe adverse effects such as:
Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) (Option 3)
Peripheral neuropathy (eg, numbness, tingling of extremities) (Options 4)
(Option 2) Rifampin, another antitubercular drug, often causes a red-orange discoloration of body fluids (ie, urine, sweat, saliva, tears). However, this effect is not associated with INH use.

(Option 5) Concurrent use of antacids containing aluminum decreases INH absorption. The medication may be taken with food if gastric irritation is a concern.

Educational objective:
Common potential side effects of INH include hepatotoxicity (eg, jaundice, vomiting, dark urine, fatigue) and peripheral neuropathy (eg, numbness, tingling of extremities). Clients should avoid alcohol use and aluminum-containing antacids, and report any experienced side effects to the health care provider immediately.

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A client has a follow-up checkup in the urology clinic. Six months ago, the client started taking tolterodine. What data collected from the client should the nurse report to the health care provider?

1. Client excitedly reports being able to go an entire work day without having to urinate [71%]
2. Client is using an over-the-counter artificial saliva product for dry mouth [10%]
3. Client reports occasional dizziness in the morning and when changing positions [14%]
4. Client reports symptoms of constipation [4%]
Omitted
Correct answer
1

Explanation:

Tolterodine (Detrol LA), oxybutynin (Ditropan), and solifenacin (Vesicare) are antimuscarinic/anticholinergic medications used for overactive bladder and urge urinary incontinence. They decrease urinary urgency and frequency. The most common side effects are anticholinergic (eg, dry mouth, constipation, cognitive dysfunction). The client’s report of not urinating the entire day while at work may indicate that the dosage is too high and is causing urinary retention. Urinary retention can lead to bladder infections and distension. This information should be reported to the health care provider (HCP).

(Option 2) Artificial saliva products and sugar-free hard candy and gum are acceptable ways to manage dry mouth caused by anticholinergic medications.

(Option 3) Occasional dizziness is a side effect of tolterodine. The client should rise and change positions slowly. However, if this client is receiving too high a dose, reduction of the dose may alleviate the dizziness. Severe dizziness should be reported to the HCP.

(Option 4) Constipation can be managed with increased fiber in the diet, fluids, stool softeners, or laxatives.

Educational objective:
Anticholinergic medications (eg, tolterodine, oxybutynin, solifenacin) are commonly used for overactive bladder. The client should experience a reduction in the number of times needed to urinate, but the number should not decrease below typical urination frequency. The nurse should also teach the client how to manage the common side effects of dry mouth, constipation, and mild dizziness.

An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which data obtained by the nurse is most important to report to the health care provider before hanging the next dose?

1. Blood pressure 104/62 mm Hg [2%]
2. Blood urea nitrogen 20 mg/dL (7.1 mmol/L) [9%]
3. Client report of tinnitus [78%]
4. Urine output of 400 mL since last dose [9%]
Omitted
Correct answer
3

Explanation:

Serious adverse reactions to aminoglycosides (eg, gentamicin, tobramycin, amikacin) include ototoxicity and nephrotoxicity. Age, renal function, and drug dose affect the occurrence of these adverse reactions. Careful dosing is especially important for older clients. Tinnitus and vertigo are early signs of ototoxicity. The nurse should carefully assess for changes in the client’s hearing, balance, and urinary output.

(Option 1) The blood pressure is low, but the nurse should compare it to previous readings. Blood pressure is not generally affected by IV antibiotics. The client may be taking antibiotics for sepsis.

(Option 2) The blood urea nitrogen (BUN) is within normal range (6-20 mg/dL [2.1-7.1 mmol/L]), but is at the high end of normal and should continue to be monitored.

(Option 4) Urine output is adequate (>30 mL/hr) but should be closely monitored.

Educational objective:
The nurse should closely monitor renal function and assess for any changes in hearing or balance in a client receiving aminoglycoside antibiotics. Ototoxicity and nephrotoxicity are serious adverse reactions related to this type of medication.

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed?

1. Instructs client to close eyelid and move eye around; applies pressure to the lacrimal duct for 30-60 seconds [15%]
2. Pulls lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac [4%]
3. Removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus [73%]
4. Rests hand on client’s forehead and holds dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac [6%]
Omitted
Correct answer
3

Explanation:

If applicable, the nurse requests that the client remove contact lenses. The nurse then dons clean gloves and uses aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye conditions (eg, glaucoma, infection). The Joint Commission disallows the use of abbreviations for right eye (OD), left eye (OS), and both eyes (OU). The nurse must verify the prescription if the health care provider (HCP) uses these abbreviations.

The general procedure for the administration of ophthalmic medications includes the following steps in sequence:

Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the inner to outer canthus to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct (Option 3)

Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa

Rest hand on client’s forehead and hold dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac, which keeps the dropper away from the eye globe and avoids contamination (Option 4)

Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac (Option 2)

Instruct client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea

Instruct client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible systemic absorption (Option 1)

Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination

Wait 5 minutes before instilling a different medication into the same eye

Educational objective:
To administer ophthalmic medications, follow these steps: (1) Remove secretions from the eyelid by wiping from the inner to outer canthus; (2) pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac; and (3) apply pressure to the lacrimal duct if medication has systemic effects (eg, beta blocker, timolol maleate).
.

The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider?

1. Vancomycin trough 10 mg/L (6.9 µmol/L), creatinine 1.1 mg/dL (97.2 µmol/L), BUN 6 mg/dL (2.1 mmol/L) [6%]
2. Vancomycin trough 14 mg/L (9.7 µmol/L), creatinine 1.2 mg/dL (106.1 µmol/L), BUN 10 mg/dL (3.6 mmol/L) [1%]
3. Vancomycin trough 18 mg/L (12.4 µmol/L), creatinine 0.6 mg/dL (53 µmol/L), BUN 18 mg/dL (6.4 mmol/L) [4%]
4. Vancomycin trough 23 mg/L (15.9 µmol/L), creatinine 1.5 mg/dL (132.6 µmol/L), BUN 24 mg/dL (8.6 mmol/L) [87%]
Omitted
Correct answer
4

Explanation:

Vancomycin (Vancocin) is a potent antibiotic used to treat gram-positive bacterial infections (eg, Staphylococcus aureus, Clostridium difficile). To lower the risk of dose-related nephrotoxicity, especially in clients with renal impairment and those who are >60 years of age, serum vancomycin trough levels should be monitored to assess for therapeutic range (10-20 mg/L [6.9-13.8 µmol/L]). A vancomycin trough level above the normal range and/or elevated creatinine and blood urea nitrogen (BUN) values should be reported to the health care provider (HCP) as this may indicate nephrotoxicity.

(Options 1, 2, and 3) Normal laboratory values do not need to be reported to the HCP. Baseline and ongoing monitoring for normal levels of creatinine (0.6-1.3 mg/dL [53-115 µmol/L]) and BUN (6-20 mg/dL [2.1-7.1 mmol/L]) are necessary in clients receiving vancomycin.

Educational objective:
The normal therapeutic level of vancomycin is 10-20 mg/L (6.9-13.8 µmol/L). Elevated vancomycin trough levels (>20 mg/L [>13.8 µmol/L]), creatinine (>1.3 mg/dL [>115 µmol/L]), and blood urea nitrogen (>20 mg/dL [>7.1 mmol/L]) are associated with nephrotoxicity and should be reported to the health care provider.

A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain. Which situation would require intervention by the precepting nurse?

1. Chooses to administer 50 mcg of the prescribed 50-100 mcg of IV fentanyl for the first dose [5%]
2. Dilutes hydromorphone with 5 mL of normal saline and injects IV push over 2 minutes [17%]
3. Injects 1 mg of morphine sulfate undiluted via IV push over 5 minutes [24%]
4. Selects a 25-gauge ½-inch (1.3-cm) needle to inject ketorolac intramuscularly [53%]
Omitted
Correct answer
4

Explanation:

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) analgesic administered (orally, IV, or intramuscularly [IM]) for short-term relief of mild to moderate pain. Usage should not exceed 5 days due to adverse effects (eg, kidney injury, gastrointestinal ulcers, bleeding). Ketorolac IM should be administered into a large muscle using the Z-track method to mitigate burning and discomfort. A 1- to 1½-in (2.5- to 3.8-cm) needle is recommended to inject medication into the proper muscular space in average-weight individuals.

(Option 1) The amount of analgesic to administer of a variable dose medication should be based on the client’s pain level, level of consciousness, and history of narcotic use. Selecting a smaller first dose is appropriate if the nurse is unsure of how the client will respond to the medication. If needed, the larger amount can be given the next time a dose is requested or an additional one-time dose can be requested from the health care provider if breakthrough pain occurs (before the next scheduled medication dose is available).

(Option 2) Hydromorphone IV push, given undiluted or diluted with 5 mL of sterile water or normal saline, should be administered slowly over 2-3 minutes; rapid infusion increases the risk of opioid-induced adverse reactions (eg, nausea, itching).

(Option 3) Undiluted morphine IV push should be administered slowly over 4-5 minutes; rapid infusion increases the risk of opioid-induced adverse reactions (eg, hypotension, flushing).

Educational objective:
Ketorolac, a nonsteroidal anti-inflammatory drug, is used for short-term (≤5 days) pain relief due to risk of bleeding, gastrointestinal ulcers, and kidney injury. Intramuscular (IM) injections (using Z-track method) should be given deep into a large muscle due to burning and discomfort. A 1- to 1½-in (2.5- to 3.8-cm) needle is used to reach the proper muscle space.

A client is 6 hours postoperative from hip surgery after receiving regional anesthesia and has epidural continuous anesthesia in place. Which is the most important reason for the nurse to contact the health care provider?

1. Client reports paresthesia bilaterally since the surgery [36%]
2. Fondaparinux is prescribed for STAT administration [25%]
3. Lower-extremity muscle strength is 3/5 bilaterally [9%]
4. Postoperative laboratory results show hemoglobin of 9.9 g/dL (99 g/L) [28%]
Omitted
Correct answer
2

Explanation:

Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place (Option 2).

Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis.

(Option 1) Paresthesia is an expected finding from postoperative analgesia for 2-24 hours after surgery, depending on the agent and location. Continuously administered analgesia usually results in some paresthesia until approximately 4-6 hours after discontinuance. As long as the level remains relatively stable or improves, it is an acceptable finding. However, paresthesia or motor weakness is a concern when the sensory or motor block outlasts the expected duration.

(Option 3) Client response to operative analgesia and postoperative continued analgesia can range from minimal to significant. As long as the analgesic is infusing and findings remain stable, reduced muscle strength is expected.

(Option 4) Major orthopedic surgery can result in significant blood loss, and it is not unusual for the client to have hemoglobin drop of 1-2 g/dL (10-20 g/L). Blood loss should be monitored over time; transfusion usually is not indicated unless hemoglobin is <7-8 g/dL (70-80 g/L).

Educational objective:
Residual paresthesia and motor weakness for several hours are expected findings after regional anesthesia. Anticoagulants are not given while an epidural catheter is in place.

A A A
The nurse is preparing to administer medications through a client’s feeding tube. Which actions should the nurse implement? Select all that apply.1. Combine all medications before administering
2. Crush each medication separately before administration
3. Determine if the medications are available in liquid form
4. Flush the tube with sterile water before and after medication administration
5. Mix medications with enteral feeding formula before administration
Omitted
Correct answer
2,3,4

Explanation:

Failure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in obstruction of the tube, reduced medication absorption or efficacy, and medication toxicity. Before administering medications through a feeding tube, the nurse should determine if any of the medications are available in a liquid form as liquid medications are less likely to clog the tube (Option 3). Medications should be crushed, dissolved, and administered separately to prevent interactions (chemical reactions) between medications or interference with absorption (Option 2).

A feeding tube should be flushed with sterile water to avoid drug interactions and eliminate contaminants found in tap water. The feeding tube should be flushed before and after each medication is given (Option 4).

(Option 1) When using a feeding tube, each medication should be administered individually to prevent interactions between medications.

(Option 5) Medications mixed with enteral feedings may form a thick consistency and clog the tube.

Educational objective:
When a feeding tube is used, medications should be crushed, dissolved, and administered separately to prevent interactions. Sterile water should be used to dissolve medications and flush the feeding tube. Liquid medications should be used if possible.

The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema?

1. “A contrast medium is administered rectally to visualize the colon via x-ray.” [10%]
2. “Bedridden clients receive this enema to stimulate defecation and relieve constipation.” [18%]
3. “This enema assists the large intestines in removing excess potassium from the body.” [58%]
4. “This enema is administered before bowel surgery to decrease bacteria in the colon.” [12%]
Omitted
Correct answer
3

Explanation:

Sodium polystyrene sulfonate (Kayexalate) retention enema is a medicated enema administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level. Kayexalate can also be given orally and is much more effective. Kayexalate can rarely be associated with intestinal necrosis.

(Option 1) A barium enema uses contrast medium (barium) administered rectally to visualize the colon using fluoroscopic x-ray.

(Option 2) A fleet enema relieves constipation by infusing a hypertonic solution into the bowel, pulling fluid into the colon and causing distension and then defecation.

(Option 4) A neomycin enema is a medicated enema that reduces the number of bacteria in the intestine in preparation for colon surgery.

Educational objective:
Kayexalate retention enemas are medicated enemas administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level.

A A A
A client is receiving IV sodium bicarbonate for acute metabolic acidosis. Which of these laboratory values would best indicate that the sodium bicarbonate has been effective?1. Serum pH 7.32, HCO3- 26 mEq/L (26 mmol/L), potassium 4.9 mEq/L (4.9 mmol/L) [7%]
2. Serum pH 7.34, HCO3- 21 mEq/L (21 mmol/L), potassium 5.1 mEq/L (5.1 mmol/L) [6%]
3. Serum pH 7.39, HCO3- 24 mEq/L (24 mmol/L), potassium 3.8 mEq/L (3.8 mmol/L) [78%]
4. Serum pH 7.41, HCO3- 18 mEq/L (18 mmol/L), potassium 4.3 mEq/L (4.3 mmol/L) [6%]
Omitted
Correct answer
3

Explanation:

Metabolic acidosis is due to an increase in the production or retention of acid (eg, lactic acidosis, ketoacidosis, renal failure) or the depletion of bicarbonate (HCO3-) via the kidneys or gastrointestinal tract. In metabolic acidosis, there is a decrease in pH (<7.35) and HCO3- (<22 mEq [22 mmol/L]). Acidosis damages cells, causing them to release intracellular contents (eg, potassium). Hyperkalemia (potassium >5.0 mEq/L [5 mmol/L]) frequently occurs with acidosis, putting the client at risk for cardiac arrhythmias.

Depending on the cause and severity of acidosis, the client can exhibit altered mental status and tachypnea. Management focuses on treating the underlying cause and administering IV sodium bicarbonate to correct the imbalance. Arterial blood gas pH 7.39, HCO3- 24 mEq/L (24 mmol/L), and serum potassium 3.8 mEq/L (3.8 mmol/L) are within normal limits, indicating the sodium bicarbonate has effectively corrected acidosis.

(Options 1, 2, and 4) These laboratory values are not within normal limits and do not indicate that the sodium bicarbonate has effectively corrected acidosis.

Educational objective:
Metabolic acidosis is an acid-base imbalance that occurs when the pH level drops from excess acid accumulation or bicarbonate (HCO3-) loss. Interventions focus on treating the underlying cause and administering IV HCO3-.

A A A
ExhibitThe nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end-stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration? Click the exhibit button for more information.

1. Atenolol [53%]
2. Calcium acetate [17%]
3. Insulin lispro [18%]
4. Vitamin E [10%]
Omitted
Correct answer
1

Explanation:

Medication administration may require modification on days that clients are scheduled to receive dialysis. The nurse should consider whether the medication will be dialyzed out of the client’s system or may create adverse effects during dialysis. Fluid is removed during dialysis, which may cause hypotension. Typically, antihypertensives are held before dialysis to prevent hypotension. In addition, some medications are dialyzed out of the client’s system and should therefore be held until after dialysis. Commonly held medications are water-soluble vitamins (eg, vitamins B and C), antibiotics, and digoxin.

(Option 2) Clients with chronic kidney disease have high phosphorus levels as the kidney is unable to filter the phosphate from the body; dialysis also does not filter it. Therefore, the client should still take phosphate binders prior to dialysis. Phosphate binders (eg, calcium containing [calcium carbonate and calcium acetate]) and non-calcium containing [sevelamer and lanthanum]) block absorption of ingested phosphate from the intestine and excrete it through feces.

(Option 3) Lispro is a fast-acting insulin that should be given 15-30 minutes before meals. It is appropriate to give scheduled lispro with breakfast prior to dialysis.

(Option 4) Vitamin E is a fat-soluble vitamin that is not affected by dialysis. It is given to some clients to prevent leg cramps that can be experienced by dialysis clients.

Educational objective:
Unless otherwise indicated by the health care provider, antihypertensives and other blood pressure-lowering medications (eg, furosemide), antibiotics, digoxin, and water-soluble vitamins (B, C, and folic acid) should be held prior to dialysis.

A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. What complications of this procedure should the nurse be aware of for monitoring and teaching?

1. Abdominal rigidity and diarrhea [4%]
2. Back pain and urge incontinence [1%]
3. Difficulty swallowing and breathing [91%]
4. Difficulty walking and hand tremor [2%]
Omitted
Correct answer
3

Explanation:

Botulinum toxin type A (Botox) blocks neuromuscular transmission by inhibiting acetylcholine release from nerve endings. The drug is used for treating wrinkles, blepharospasm, and cervical dystonia. Complications are uncommon when Botox is used for cosmetic purposes but can be life-threatening if they occur. The toxin can also relax the muscles used for swallowing and breathing, resulting in dysphagia (aspiration risk) and respiratory paralysis.

(Options 1 and 2) Botulism can be associated with constipation and urinary retention due to relaxation of smooth muscle. Unlike in Clostridium tetani infection (tetanus), painful rigidity and spasms of the neck, back, and abdominal muscles are absent.

(Option 4) Ataxia and hand tremor usually indicate drug toxicity (eg, phenytoin, lithium).

Educational objective:
Botulinum toxin type A (Botox) inhibits the release of acetylcholine from nerve endings and causes relaxation of skeletal/smooth muscles. On occasion, surrounding muscle weakness can lead to dysphagia and respiratory paralysis.

The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse teach the client to expect while taking this medication?

1. Constipation [5%]
2. Difficulty sleeping [2%]
3. Discoloration of urine [75%]
4. Dry mouth [16%]
Omitted
Correct answer
3

Explanation:

Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve the pain and burning associated with a urinary tract infection. The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well. Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication. Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client take a full course of antibiotics.

(Options 1, 2, and 4) Constipation, difficulty sleeping, and dry mouth are not common adverse effects of phenazopyridine hydrochloride.

Educational objective:
Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve symptoms of dysuria associated with a urinary tract infection. An expected side effect of the drug is orange-red discoloration of urine.

A nurse has received new medication prescriptions for a client admitted with hypertension and an exacerbation of chronic obstructive pulmonary disease. Which prescription should the nurse question?

1. Amlodipine [12%]
2. Codeine [63%]
3. Ipratropium [13%]
4. Methylprednisolone [11%]
Omitted
Correct answer
2

Explanation:

Codeine is a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (eg, narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (eg, asthma, COPD).

(Option 1) Calcium channel blockers (eg, amlodipine, nifedipine) are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (eg, metoprolol, atenolol).

(Option 3) Ipratropium (Atrovent) is a short-acting inhaled anticholinergic often used in combination with a short-acting beta-agonist (eg, albuterol) to promote bronchodilation and reduce bronchospasm.

(Option 4) Methylprednisolone (Solu-Medrol) is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD.

Educational objective:
Codeine is a narcotic medication with antitussive properties that can cause an accumulation of secretions in clients with chronic obstructive pulmonary disease and lead to respiratory distress. Caution is advised when sedatives are prescribed for clients with respiratory diseases.

Exhibit

A client with chronic kidney disease is admitted with pneumonia and pleurisy. The client’s laboratory results are shown in the exhibit. Which prescription will the nurse question? Click on the exhibit button for additional information.

1. Acetaminophen 500 mg PO every 6 hours, as needed for fever [21%]
2. Epoetin alfa 15,000 units subcutaneus injection, once weekly [21%]
3. Ketorolac 15 mg IV every 6 hours, as needed for pain [29%]
4. Levofloxacin 500 mg IV, once daily [26%]
Omitted
Correct answer
3

Explanation:

This client has chronic kidney disease with an elevated serum creatinine level. Ketorolac (Toradol) is a highly potent nonsteroidal anti-inflammatory drug (NSAID) often used for pain and available in intravenous form. However, NSAIDs (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. Also, the client should not be given 2 types of NSAIDs simultaneously (eg, naproxen plus ibuprofen) as they can be toxic to the stomach and kidneys.

(Option 1) Prescribing acetaminophen as needed is appropriate to treat fever.

(Option 2) Clients with chronic kidney disease often have anemia due to erythropoietin deficiency. Recombinant erythropoietin injections are often prescribed to treat anemia.

(Option 4) Levofloxacin is an appropriate antibiotic to use for treating pneumonia.

Educational objective:
Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. In addition, clients taking a NSAID medication should not take a different NSAID medication at the same time.

d.

A client with a chronic kidney disease has blood laboratory values as shown in the exhibit. The nurse administers sodium polystyrene sulfonate by mouth per the health care provider’s prescription. The nurse evaluates that the therapy is effective when which value is noted on the follow-up results? Click on the exhibit button for additional information.

1. Calcium 7.4 mg/dL (1.85 mmol/L) [4%]
2. Creatinine 4.0 mg/dL (353 µmol/L) [10%]
3. Phosphorus 3.9 mg/dL (1.26 mmol/L) [9%]
4. Potassium 4.9 mEq/L (4.9 mmol/L) [76%]
Omitted
Correct answer
4

Explanation:

The client with kidney disease is at risk for both hyperkalemia (normal potassium 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) and hyperphosphatemia due to reduced glomerular filtration rate. Untreated hyperkalemia may cause life-threatening cardiac arrhythmias. Sodium polystyrene sulfonate (Kayexalate) can be used to treat hyperkalemia. It works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level.

(Option 1) Serum calcium levels (normal 8.6-10.2 mg/dL [2.15-2.55 mmol/L]) may decrease with diminished renal function due to lower activation of vitamin D and subsequent impaired gut absorption of calcium. Calcium supplements are used to increase the serum calcium level. Sodium polystyrene sulfonate does not affect the serum calcium level.

(Option 2) Sodium polystyrene sulfonate does not affect serum creatinine levels. Creatinine levels may decrease after dialysis.

(Option 3) Phosphorus is also not filtered with kidney injury and the levels increase in serum (normal 2.4-4.4 mg/dL [0.78-1.42 mmol/L]). Phosphate binders (calcium acetate/carbonate) administered orally eliminate phosphorous through stool. Sodium polystyrene sulfonate does not bind phosphorous.

Educational objective:
Clients with kidney disease are at risk for hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level.

A client recently diagnosed with a major depressive disorder reports use of herbal supplements. It is most important for the nurse to provide education about which supplement reported by the client?

1. Echinacea [4%]
2. Garlic [4%]
3. Glucosamine [2%]
4. St John’s wort [88%]
Omitted
Correct answer
4

Explanation:

St John’s wort is an herbal supplement commonly used to treat depression and anxiety. Some clients with mild or moderate depression claim that its antidepressant effect is comparable to that of prescription medications. The herbal supplement mimics the action of selective serotonin reuptake inhibitors (SSRIs) by increasing available serotonin in the brain. Taken in combination with an SSRI (eg, sertraline, fluoxetine, citalopram, paroxetine), St John’s wort may cause an excess of serotonin, resulting in serotonin syndrome, which is characterized by mental status changes, autonomic dysregulation, and neuromuscular hyperactivity.

The client with a newly diagnosed depressive disorder will likely be prescribed an antidepressant. The nurse should teach the client not to take St John’s wort concurrently with SSRIs to prevent serotonin syndrome (Option 4).

(Option 1) Echinacea is commonly used to prevent or treat the common cold/flu, although there is no evidence of its efficacy. It is thought to work by stimulating the immune system. Worsening asthma and anaphylaxis have been reported.

(Option 2) Garlic is used to improve cholesterol and lower blood pressure. Ginkgo, garlic, and ginseng (the 3 Gs) increase bleeding risk when taken with anticoagulants or thrombolytics.

(Option 3) Glucosamine is used to improve joint function. Hypoglycemia may result when it is taken with antidiabetic drugs.

Educational objective:
Selective serotonin reuptake inhibitors and St John’s wort increase serotonin levels in the brain. Clients taking both products concurrently are at risk for potentially life-threatening serotonin syndrome (agitation, confusion, tachycardia, diaphoresis, tremors, hyperreflexia).

The nurse cares for a client following a percutaneous coronary intervention via the right groin. The client received an IV infusion of abciximab during the procedure. Which actions should the nurse implement? Select all that apply.

1. Assess invasive procedure sites for bleeding
2. Check hemoglobin and platelet count
3. Initiate a second large-bore IV line
4. Place the client on continuous cardiac monitoring
5. Report black tarry stools to the health care provider
Omitted
Correct answer
1,2,4,5

Explanation:

Glycoprotein (GP) IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) are used as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent acute ischemic complications. GP IIb/IIIa receptor inhibitors can cause serious bleeding. The nurse should closely monitor the client for any bleeding at the groin puncture site after the percutaneous coronary intervention (Option 1).

The nurse should check the client’s baseline complete blood count (eg, hemoglobin, platelet count). Some clients may develop serious thrombocytopenia within a few hours, further increasing the bleeding risk (Option 2). Hypotension, tachycardia, changes in heart rhythm, blood in the urine, abdominal/back pain, mental status changes, and black tarry stools may also indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor inhibitors are administered (Options 4 and 5).

(Option 3) During and after the infusion of GP IIb/IIIa receptor inhibitors, no traumatic procedures (initiation of IV sites, intramuscular injections) should be performed unless absolutely necessary due to the risk of bleeding.

Educational objective:
Glycoprotein IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) inhibit platelet aggregation and increase bleeding risk. Serious thrombocytopenia can occur within few hours, further increasing bleeding risk. After administration, the nurse should monitor the client’s blood counts, blood pressure, and heart rate and rhythm, as well as watch for signs of bleeding.

A client with a history of heart failure calls the clinic and reports a 3-lb (1.4-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client’s medications and anticipates the immediate need for dosage adjustment of which medication?

1. Bumetanide [54%]
2. Candesartan [11%]
3. Carvedilol [18%]
4. Isosorbide [16%]
Omitted
Correct answer
1

Explanation:

Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide).

(Option 2) Losartan, valsartan, and candesartan (sartans) are the commonly used angiotensin II receptor blockers. They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-aldosterone system but will not affect the fluid status of the client with acute heart failure.

(Option 3) Metoprolol, bisoprolol, and carvedilol (lols) are the commonly used beta blockers for treatment of chronic heart failure. They block the negative effects of the sympathetic nervous system (increased heart rate) and reduce the cardiac workload. However, they can worsen heart failure if used in the acute setting of this condition.

(Option 4) Isosorbide (nitrate) and hydralazine are used in African American clients with heart failure; this combination decreases cardiac workload by reducing preload and afterload. However, it does not decrease excess fluid.

Educational objective:
A client who reports weight gain and edema requires evaluation for additional symptoms of fluid volume overload (eg, shortness of breath) and adherence to the current treatment plan. If the client is stable, an increase in the dosage of loop diuretic (eg, furosemide, torsemide, bumetanide) is anticipated.

A client has a serum potassium level of 2.8 mEq/L, and the health care provider (HCP) prescribes intravenous (IV) potassium chloride (KCL). The nurse administers 10 mEq KCL/100 mL 5% dextrose in water at 100 mL/hr through the client’s peripheral IV line using an infusion pump. Shortly after initiation of the infusion, the client reports feeling burning and discomfort at the IV site. What is the nurse’s priority action?

1. Notify HCP to request a peripherally inserted central catheter (PICC) [1%]
2. Notify HCP to request an oral preparation of KCL [1%]
3. Slow the rate of the KCL infusion [49%]
4. Stop the infusion of KCL immediately [48%]
Omitted
Correct answer
3

Explanation:

KCL, an electrolyte replacement to correct hypokalemia, is a high-alert drug that is never administered by the IV push, intramuscular, or subcutaneous routes. The recommended peripheral infusion rate is 5-10 mEq/hr. However, the nurse should always follow institution IV guidelines and policy and procedure for administering KCL.

The nurse’s priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the infusion rate is effective in alleviating discomfort.

(Option 1) KCL in concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a central venous access device (CVAD) (eg, PICC, centrally inserted catheter) to prevent postinfusion phlebitis. A concentration of 10 mEq KCL/100 mL can be administered through a peripheral vein at the recommended infusion rate.

(Option 2) The IV infusion is preferred over the oral preparation to decrease the risk for dysrhythmias when hypokalemia must be corrected quickly. Some clients may need both oral and IV forms if the serum potassium levels are markedly low. However, this action is not a priority.

(Option 4) Rapid correction of this client’s hypokalemia (2.8 mEq/L) is necessary due to risk for hypokalemia-associated dysrhythmias. Stopping the infusion when not necessary further increases risk. The nurse assesses the site at least every hour for adverse reactions (eg, redness, pain, swelling, phlebitis, thrombosis, extravasation or infiltration), and stops the infusion if any occur.

Educational objective:
Potassium chloride (KCL) administered by the IV route is prescribed for rapid correction of hypokalemia (<3.5 mEq/L). It is irritating to the vein but can be administered slowly through a peripheral vein at recommended infusion rates (5-10 mEq/hr). KCL concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a CVAD to prevent postinfusion phlebitis or infiltration.

A nurse is preparing an educational presentation on herbal supplements for the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial?

1. Clients diagnosed with heart failure [6%]
2. Clients experiencing major depressive disorder [13%]
3. Elderly clients with benign prostatic hyperplasia [50%]
4. Perimenopausal clients experiencing hot flashes [29%]
Omitted
Correct answer
3

Explanation:

Herbal preparations are not regulated by governmental agencies and are generally classified as food or dietary supplements. Manufacturers are therefore able to avoid the scientific scrutiny exercised when prescription drugs are readied for the market. Saw palmetto is one such herbal preparation, and clients most often use it to treat benign prostatic hyperplasia.

(Option 1) Hawthorn extract is used to treat heart failure and in some countries (eg, Germany) is an approved treatment for this purpose.

(Option 2) St John’s wort has been used for centuries to treat depression. It may cause hypertension and serotonin syndrome when used with other antidepressants.

(Option 4) Black cohosh is an herbal supplement often used by perimenopausal clients experiencing hot flashes.

Educational objective:
Saw palmetto, a herbal preparation, is often used to treat benign prostatic hyperplasia. St John’s wort has been used for centuries to treat depression.

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. An assessment of laboratory work shows hemoglobin of 9.7 g/dL (97 g/L) and hematocrit of 29% (0.29). What is the best nursing action?

1. Administer the erythropoietin in the client’s abdominal area [46%]
2. Check the client’s blood pressure prior to administering the erythropoietin [36%]
3. Hold the client’s next scheduled iron sucrose dose [2%]
4. Hold the erythropoietin dose and inform the health care provider [14%]
Omitted
Correct answer
2

Explanation:

Anemia associated with chronic kidney disease is treated with recombinant human erythropoietin (Epogen/Procrit, epoetin). Therapy is initiated to achieve a target hemoglobin of 10-11.5 g/dL (100-115 g/L) and to alleviate the symptoms of anemia (eg, fatigue) and the need for blood transfusions. However, higher hemoglobin concentrations, especially >13 g/dL (130 g/L), are associated with venous thromboembolism and adverse cardiovascular outcomes. Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administration of erythropoietin.

(Option 1) Erythropoietin is administered intravenously or in any subcutaneous area. However, checking the client’s blood pressure must be done prior to administering.

(Option 3) Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an adequate response to erythropoietin. Adequate stores of iron, vitamin B-12, and folic acid are required for the erythropoietin to work. There is no reason to hold iron therapy at this time.

(Option 4) The dose is held if the client has higher target hemoglobin or uncontrolled hypertension.

Educational objective:
The kidneys release erythropoietin to stimulate the production of red blood cells. Anemia of chronic kidney disease is treated with recombinant erythropoietin for a target hemoglobin of 10-11.5 g/dL (100-115 g/L). Hemoglobin levels >13 g/dL (130 g/L) are associated with thromboembolic and cardiovascular events. Uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy.
.

The health care provider is starting an elderly client on terazosin to treat benign prostatic hyperplasia (BPH). Which information should be included when teaching this client about the new medication?

1. Change positions slowly when going from lying to standing [44%]
2. Do not drink grapefruit juice when taking this drug [44%]
3. Take this medication first thing in the morning, before breakfast [7%]
4. Your stool may become darker and that’s normal [3%]
Omitted
Correct answer
1

Explanation:

Terazosin is an alpha-adrenergic blocker that can relieve urinary retention in clients with BPH. It relaxes the smooth muscle in the bladder neck and prostate gland; however, it also relaxes smooth muscle in the peripheral vasculature, which can cause orthostatic hypotension, syncope (blacking out), and falls. This is particularly common when the drug is started (first-dose hypotension) or when the dosage is increased. The serious effects can be avoided by instructing the client to take the medication at bedtime, change positions slowly when going from lying to standing, and avoid any medications that also increase smooth muscle relaxation (eg, phosphodiesterase-5 inhibitors [sildenafil or vardenafil] used to treat erectile dysfunction). Some clients may also experience ejaculatory dysfunction (decreased or absent ejaculation).

(Option 2) Grapefruit juice can cause significant interactions with drugs such as calcium channel blockers and sildenafil. However, it does not appear to interact with alpha blockers such as terazosin.

(Option 3) Alpha-1-adrenergic antagonists (eg, terazosin, doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in the morning, to avoid orthostatic hypotension.

(Option 4) Oral iron tablets and bismuth salts (Pepto-Bismol) can turn stools dark, an expected side effect. This can be confused with upper gastrointestinal bleeding, which can also cause melena.

Educational objective:
Alpha blockers are commonly used to treat symptoms of urinary retention in clients with BPH. Orthostatic hypotension is a common side effect that can be avoided by teaching the client to take the medication at bedtime, avoid abrupt position changes, and avoid medications for erectile dysfunction, which can worsen hypotension.

Block Time Remaining: 00:09:43
TUTOR
Test Id: 80931650
QId: 32609 (921666)
39 of 48
A A A
The nurse is working in the emergency department. Which client should the nurse see first?1. 12-year-old with severe neck muscle spasms who is taking haloperidol for Tourette syndrome [9%]
2. 80-year-old with irritability and agitation who has taken alprazolam for 2 weeks [1%]
3. Client taking clozapine who has sudden onset of high fever, diaphoresis, and change in mental status [88%]
4. Client taking olanzapine who has dry mouth, blurry vision, and constipation [1%]
Omitted
Correct answer
3
Answered correctly
88% Time: 1 seconds
Updated: 01/10/2017
Explanation:

The client taking clozapine is exhibiting classic signs of neuroleptic malignant syndrome (NMS), an uncommon but life-threatening adverse reaction to anti-psychotic medications. NMS is characterized by high fever, muscular rigidity, altered mental status, and autonomic dysfunction. Treatment includes supportive care (eg, rehydration, cooling body temperature) and immediate discontinuation of the medication. Due to the life-threatening nature of NMS, this client needs to be seen first to assess for generalized muscle rigidity.

(Option 1) Severe neck spasms in an individual taking haloperidol (and other psychotropic medications) indicate a dystonic reaction. This client is in no immediate danger but needs treatment with IV benztropine (Cogentin) as soon as possible. The client should be seen second.

(Option 2) Benzodiazepines can cause paradoxical worsening of agitation in elderly clients. This client needs a change in medication but does not need to be seen immediately.

(Option 4) Dry mouth, blurry vision, and constipation are common anti-cholinergic side effects of olanzapine (and other psychotropic medications). These symptoms usually resolve after the client has taken the medication for a few weeks; treatment is symptomatic (eg, increased fluids, sugar-free chewing gum, high-fiber foods, avoidance of driving). This client can be seen last.

Educational objective:
Neuroleptic malignant syndrome (NMS) usually presents with mental status changes, fever, muscle rigidity, and autonomic instability after starting antipsychotic medications. Treatment involves discontinuation of the medication and supportive care (eg, rehydration, cooling body temperature). NMS is a life-threatening condition.

Block Time Remaining: 00:09:44
TUTOR
Test Id: 80931650
QId: 30994 (921666)
40 of 48
A A A
Which prescriptions for these clients does the nurse question? Select all that apply.1. Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO
2. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously
3. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous
4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO
5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO
Omitted
Correct answer
4,5
Answered correctly
41% Time: 1 seconds
Updated: 01/15/2017
Explanation:

The nurse would question the prescriptions for the following clients:

Client with hypertension and BP 94/40 mm Hg, prescribed metoprolol succinate SR (Toprol-XL) 50 mg PO: This client’s mean arterial pressure (MAP) is only 58 mm Hg ({[2x diastolic] + systolic} ÷ 3). A MAP >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Toprol-XL is a long-acting beta blocker and will continue to drop the client’s BP over a 24-hour period.

Client with otitis media and penicillin allergy prescribed ampicillin 500 mg PO: Ampicillin is classified as a penicillin antibiotic and is contraindicated in clients with a penicillin allergy.

(Option 1) C difficile colitis is treated with metronidazole or vancomycin, depending on severity and number of relapses. Vancomycin is typically given orally in this situation, unlike other nonintestinal infections in which IV is the standard route. There is no reason to question this prescription.

(Option 2) A sliding insulin (correction) scale is used to prescribe rapid-acting lispro (Humalog) to control postprandial hyperglycemia. The nurse would not question this prescription.

(Option 3) Proton pump inhibitors (eg, pantoprazole, omeprazole) are prescribed for gastroesophageal reflux disease, and ulcer treatment and prophylaxis. The IV preparation is administered when the oral route is contraindicated. The nurse would not question this prescription.

Educational objective:
IV proton pump inhibitors are used for gastric ulcer bleeding. Oral vancomycin can be used for C difficile colitis. Ampicillin or amoxicillin are contraindicated in clients with a penicillin allergy. Antihypertensives are held if the client has borderline low BP.
.

Block Time Remaining: 00:09:47
TUTOR
Test Id: 80931650
QId: 34325 (921666)
41 of 48
A A A
The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client’s caregiver?1. Administer the medication around the clock even if the client denies having pain [50%]
2. Avoid administering with immediate-release opioids to prevent respiratory depression [38%]
3. Change the dosage and frequency to 20 mg every 6 hours if breakthrough pain occurs [2%]
4. Request a tapered dose from the health care provider if pain decreases to prevent tolerance [9%]
Omitted
Correct answer
1
Answered correctly
50% Time: 3 seconds
Updated: 01/09/2017
Explanation:

Extended-release oxycodone (Oxycontin) is a long-acting opioid agonist prescribed to manage severe chronic pain when nonopioids and immediate-release opioids (eg, immediate-release oxycodone, hydrocodone) are inadequate. The nurse should teach the client’s caregiver to administer extended-release oxycodone as scheduled, even if the client does not report pain. Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours.

(Option 2) Immediate-release opioids and nonopioids are coadministered with long-acting opioids for relief of breakthrough pain. Respiratory status should be monitored; however, clients who receive long-term therapy become opioid tolerant and are less likely to experience adverse effects. Because the goal of hospice care is comfort, this client should be relieved of breakthrough pain regardless of respiratory status.

(Option 3) The dose and frequency cannot be changed without a prescription. Also, breakthrough pain is best treated with short-acting opioids.

(Option 4) Long-term opioid therapy leads to drug tolerance and physical dependence; higher doses are eventually required for therapeutic effect. In the dying client, it is not appropriate to taper the dose. Rather, it should be titrated upward for effective pain relief.

Educational objective:
Long-acting controlled-release opioid drugs for chronic pain require regularly scheduled dosing to maintain a therapeutic drug level. Immediate-release opioids may be required for breakthrough pain. Long-term opioid use leads to tolerance and physical dependence; higher doses are eventually required for therapeutic effect.

Block Time Remaining: 00:09:48
TUTOR
Test Id: 80931650
QId: 33787 (921666)
42 of 48
A A A
A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse’s priority action?1. Assess the condition of the IV site [15%]
2. Check 2 client identifiers before administering medications [14%]
3. Consult a medication guide for compatibility [61%]
4. Wash hands prior to administering medications [8%]
Omitted
Correct answer
3
Answered correctly
61% Time: 1 seconds
Updated: 02/25/2017
Explanation:

The priority when administering 2 IV medications concurrently is to determine drug compatibility. Incompatible drugs given through the same IV line will deteriorate or form a precipitate. This change is visualized through either a color change, a clouding of the solution, or the presence of particles. If 2 or more drugs are not compatible, the nurse may consider inserting a second IV or consulting the pharmacist and the health care provider to determine the safest and most beneficial plan for the client.

(Option 1) Assessing the IV site for complications (eg, infiltration, phlebitis) should always be performed before giving any IV medication. This will be completed after determining drug compatibility.

(Option 2) Verification using 2 client identifiers pertains to the “right client” in the “6 rights” of medication administration. Drug compatibility should be determined prior to entering the client’s room and verifying identity.

(Option 4) Hand hygiene is a standard precaution taken before any type of client interaction to prevent contamination and infection; hand washing will be completed after checking for drug compatibility.

Educational objective:
Checking for drug compatibility is a priority before administering 2 IV medications concurrently in the same IV site. Incompatible drugs will deteriorate or form a precipitate that is visible as a color change, cloudiness, or particulates.

Block Time Remaining: 00:09:54
TUTOR
Test Id: 80931650
QId: 30741 (921666)
43 of 48
A A A
The nurse performs medication reconciliation for a 94-year-old client who has type 2 diabetes, hypothyroidism, and heart failure caused by a previous myocardial infarction. Due to risks outweighing benefits, the nurse plans to talk with the health care provider about discontinuing which medication?1. Aspirin 81 mg PO once a day [30%]
2. Furosemide 40 mg PO once a day [25%]
3. Glyburide 10 mg PO once a day [29%]
4. Levothyroxine 50 mcg PO once a day [14%]
Omitted
Correct answer
3
Answered correctly
29% Time: 6 seconds
Updated: 02/09/2017
Explanation:

Beers Criteria lists medications that may be inappropriate for the geriatric population due to risks outweighing benefits. The nurse collaborates with the health care provider to minimize polypharmacy and reduce adverse effects (eg, falls, confusion).

Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin) (Option 3).

(Option 1) Aspirin is used to prevent platelet aggregation in clients with a history of stroke or myocardial infarction. Aspirin and other nonsteroidal anti-inflammatory medications (eg, ibuprofen) have an increased risk of gastrointestinal bleeding. Therefore, aspirin is used cautiously in the older adult population, and doses should not exceed 325 mg/day.

(Option 2) Furosemide is a loop diuretic used to treat fluid overload in heart failure, making it an important part of symptom management. This drug may cause dehydration if the client is not ingesting food and fluids well; otherwise, it should be continued.

(Option 4) Levothyroxine is required to maintain thyroid hormone levels in clients with hypothyroidism. Major side effects typically occur only with improper dosing (eg, elevated levels).

Educational objective:
The Beers Criteria can be used to identify potentially inappropriate drugs that contribute to adverse events (eg, falls, confusion) and drug toxicity in older adults. Sulfonylureas (eg, glyburide) should be avoided due to potential delayed elimination causing risk for prolonged hypoglycemia.

Block Time Remaining: 00:09:55
TUTOR
Test Id: 80931650
QId: 30896 (921666)
44 of 48
A A A
A nurse is giving medications to a client who is being evaluated for a brain malignancy. The health care provider (HCP) has ordered a computed tomography (CT) scan with intravenous (IV) iodinated contrast for the next morning. Which medication should the nurse plan to withhold from this client?1. Amlodipine [7%]
2. Gabapentin [8%]
3. Metformin [66%]
4. Phenytoin [16%]
Omitted
Correct answer
3
Answered correctly
66% Time: 1 seconds
Updated: 05/28/2017
Explanation:

IV iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury (contrast-induced nephropathy). The side effect of metformin (Glucophage) is lactic acidosis. If the client takes metformin and develops kidney injury from contrast, then the lactic acidosis will worsen. As a result, most HCPs discontinue metformin on the day of IV iodine contrast exposure (regardless of baseline creatinine) and restart the drug at least 48 hours later, after stable renal function has been documented.

(Options 1, 2, and 4) Amlodipine (Norvasc) is a calcium channel blocker commonly used to treat hypertension. Gabapentin (Neurontin) is commonly used for neuropathic pain. Phenytoin (Dilantin) is an antiseizure medication. None of these medications interact with the iodinated contrast or worsen kidney injury. Therefore, these can be safely administered.

Educational objective:
Iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury. Metformin (Glucophage) can worsen lactic acidosis in the presence of kidney injury. Metformin should be withheld prior to the contrast exposure and can be resumed when kidney function is within normal limits.

Block Time Remaining: 00:09:56
TUTOR
Test Id: 80931650
QId: 34537 (921666)
45 of 48
A A A
The nurse is caring for a client who is taking riluzole for amyotrophic lateral sclerosis (ALS). The client asks, “There’s no cure for ALS, so why should I keep taking this expensive drug?” What is the nurse’s best response?1. “It may be able to slow the progression of ALS.” [78%]
2. “It reduces the amount of glutamate in your brain.” [14%]
3. “The case manager may be able to find a program to assist with cost.” [4%]
4. “You have the right to refuse the medication.” [2%]
Omitted
Correct answer
1
Answered correctly
78% Time: 1 seconds
Updated: 02/23/2017
Explanation:

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a debilitating, progressive neurodegenerative disease with no cure. Clients develop fatigue and muscle weakness that progresses to paralysis, dysphagia, difficulty speaking, and respiratory failure. Most clients diagnosed with ALS survive only 3-5 years.

Riluzole (Rilutek) is the only medication approved for ALS treatment. Riluzole, a glutamate antagonist, is thought to slow neuron degeneration by decreasing the production and activity of the neurotransmitter glutamate in the brain and spinal cord. In some clients, riluzole may slow disease progression and prolong survival by 3-6 months. The nurse should provide teaching about the purpose of the medication so that the client can make an informed decision about taking it (Option 1).

(Option 2) Explaining the pharmacology of riluzole is not the best response for helping the client understand the purpose of taking the medication.

(Option 3) It would be appropriate to consult the case manager if the client expresses concern about not having the appropriate resources to acquire a costly medication, but the nurse should first ensure that the client understands the medication’s purpose.

(Option 4) The client has the right to refuse any medication, but the nurse should first ensure that the client is informed and understands the purpose of the medication.

Educational objective:
Although there is no cure for amyotrophic lateral sclerosis, the medication riluzole may slow disease progression and prolong survival.

Block Time Remaining: 00:09:57
TUTOR
Test Id: 80931650
QId: 31984 (921666)
46 of 48
A A A
The nurse provides discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder (ADHD). The nurse advises the parent that the child might experience which side effects?1. Decreased blood pressure and growth delays [18%]
2. Heart palpitations and weight gain [16%]
3. Loss of appetite and restlessness [51%]
4. Trouble sleeping and a dry cough [14%]
Omitted
Correct answer
3
Answered correctly
51% Time: 1 seconds
Updated: 12/16/2016
Explanation:

Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants.

The major problems with stimulant medications include:

Decreased appetite and weight loss – can lead to growth delays
Cardiovascular effects – hypertension and tachycardia (particularly in adults)
Appearance of new or exacerbation of vocal/motor tics
Excess brain stimulation – restlessness, insomnia
Abuse potential – misuse, diversion, addiction
(Option 1) Growth delays are a common side effect. The medications may cause hypertension, not hypotension.

(Option 2) Heart palpitations are a common side effect; weight loss, not weight gain, can be a problem.

(Option 4) Trouble sleeping is a common side effect, but the medications do not cause a dry cough.

Educational objective:
Methylphenidate (Ritalin) is a central nervous system stimulant with the following potential side effects: anorexia and weight loss/growth delays, restlessness and insomnia, hypertension and tachycardia, vocal or motor tics, and abuse potential.

Block Time Remaining: 00:10:02
TUTORA nurse is discontinuing patient-controlled analgesia per the health care provider’s prescription and notes that there is 10 mL of morphine sulfate left in the syringe. No other nurse is available to witness the waste of the medication. What is the best action by the nurse?

1. Ask the unlicensed assistive personnel on the unit to waste the medication [1%]
2. Document that another nurse was not available to waste the medication [6%]
3. Wait until another nurse is available to witness the waste [90%]
4. Waste the medication and have another nurse sign off on it later [1%]
Omitted
Correct answer
3
Answered correctly
90% Time: 5 seconds
Updated: 05/15/2017
Explanation:

Opioids (eg, morphine, hydromorphone, fentanyl) are controlled medications, regulated in the United States by the Controlled Substances Act and in Canada by the Controlled Drugs and Substances Act. These laws contain regulations for various controlled substances. To properly dispose of leftover medication, the nurse must have a second licensed nurse witness the waste of the medication to comply with facility policy and procedure as well as government regulations. The nurse must wait for another nurse to become available to appropriately dispose of the medication (Option 3).

(Option 1) Unlicensed assistive personnel (UAP) cannot witness a medication waste as 2 licensed nurses must document the waste. This is outside the scope of practice for UAP.

(Option 2) The nurse cannot document that another nurse is unavailable as the waste of medication legally requires a second nurse witness.

(Option 4) It is never appropriate to waste a controlled substance without the witness of another nurse. In addition, nurses should never document or sign off on anything that was not personally witnessed or completed as this constitutes falsified documentation.

Educational objective:
Waste of controlled substances must be witnessed by 2 nurses to comply with facility policy and government regulations.

A nurse has completed teaching a client who is being discharged on lithium for a bipolar disorder. Which statement by the client indicates a need for further teaching?

1. “I need to drink 1-2 liters of fluid daily.” [8%]
2. “I need to have my blood levels checked periodically.” [3%]
3. “I should not limit my sodium intake.” [49%]
4. “I should use ibuprofen for pain relief.” [39%]

Correct answer
4

Explanation:

Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a very narrow therapeutic serum range of 0.6-1.2 mEq/L (0.6-1.2 mmol/L). Levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity usually occurs with the following:

Dehydration
Decreased renal function (eg, elderly clients)
Diet low in sodium
Drug-drug interactions (nonsteroidal anti-inflammatory drugs [NSAIDs] and thiazide diuretics)
Lithium is cleared renally. Even a mild change in kidney function (as seen in elderly clients) can cause serious lithium toxicity. Therefore, drugs that decrease renal blood flow (eg, NSAIDs) should be avoided. Acetaminophen would be a better choice for pain relief (Option 4).

(Options 1 and 3) Sodium, water, and lithium are normally filtered by the kidneys. Restriction of dietary sodium/water or dehydration signals renal sodium and water reabsorption which will also increase lithium absorption, resulting in toxicity. Therefore, clients should never restrict their sodium or water intake while taking lithium; instead, they should maintain a consistent sodium intake.

(Option 2) Blood should be drawn frequently to monitor for therapeutic lithium levels and toxicity.

Educational objective:
Dehydration, decreased renal function, diet low in sodium, and drug-drug interactions (eg, NSAIDs and thiazide diuretics) can cause lithium toxicity.

CARDIOVASCULAR PHARM <3 <3 <3 <3 <3

A major side effect of angiotensin-converting enzyme (ACE) inhibitors is intractable cough. The nurse recognizes which ethnic group to be at highest risk for this side effect?

1. Asians [24%]
2. Hispanics [23%]
3. Native Americans [29%]
4. Whites [21%]

Explanation:

Intractable dry cough is a common side effect of ACE inhibitors. It is thought to be related to the accumulations of kinins (bradykinin).

Asians, especially those of Chinese descent, have a high risk (15%-50%) for ACE inhibitor-related cough.
Persons of African descent are also at high risk of developing cough and angioedema.
This information should be incorporated into the teaching that the nurse provides to this client population.

Educational objective:
The nurse should be aware that certain ethnic groups are at a higher risk for developing intractable dry cough with the use of ACE inhibitors. Asians and African Americans have the highest incidence of ACE inhibitor-related cough. Persons of African descent are also at high risk for angioedema.

A client is admitted with palpitations. The ECG shows supraventricular tachycardia (SVT) with a rate of 220/min. The nurse has received an order to administer adenosine 6 mg IV. Which action should the nurse take?

1. Adenosine is contraindicated for SVT. Verify the order with the health care provider [21%]
2. Administer medication only through a central venous access [8%]
3. Administer medication rapidly over 1-2 seconds followed by a saline flush [47%]
4. Mix medication in 50 mL normal saline and administer over 10 minutes [22%]

Correct answer
3

Explanation:

Adenosine is the first-line drug of choice for the treatment of paroxysmal supraventricular tachycardia (SVT; a rapid rhythm exceeding 150/min). The half-life is <5 seconds, so adenosine should be administered rapidly as a 6-mg bolus IV over 1-2 seconds followed by a 20-mL saline flush. Repeat boluses of 12 mg may be given twice if the rapid rhythm persists. The injection site should be as close to the heart as possible (eg, antecubital area). The client’s ECG should be monitored continuously. A brief period of asystole is due to adenosine slowing impulse conduction through the atrioventricular node. The client should be monitored for flushing, dizziness, chest pain, or palpitations during and after administration.

(Option 1) Adenosine is the first-line drug for paroxysmal SVT.

(Option 2) Although the drug should be administered as close to the heart as possible, central venous access is not required.

(Option 4) Because of the drug’s short half-life (5-10 seconds), it should be administered rapidly, not slowly, and should not be diluted.

Educational objective:
Adenosine is the drug of choice for the treatment of paroxysmal supraventricular tachycardia. It has a short half-life and should be administered rapidly over 1-2 seconds, followed with a 20-mL saline bolus. A brief period of asystole can be common. Flushing from vasodilation is seen frequently.

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention does the nurse anticipate?

1. Administering PRN antiemetic prior to the infusion [2%]
2. Administering via an infusion pump over at least 30 minutes [20%]
3. Drawing a trough level just prior to administration of the vancomycin [71%]
4. Starting a new IV line before administration [5%]
Omitted
Correct answer
3

Explanation:

Vancomycin is a very potent antibiotic that can cause nephrotoxicity and ototoxicity. Measuring for serum concentrations is a way to monitor for risk of nephrotoxicity as well as for therapeutic response. Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A trough should be obtained just prior (about 15-30 minutes) to administration of the next dose.

(Option 1) Unlike some chemotherapy medications, vancomycin does not commonly cause nausea or vomiting. Premedication with antiemetics is not required. However, premedication with antihistamines (diphenhydramine) is recommended if the client had developed red man syndrome, also known as red neck syndrome, with prior vancomycin infusion. This syndrome is characterized by red blotching of the face, neck, and chest due to too rapid administration.

(Option 2) Vancomycin should be administered over a minimum of 60 minutes. Too rapid administration can cause red man syndrome, considered a toxic effect rather than an allergic reaction.

(Option 4) The nurse would want to verify patency of the IV line prior to administration as thrombophlebitis is a possibility with vancomycin; however, a new IV line is not necessarily required.

Educational objective:
To measure for efficacy and risk of nephrotoxicity with vancomycin, the nurse should draw periodic trough levels just prior to administration of the next IV dose.

A client with long-term hypertension and hypercholesterolemia comes to the clinic for an annual checkup. The client takes nifedipine, simvastatin, and spironolactone and reports some occasional dizziness. Which statement by the client would warrant intervention by the nurse?

1. “I’ve been better about walking for 20 minutes 3 days a week on my treadmill.” [1%]
2. “I’ve been trying to eat more fruits and vegetables. I discovered that I really like grapefruit.” [70%]
3. “I’ve heard that having a glass of red wine with dinner every night is good for my heart.” [24%]
4. “We no longer add salt when preparing meals. It has really been hard to get used to that.” [2%]

Correct answer
2

Explanation:

The nurse should intervene when the client talks about eating grapefruit. Grapefruit inhibits enzyme CYP3A4. The drugs that are metabolized by the same pathway would not be metabolized, resulting in higher drug levels and serious side effects. Calcium channel blocker (eg, nifedipine) use with grapefruit juice can cause severe hypotension; some statins (eg, simvastatin) may result in myopathy.

(Option 1) The nurse should praise and encourage the client to continue exercising and possibly increase the amount. This is a positive lifestyle change. The client should engage in moderate-intensity aerobic exercise for at least 30 minutes most days of the week or vigorous-intensity aerobic exercise for 20 minutes 3 days a week.

(Option 3) It is thought that red wine in moderation has some beneficial effects on the heart. The nurse would not encourage a client to start drinking red wine if the client didn’t already. Excessive alcohol consumption is strongly associated with hypertension. The nurse should encourage the client to discuss alcohol consumption with the health care provider (HCP).

(Option 4) Sodium restriction is important in the management of hypertension. This teaching should be reinforced and the client should be encouraged to restrict the use of salt.

Educational objective:
The nurse should tell the client not to eat grapefruit or drink grapefruit juice while taking calcium channel blockers due to the possible development of severe hypotension. The nurse should report this client’s statement to the HCP.

in the cardiovascular clinic for a 3-month follow-up visit. At the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension. Which statement by the client would be concerning to the nurse and should be reported to the primary health care provider (PHCP)?

1. “I like to have a banana every morning with my breakfast.” [8%]
2. “I occasionally experience slight dizziness when I get up in the morning.” [8%]
3. “I started taking licorice root for my occasional heartburn.” [79%]
4. “I usually take my hydrochlorothiazide first thing in the morning.” [2%]

Correct answer
3

Explanation:

Licorice root is an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. When used in combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered “potassium-wasting” diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should discourage the client from using this herbal remedy and report the client’s use to the PHCP.

(Option 1) Bananas are rich in potassium. Eating one each morning is beneficial.

(Option 2) Diuretics and calcium channel blockers (eg, nifedipine, amlodipine, felodipine) commonly cause postural hypotension or dizziness on rising. The nurse should encourage the client to rise slowly and sit on the side of the bed for a few minutes before getting up. Persistent dizziness should be reported to the PHCP.

(Option 4) Diuretics should be taken in the morning as nighttime dosing will cause nocturia and interrupted sleep.

Educational objective:
The nurse should discourage the client from using the herbal remedy licorice root when taking thiazide diuretics. Licorice root can potentiate potassium loss and increase the client’s risk for hypokalemia. Use of licorice root should be reported to the PCHP.

Exhibit

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. Click on the exhibit button for additional information.

1. Albuterol inhaler
2. Diltiazem extended-release PO
3. Heparin subcutaneous injection
4. Lisinopril PO
5. Metoprolol PO
6. Timolol eye drops

Correct answer
1,3,4

Explanation:

Clients with atrial fibrillation can have either bradycardia (slow ventricular response) or tachycardia (rapid ventricular response). This client’s vital signs are significant for bradycardia (heart rate <60/min). Therefore, the medications that can decrease heart rate should be held and the health care provider (HCP) should be notified. The reason for holding the medication (heart rate 46/min) and an HCP contact note should be documented.

Albuterol, a short-acting beta-adrenergic inhaler to control asthma, can increase the heart rate and is a safe choice (Option 1).

Heparin is an anticoagulant; the subcutaneous injection is most commonly used to prevent deep venous thrombosis in hospitalized clients on bed rest. This medication will not affect the vital signs and so is also safe to administer (Option 3).

Lisinopril, an ACE inhibitor, does not lower the heart rate and is not contraindicated in clients with bradycardia (Option 4). This client’s blood pressure is considered normal and lisinopril is safe to administer. Withholding this medication could cause rebound hypertension.

(Option 2) Diltiazem is a calcium channel blocker that can decrease the heart rate and so should be held. Verapamil, another calcium channel blocker, can also cause bradycardia.

(Options 5 and 6) This client is on 2 beta blockers, oral metoprolol and timolol eye drops that can be absorbed systemically. All beta blockers can further decrease the heart rate and should be held untilBlock Time Remaining: 00:00:29

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. Click on the exhibit button for additional information.

1. Albuterol inhaler
2. Diltiazem extended-release PO
3. Heparin subcutaneous injection
4. Lisinopril PO
5. Metoprolol PO
6. Timolol eye drops

Correct answer
1,3,4

Explanation:

Clients with atrial fibrillation can have either bradycardia (slow ventricular response) or tachycardia (rapid ventricular response). This client’s vital signs are significant for bradycardia (heart rate <60/min). Therefore, the medications that can decrease heart rate should be held and the health care provider (HCP) should be notified. The reason for holding the medication (heart rate 46/min) and an HCP contact note should be documented.

Albuterol, a short-acting beta-adrenergic inhaler to control asthma, can increase the heart rate and is a safe choice (Option 1).

Heparin is an anticoagulant; the subcutaneous injection is most commonly used to prevent deep venous thrombosis in hospitalized clients on bed rest. This medication will not affect the vital signs and so is also safe to administer (Option 3).

Lisinopril, an ACE inhibitor, does not lower the heart rate and is not contraindicated in clients with bradycardia (Option 4). This client’s blood pressure is considered normal and lisinopril is safe to administer. Withholding this medication could cause rebound hypertension.

(Option 2) Diltiazem is a calcium channel blocker that can decrease the heart rate and so should be held. Verapamil, another calcium channel blocker, can also cause bradycardia.

(Options 5 and 6) This client is on 2 beta blockers, oral metoprolol and timolol eye drops that can be absorbed systemically. All beta blockers can further decrease the heart rate and should be held until the prescriptions can be clarified by the HCP.

Educational objective:
Medications that decrease the heart rate should be held in clients with bradycardia. These include beta blockers such as metoprolol (including eye drops) and some types of calcium channel blockers (eg, diltiazem, verapamil).

the prescriptions can be clarified by the HCP.

Educational objective:
Medications that decrease the heart rate should be held in clients with bradycardia. These include beta blockers such as metoprolol (including eye drops) and some types of calcium channel blockers (eg, diltiazem, verapamil).

The nurse is discharging a client who has been prescribed warfarin for chronic atrial fibrillation. The nurse should instruct the client to avoid excess or inconsistent intake of which foods? Select all that apply.

1. Bananas
2. Broccoli
3. Grapefruit juice
4. Red meat
5. Spinach

Correct answer
2,3,5

Explanation:

Large amounts of vitamin K-rich foods can decrease the anticoagulant effects of warfarin therapy. Clients are not instructed to remove those foods from their diet but are encouraged to be consistent in the intake of foods high in vitamin K, including leafy green vegetables, asparagus, broccoli, kale, Brussels sprout, and spinach.

Several beverages also affect warfarin therapy. Green tea, grapefruit juice, and cranberry juice may alter its anticoagulant effects.

(Option 1) Certain fruits (eg, bananas, oranges) are rich in potassium and may increase the risk for hyperkalemia with the use of potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone). However, bananas and oranges are low in vitamin K and are not known to interact with warfarin.

(Option 4) Eating less red meat and reducing sodium intake are part of a heart-healthy diet but are not specific to a warfarin regimen.

Educational objective:
The nurse should teach the client receiving warfarin therapy to be consistent with intake of foods high in vitamin K. Clients do not need to restrict vitamin K-rich foods completely. Leafy green vegetables and grapefruit juice are the most important to teach.

.

An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently?

1. Apical heart rate is 62/min [21%]
2. Blood sugar level is 240 mg/dL (13.3 mmol/L) [6%]
3. Client is taking 20 mg fluoxetine daily [13%]
4. Serum creatinine is 2.3 mg/dL (203 µmol/L) [58%]

Correct answer
4

Explanation:

Digoxin (Lanoxin) is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It is used in heart failure (to increase cardiac output) and atrial fibrillation (to reduce the heart rate).

The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney function. The normal range for creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). Elderly clients tend to develop age-related decrease in glomerular filtration rate (GFR). These clients and those with obvious kidney injury (possibly due to diabetes in this client) can accumulate digoxin. The early symptoms of toxicity are nausea and vomiting. Later signs of toxicity are arrhythmias, including heart blocks. Therefore, clients at risk for digoxin toxicity require frequent drug level monitoring and dose adjustment.

(Option 1) An apical heart rate is taken for a full minute prior to administration. It is safe to administer the drug when the apical heart rate is ≥60/min.

(Option 2) An elevated blood sugar level requires attention but is unrelated to digoxin toxicity. However, hypokalemia can increase the risk of digoxin toxicity.

(Option 3) Fluoxetine (Prozac) is an antidepressant drug that is a selective serotonin reuptake inhibitor. It does not usually interact with digoxin and its use is unaltered by cardiac disease. This is a normal dose.

Educational objective:
Digoxin (Lanoxin) is excreted almost exclusively by the kidneys. Decreased kidney function usually requires decreased digoxin dosage and frequent drug level monitoring. BUN and creatinine are measurements of kidney function.

.

A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply.

1. “Antibiotics can affect my INR value.”
2. “I am going to eat more leafy greens.”
3. “I will shoot for my INR value to be between 4 and 5.”
4. “I will take warfarin at the same time daily.”
5. “If I miss a dose, I can double it on the following day.”

Correct answer
1,4

Explanation:

A therapeutic INR for most conditions is 2-3 but can be up to 3.5 for heart valve disease. However, it is never between 4 and 5 (Option 3).

Intestinal bacteria produce vitamin K; most antibiotics kill these bacteria, leading to vitamin K deficiency. Warfarin is a vitamin K antagonist; therefore, INR would overshoot in the setting of vitamin K deficiency, placing the client at risk for bleeding (Option 1).

Leafy-green vegetables contain a high amount of vitamin K, which may lower a client’s INR and make it difficult to maintain a therapeutic INR. Clients do not have to avoid consumption of leafy-green vegetables, but they should eat a consistent quantity and have their INR checked periodically (Option 2).

(Option 4) It is important to take warfarin at the same time daily to maintain a consistent therapeutic drug level.

(Option 5) Clients should call their health care provider if they miss or forget to take a warfarin dose. Double dosing is contraindicated.

Educational objective:
Warfarin must be taken at the same time daily to reach a therapeutic INR of 2-3. A diet high in vitamin K may decrease warfarin’s anticoagulant effect. Most antibiotics will increase INR by causing a vitamin K deficiency.

A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective?

1. “I can keep a few pills in a plastic bag in my pocket in case I need them while I’m out.” [5%]
2. “I can still take this with my vardenafil prescription.” [4%]
3. “I can take up to 3 pills in a 15-minute period if I am experiencing chest pain.” [86%]
4. “I should stop taking the pills if I experience a headache.” [3%]

Correct answer
3

Explanation:

Current evidence shows that up to 50% of clients lack knowledge about NTG administration procedures, storage, and side effects. Proper teaching can prevent many hospital visits for chest pain due to stable angina.

Instructions for proper NTG administration include:

Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months (Option 1).
Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS) should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment (Option 3).
Avoid fatal drug interactions: Concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers (terazosin, tamsulosin) is contraindicated due to potentially fatal hypotension (Option 2).
Headache may occur: Headache and flushing are common side effects of NTG due to systemic vasodilation and do not warrant medication discontinuation (Option 4).
Educational objective:
The nurse should instruct the client who is taking sublingual NTG to keep the tablets in a tightly capped, dark bottle away from heat and light. The client should be taught to take 1 tablet every 5 minutes (up to 3 tablets), but notify EMS if the pain does not improve or worsens 5 minutes after the first pill has been taken. These instructions should be reinforced at each appointment.

The health care provider prescribes simvastatin for a client with hyperlipidemia. The nurse instructs the client to take this medication in which manner?

1. At noon with a meal [1%]
2. In the morning on an empty stomach [25%]
3. In the morning with breakfast [26%]
4. With the evening meal [46%]

Correct answer
4

Explanation:

Statin drugs (eg, simvastatin, atorvastatin, rosuvastatin) are prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. Most of the cholesterol in the body is synthesized by the liver during the fasting state, at night. Trials have found greater reductions in total and LDL cholesterol when statins (especially those that are short-acting; eg, simvastatin) are taken in the evening or at bedtime as opposed to during the day.

(Options 1 and 3) Medications that can cause stomach upset (eg, NSAIDs) should be taken with food.

(Option 2) Medications such as levothyroxine should be taken on an empty stomach in the morning. Acid-suppressing medications (eg, proton pump inhibitors, H2 blockers) should also be taken 30 minutes before the meal.

Educational objective:
The client taking a statin drug such as simvastatin should be taught to take the medication with the evening meal or at bedtime to promote maximal effectiveness.

An 80-year-old client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the office nurse?

1. Dizziness on standing [23%]
2. Fasting blood sugar of 160 mg/dL (8.9 mmol/L) [12%]
3. Presence of muscle cramps [59%]
4. Sunburn [4%]

Correct answer
3

Explanation:

Hydrochlorothiazide and chlorthalidone are the most commonly used thiazide diuretics for treating hypertension. The major side effects of thiazide diuretics include:

Hypokalemia (manifests as muscle cramps)
Hyponatremia (manifests as altered mental status and seizures)
Hyperuricemia (may worsen gout attacks)
Hyperglycemia (requires adjustment of diabetic medications)
Of the above side effects, hypokalemia is the most serious as it can lead to life-threatening cardiac arrhythmias.

(Option 1) Orthostatic hypotension may be a side effect of many diuretics. The nurse should teach the client to rise slowly and sit for a few minutes before standing. The elderly client may need to use a cane or walker to prevent falls. Additionally, the nurse should check that the client’s blood pressure is not too low.

(Option 2) Mild to moderate hyperglycemia is common with thiazides and needs to be addressed. However, it is not life-threatening and therefore not a priority.

(Option 4) Most thiazide diuretics are sulfa derivatives. Therefore, they can cause photosensitivity. The nurse should encourage the client to use sunscreen and wear protective clothing.

Educational objective:
The nurse should suspect hypokalemia in the presence of muscle cramps in a client taking diuretics. Hypokalemia can lead to dangerous ventricular dysrhythmias.

A hospitalized client has been treated for the past 48 hours with a continuous heparin infusion for a deep vein thrombosis (DVT). When the nurse prepares to administer the evening dose of warfarin, the client’s spouse says “Wait! My spouse can’t have that! My spouse is already getting heparin for DVT.” How should the nurse respond?

1. “Both medications will be given for several days until the warfarin has time to take effect.” [69%]
2. “I will be discontinuing the heparin infusion as soon as I give this dose of warfarin.” [3%]
3. “The two medications work synergistically to help break down the clot in your spouse’s leg.” [19%]
4. “We will hold the medication until I can call the health care provider (HCP) for clarification.” [7%]

Correct answer
1

Explanation:

Warfarin begins to take effect in 48-72 hours and then takes several more days to achieve a maximum effect. Therefore, an overlap of a parenteral anticoagulant like heparin with warfarin is required. The typical overlap is 5 days or until the INR reaches the therapeutic level. The nurse will need to explain this overlap of the 2 medications to the client and the spouse.

(Option 2) The nurse should not discontinue the heparin infusion until the INR is at the therapeutic level.

(Option 3) Anticoagulants like heparin and warfarin will not break down or dissolve clots. However, they inhibit any further clot formation and keep the current clot from getting larger. Thrombolytics, such as tissue plasminogen activator, do break down clots.

(Option 4) Clarification from the HCP is not needed. The warfarin should be administered to the client after explaining the reasons for its use to the client and the spouse.

Educational objective:
Warfarin requires an overlap of therapy with unfractionated heparin infusion or low-molecular-weight heparin (eg, enoxaparin, dalteparin) for several days until the INR is in the therapeutic range for the client’s condition.

.

A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that further teaching is required?

1. “I may experience flushing but will continue to take the medication as prescribed.” [17%]
2. “I should lie down before taking the medication.” [22%]
3. “I should not swallow the tablet.” [2%]
4. “I will wait to call 911 if I don’t experience relief after the third tablet.” [57%]

Correct answer
4

Explanation:

Current evidence indicates that up to 50% of clients lack knowledge about administration procedures, storage, and side effects of NTG. Proper teaching can prevent many hospital visits for chest pain from stable angina. The client should be instructed to take 1 pill (or 1 spray) every 5 minutes for up to 3 doses, but emergency medical services (EMS) should be called if pain is unimproved or worsening 5 minutes after the first tablet. Previously, clients were taught to call EMS after the third dose, but newer studies suggest that this causes a significant delay in treatment (Option 4).

NTG should cause a slight tingling sensation under the tongue if it is potent; otherwise, the medication is likely outdated. The oral mucosa needs to be moist for adequate absorption of NTG, and clients should be instructed to take a drink of water before administration if needed for dry mouth. Sublingual tablets should never be swallowed (Option 3). If using a spray, the client should not inhale it but direct it onto/under the tongue instead.

(Option 1) Headache and flushing are common side effects of NTG due to systemic vasodilation.

(Option 2) The client should lie down before taking the pill as it can cause dizziness from possible orthostatic hypotension.

Educational objective:
The nurse should instruct clients taking sublingual NTG that they should call EMS if their chest pain is unrelieved or worsening 5 minutes after the first tablet. The tablet should be allowed to dissolve under the tongue to allow for adequate absorption and should never be swallowed.

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which data collected during the health history should be reported to the health care provider (HCP) immediately?

1. Blood pressure taken in the clinic is 158/84 mm Hg [4%]
2. Client has a dry hacking cough [24%]
3. Client has noticed that the tongue is swelling slightly [68%]
4. Client has occasional dizziness upon rising in the morning [2%]

Correct answer
3

Explanation:

Swelling of the tongue can be a sign of angioedema. Angioedema is swelling that can occur in the eyelids, lips, tongue, larynx, hands, feet, gastrointestinal tract, and genitalia. It often starts in the face and then progresses to the airways, which can be life-threatening. This can be an adverse effect of an angiotensin-converting-enzyme (ACE) inhibitor and African Americans are at a higher risk for its occurrence. Unlike other typical drug allergies, this side effect can occur any time after starting the medication (eg, sometimes after 1 year). The nurse should carefully monitor the client and report this immediately to the HCP.

(Option 1) The nurse should review the client’s log of recorded blood pressure readings over the past month since starting enalapril. The client may need a dosage change or an additional medication. This should be reported, but it is not the priority in this situation.

(Option 2) A dry hacking cough is a common side effect of ACE inhibitors. It is not life-threatening, but the medication should be discontinued to resolve the cough.

(Option 4) Occasional dizziness upon rising is a common side effect of most antihypertensives. The client should be taught to rise slowly and sit on the side of the bed for a few minutes before rising.

Educational objective:
Swelling of the tongue can be a sign of angioedema in the client taking ACE inhibitors; this can be potentially life-threatening if the airway becomes compromised. The nurse should report this immediately to the HCP. Angioedema can be a more common occurrence in African Americans.

A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication? Select all that apply.

1. Blood pressure of 140/84 mm Hg
2. Heart rate of 98/min
3. Platelet count of 200,000/mm3 (200 x 109/L)
4. Report of Ginkgo biloba use
5. Report of peptic ulcer disease

Correct answer
4,5

Explanation:

Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider before the client is discharged.

(Option 1) This blood pressure is slightly elevated, but is unaffected by antiplatelet agents.

(Option 2) Normal heart rate is between 60/min-100/min.

(Option 3) This is a normal platelet count (150,000/mm3-400,000/mm3 [150-400 x 109/L]).

Educational objective:
If a client is prescribed clopidogrel, the nurse should be concerned about a history of peptic ulcer disease and Ginkgo biloba use. In this situation, the client would be at increased risk for bleeding. This data should be reported to the prescribing health care provider before the client is discharged.

A nurse in the emergency department is titrating a continuous infusion of nitroglycerin to a client admitted for acute coronary syndrome. The client’s vital signs, including blood pressure (BP), heart rate (HR), and pain level, are being monitored frequently. Which assessment findings indicate that the current rate of administration should be maintained?

1. BP 80/50 mm Hg, HR 110/min; client reports pain is 0 out of 10 [4%]
2. BP 100/60 mm Hg, HR 90/min; client reports pain is 3 out of 10 [5%]
3. BP 110/70 mm Hg, HR 80/min; client reports pain is 0 out of 10 [67%]
4. BP 120/80 mm Hg, HR 70/min; client reports pain is 5 out of 10 [22%]

Correct answer
3

Explanation:

Acute coronary syndrome (ACS) is a broad term that encompasses a range of cardiac events, including unstable angina and myocardial infarction (with or without ST-segment elevation). Clients with ACS require immediate treatment to prevent continued ischemia of cardiac muscle.

Intravenous nitroglycerin (glyceryl trinitrate) is used to increase cardiac blood flow and provide pain relief for clients with ACS until a definitive treatment plan (eg, percutaneous coronary intervention, thrombolytic therapy, bypass surgery) is determined. Because nitroglycerin is a vasodilator, continuous hemodynamic monitoring is required to prevent severe hypotension. The infusion rate is titrated by the nurse based on pain level and blood pressure (BP), usually every 3-5 minutes until pain is relieved and BP is stable. If systolic BP drops to <90 mm Hg or falls >30 mm Hg below client baseline, the infusion rate should be decreased or stopped.

(Option 1) The client is hypotensive (systolic BP <90 mm Hg) and tachycardic. The infusion rate should be decreased or stopped.

(Option 2) The client’s BP is low, but in an acceptable range. However, complete pain relief has not been achieved. The nurse should continue to increase the infusion rate while closely observing BP.

(Option 4) Although the BP is acceptable, pain relief has not been achieved. The nurse should continue titrating to a higher dose until the client’s pain is relieved.

Educational objective:
Nitroglycerin and other nitrates increase cardiac blood flow and provide relief from the pain of ischemia in acute coronary syndrome by causing vasodilation. Their infusion should not cause systolic blood pressure to fall to <90 mm Hg or to drop >30 mm Hg below baseline.

A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client’s symptoms? Select all that apply.

1. Atorvastatin
2. Metformin
3. Metoprolol
4. Olanzapine
5. Omeprazole

Correct answer
3,4

Explanation:

Drugs commonly associated with orthostatic hypotension include:

Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha blockers (eg, terazosin) (Option 3)
Antipsychotic medications (eg, olanzapine, risperidone) and antidepressants (eg, selective serotonin reuptake inhibitors) (Option 4)
Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide)
Vasodilator medications (eg, nitroglycerine, hydralazine)
Narcotics (eg, morphine)
Clients at risk for developing orthostatic hypotension should be instructed to:

Take medications at bedtime, if approved by the health care provider
Rise slowly from a supine to standing position, in stages (especially in the morning)
Avoid activities that reduce venous return and worsen orthostatic hypotension (eg, straining, coughing, walking in hot weather)
Maintain adequate hydration
(Option 1) Muscle cramps and liver injury, not orthostatic hypotension, are the major adverse effects of statin medications (eg, atorvastatin).

(Option 2) Major side effects of metformin are lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea). Unlike insulin, metformin does not usually cause hypoglycemia. Orthostatic hypotension is not a common side effect.

(Option 5) Proton pump inhibitors (eg, omeprazole) are associated with increased risk of pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis), but not orthostatic hypotension.

Educational objective:
Medications commonly associated with orthostatic hypotension include most antihypertensives, most antipsychotics and antidepressants, and volume-depleting agents. Clients are instructed to rise slowly when standing to prevent a drop in blood pressure.

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern?

1. “I periodically take docusate sodium for constipation.” [12%]
2. “I regularly take ibuprofen for chronic low back pain.” [41%]
3. “I take hydrochlorothiazide to prevent swelling around my ankles.” [29%]
4. “I take omeprazole daily to prevent heartburn.” [17%]
Omitted
Correct answer
2

Explanation:

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time. In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease. These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time. The nurse should notify the health care provider that this client is routinely taking ibuprofen.

(Option 1) Taking docusate sodium occasionally for constipation is appropriate.

(Option 3) Hydrochlorothiazide is a weak diuretic and is commonly used to treat hypertension.

(Option 4) Omeprazole for heartburn is appropriate for this client.

Educational objective:
NSAIDs may cause heart attack, stroke, high blood pressure, and possible heart failure after long-term use. NSAIDs decrease the effectiveness of diuretic and blood pressure medications. Long-term use is also associated with chronic kidney disease and peptic ulcers.

Exhibit

A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority for this client? Click on the exhibit button for additional information.

1. Bleeding risk [76%]
2. Bronchospasm [13%]
3. Muscle injury [4%]
4. Tinnitus [5%]
Omitted
Correct answer
1

Explanation:

This client is on 3 different medications that affect bleeding risk (aspirin, clopidogrel, and rivaroxaban); this drug combination places the client at increased risk for bleeding. Teaching the client about the signs and symptoms of bleeding and risk reduction is the highest priority. The nurse should instruct the client to monitor for black, tarry stools, bleeding gums, and excessive bruising. The client should also use a soft bristle toothbrush, shave with an electric razor, and refrain from playing contact sports.

(Option 2) Bronchospasm rarely occurs with high doses of aspirin and metoprolol. This client is on low-dose aspirin and metoprolol. Although this should be a teaching topic for the client, bleeding is more likely to occur than this adverse reaction.

(Option 3) Muscle cramps can be common with statins (eg, rosuvastatin, atorvastatin, simvastatin). However, muscle injury is rare and not as high in priority as bleeding risk.

(Option 4) Tinnitus may occur with aspirin toxicity. However, this client is on baby aspirin (81 mg) and is very unlikely to experience adverse effects.

Educational objective:
Clients taking a combination of antiplatelet agents (eg, aspirin, clopidogrel, ticagrelor, prasugrel) and anticoagulants (eg, warfarin, rivaroxaban, apixaban) are at very high risk for life-threatening bleeding complications. The nurse should teach the client how to recognize and prevent signs and symptoms of increased bleeding.

The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply.

1. “I will need to take my blood thinner for about 3-6 months.”
2. “I will place small rugs on my wood floors to cushion a fall.”
3. “I will take a baby aspirin if I have mild chest pain.”
4. “I will use a soft-bristled toothbrush to clean my teeth.”
5. “I will wear a blood thinner MedicAlert tag.”
Omitted
Correct answer
2,3

Explanation:

Clients discharged on warfarin (Coumadin) are taught interventions to prevent injury, such as removing scatter rugs in the home to reduce the risk of tripping and falling (especially in elderly) (Option 2).

Clients are educated to avoid aspirin, drugs containing aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and alcohol when taking warfarin due to an increased risk for bleeding (Option 3).

(Option 1) Warfarin is usually administered for 3-6 months following PE to prevent further thrombus formation. A longer duration (lifelong) of anticoagulation is recommended in clients with recurrent PE. Prothrombin time and INR must be monitored regularly to adjust the dose and maintain a therapeutic anticoagulant level.

(Option 4) Clients should be taught to avoid trauma or injury to decrease the risk for bleeding. Preventive measures include gently brushing teeth with a soft-bristled toothbrush, avoiding use of alcohol-based mouthwash, avoiding contact sports or rollerblading, and using a straight razor. Flossing should also be avoided in general, but waxed dental floss may be used with care in some clients.

(Option 5) Clients are instructed to wear a MedicAlert tag (eg, necklace, bracelet) when taking anticoagulants (eg, warfarin, heparin).

Educational objective:
Clients on warfarin or heparin should avoid using aspirin or nonsteroidal anti-inflammatory drugs, wear a MedicAlert device, avoid activities that increase the risk for bleeding, and limit alcohol intake.

The nurse is preparing medications for a group of clients. Which prescription should the nurse clarify with the health care provider before administering?

1. Client diagnosed with cirrhosis had 2 stools today; laxative lactulose prescribed daily [8%]
2. Client is prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L (5.6 mmol/L) [59%]
3. Client is receiving vancomycin IV; mild facial flushing noted after 30 minutes [25%]
4. Client with diabetes has insulin glargine prescribed; current blood glucose is 100 mg/dL (5.6 mmol/L) [7%]
Omitted
Correct answer
2

Explanation:

ACE inhibitors (“-prils”) and angiotensin II receptor blockers (ARBs) (“-sartans”) may potentiate hyperkalemia. ACE inhibitors decrease the excretion of aldosterone. Aldosterone promotes sodium retention and causes potassium excretion. However, when the ACE inhibitor suppresses aldosterone, potassium rises, placing clients at risk for hyperkalemia, especially in the presence of impaired renal function. The nurse should question the administration of an ACE inhibitor in a client with hyperkalemia (Option 2).

(Option 1) Lactulose is administered to clients with cirrhosis and hepatic encephalopathy to promote excretion of ammonia via fecal elimination and not solely for the treatment of constipation. The dose is adjusted to achieve 2-3 soft stools each day.

(Option 3) Vancomycin should be infused over at least 60 minutes (100 minutes if infusing ≥1 gram). When the infusion is given too fast, the client may develop red man syndrome, which is characterized by facial and upper body flushing. If this occurs, the infusion should be slowed or stopped and restarted at a slower rate after 30 minutes. Facial flushing in isolation is not indicative of an allergic or anaphylactic reaction, and the nurse can independently manage this side effect.

(Option 4) Basal insulin glargine (Lantus) is used for glucose control in diabetic clients. Insulin glargine has no peak and should be administered even if the current blood glucose level is within normal limits.

Educational objective:
Clients receiving ACE inhibitors should be monitored for hyperkalemia, especially in the presence of renal insufficiency. The nurse should clarify a prescription for ACE inhibitor administration in a client with hyperkalemia.

d.

A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch. The nurse has reviewed discharge instructions on the medication with the client. Which statement by the client indicates that teaching has been effective?

1. “I can continue to take my prescription of sildenafil.” [3%]
2. “I should take the patch off when I shower.” [2%]
3. “I will remove the patch if I develop a headache.” [2%]
4. “I will rotate the site where I apply the patch.” [90%]
Omitted
Correct answer
4
Answered correctly
90% Time: 1 seconds
Updated: 04/28/2017
Explanation:

Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. They are usually applied once a day (not as needed) and worn for 12-14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arms. Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation.

(Option 1) Phosphodiesterase inhibitors used in erectile dysfunction (eg, tadalafil, sildenafil, vardenafil) are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle dilation. Combined use can result in severe hypotension.

(Option 2) Patches may be worn in the shower.

(Option 3) Headaches are common with the use of nitrates. The client may need to take an analgesic.

Educational objective:
Nursing education about transdermal nitroglycerin includes application of the patch to the upper arms or body, rotating the sites daily, removing the patch at night, taking no erectile dysfunction medications, and informing clients that headaches are common. Patches do not need to be removed for bathing.

A home health nurse is preparing to start a milrinone infusion via a peripherally inserted central catheter for a client with end-stage heart failure. What equipment is most important to be present in the home? Select all that apply.

1. Bathroom scale for daily weights
2. Blood pressure cuff
3. Central line dressing change kits
4. Infusion pump
5. Intermittent urinary catheterization kits
Omitted
Correct answer
1,2,3,4
Answered correctly
27% Time: 1 seconds
Updated: 05/14/2017
Explanation:

Milrinone (Primacor) is a phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote vasodilation. Milrinone, an inotropic agent, is often prescribed to clients with heart failure unresponsive to other pharmacologic therapies. The medication is usually infused over 48-72 hours in a hospital setting; however, home infusion through a central line is becoming more common as a palliative measure for end-stage heart failure. Milrinone infusion requires central venous access (eg, peripherally inserted central catheter) as the medication is a vesicant and can cause extravasation if infused through a peripheral IV line.

The home health nurse should perform the following:

Ensure that an infusion pump is used to control the rate, and instruct the family on basic troubleshooting (Option 4).
Evaluate medication effectiveness and possible side effects.
Monitor the central line insertion site for infection.
Change the central line dressing as prescribed (Option 3).
Monitor daily weight (Option 1).
Monitor blood pressure for possible hypotension (Option 2).
Implement safety precautions as hypotension increases the client’s risk of falling.
(Option 5) Milrinone causes vasodilation, which may result in increased urinary output; however, intermittent catheterization is not indicated.

Educational objective:
A client may receive a milrinone infusion in the home for palliative treatment of end-stage heart failure. The infusion is set up via an infusion pump and infused through a central line. The client and family should be instructed on basic pump troubleshooting as well as the importance of measuring daily weight and blood pressure.

Block Time Remaining: 00:00:58
TUTOR
Test Id: 80937794
QId: 31865 (921666)
25 of 53
A A A
A client with chronic heart failure is being discharged home on furosemide and sustained-release potassium chloride tablets. Which instructions related to the potassium supplement should the nurse give to the client?1. “A diet rich in protein and vitamin D will help with absorption.” [13%]
2. “If the tablet is too large to swallow, crush and mix it with applesauce or pudding.” [9%]
3. “Potassium tablets should be taken on an empty stomach.” [15%]
4. “Take it with a full glass of water and stay sitting upright afterward.” [61%]
Omitted
Correct answer
4
Answered correctly
61% Time: 2 seconds
Updated: 05/19/2017
Explanation:

Loop diuretics (eg, furosemide [Lasix], bumetanide [Bumex]) are “potassium-wasting” diuretics, meaning that clients may experience potassium loss and hypokalemia. Hypokalemia in a client with heart failure creates a risk for life-threatening cardiac dysrhythmias. Therefore, clients taking loop diuretics usually require potassium supplementation.

Potassium is an erosive substance that can cause pill-induced esophagitis. To prevent esophageal erosion, the client should take potassium tablets with plenty of water (at least 4 oz [120 mL]) and remain sitting upright for ≥30 minutes after ingestion. This prevents the tablet from becoming lodged in the esophagus or refluxing from the stomach (Option 4).

Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates (“dronates”: alendronate, ibandronate, pamidronate, risedronate), so clients taking these medications should be given similar instructions.

(Option 1) A diet rich in protein and vitamin D helps with calcium-supplement, not potassium, absorption.

(Option 2) Sustained-release medications should never be crushed as this would cause the client to absorb the medication too rapidly.

(Option 3) Potassium should be taken during or immediately following meals to prevent gastric upset.

Educational objective:
The nurse should teach the client to take potassium tablets with plenty of water (≥4 oz [120 mL]) and to sit upright after ingestion to prevent pill-induced esophagitis. Potassium should be taken during or immediately following meals to prevent gastric upset. Sustained-release tablets should not be crushed.

Block Time Remaining: 00:00:58
TUTOR
Test Id: 80937794
QId: 30319 (921666)
26 of 53
A A A
A client with a diagnosis of atrial fibrillation has just been placed on warfarin therapy. The registered nurse (RN) overhears a student nurse teaching the client about potential food-drug interactions. Which statement made by the student nurse requires an intervention by the RN?1. “Do you take any nutritional supplements?” [7%]
2. “You will need to monitor your intake of foods containing vitamin K.” [17%]
3. “You will not be able to eat green, leafy vegetables while taking this medication.” [71%]
4. “Your blood will be tested at regular intervals.” [4%]
Omitted
Correct answer
3
Answered correctly
71% Time: 0 seconds
Updated: 04/26/2017
Explanation:

Warfarin (Coumadin) works by blocking the availability of vitamin K, which is essential for blood clotting. As a result, the clotting mechanism is disrupted, reducing the risk of a stroke, venous thrombosis, or pulmonary embolism.

Sudden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. An increase in vitamin K could decrease the effectiveness of warfarin, placing the client at increased risk of blood clot formation; a decrease could increase the effectiveness of warfarin, placing the client at increased risk for bleeding.

(Option 1) Many medications can interfere with warfarin metabolism. Nutritional supplements may contain vitamin K, and so any new medication or nutritional supplement should be approved by the health care provider. Cranberry juice, grapefruit, green tea, and alcohol may also interfere with the effectiveness of warfarin.

(Option 2) Rather than avoid vitamin K-rich foods, the client needs to keep vitamin K intake consistent from day to day to keep International Normalized Ratio (INR)/prothrombin time (PT) stable and within the recommended therapeutic range. If the client enjoys vitamin K-rich foods (eg, kale, broccoli, spinach, Brussels sprouts, cabbage, green leafy vegetables), these may be consumed in the same amounts, consistently on a daily basis. There is some evidence that a very low intake of vitamin K could decrease the overall effectiveness of warfarin.

(Option 4) INR/PT will be monitored on an ongoing basis to determine the safest, most therapeutic warfarin dosage.

Educational objective:
Sudden increases or decreases in the consumption of vitamin K-rich foods could inversely alter the effectiveness of warfarin. Rather than avoid vitamin K-rich foods, the client needs to keep vitamin K intake consistent from day to day to keep INR/PT stable and within the recommended therapeutic range. INR/PT is monitored at regular intervals. Pharmacy personnel and dieticians can provide additional teaching.

Copyright © UWorld. All rights reserved.

Block Time Remaining: 00:01:02
TUTOR
Test Id: 80937794
QId: 30608 (921666)
27 of 53
A A A
The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client’s blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, a stuffy nose, and sneezing for 3 days. Which question is most appropriate for the nurse to ask?1. “Are you taking any over-the-counter medicines for your cold?” [87%]
2. “Are you taking extra vitamin C?” [0%]
3. “Did you babysit your granddaughter this past week?” [1%]
4. “Did you get a flu shot in the past week?” [9%]
Omitted
Correct answer
1
Answered correctly
87% Time: 4 seconds
Updated: 05/16/2017
Explanation:

Clients with hypertension should be instructed not to take potentially high-risk over-the-counter (OTC) medications such as high-sodium antacids, appetite suppressants, and cold and sinus preparations.

It is appropriate to ask a client with hypertension about taking OTC cold medications as many cold and sinus medications contain phenylephrine or pseudoephedrine. These sympathomimetic decongestants activate alpha-1 adrenergic receptors, producing vasoconstriction. The resulting decreased nasal blood flow relieves nasal congestion. These agents have both oral and topical forms. With systemic absorption, these agents can cause dangerous hypertensive crisis.

(Option 2) Taking extra vitamin C may offer some protection for the immune system, but it does not cause an increase in blood pressure.

(Option 3) Exposure to young children increases the risk for contracting a contagious respiratory illness, but it does not directly increase blood pressure.

(Option 4) A flu shot would not offer protection against the flu within a week and does not cause an increase in blood pressure.

Educational objective:
Clients with hypertension should be instructed not to take potentially high-risk over-the-counter medications, including high-sodium antacids, appetite suppressants, and cold and sinus preparations, as they can increase blood pressure.

Block Time Remaining: 00:01:04
TUTOR
Test Id: 80937794
QId: 31350 (921666)
28 of 53
A A A
The nurse evaluating a 52-year-old diabetic male client’s therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply.1. Alanine aminotransferase from 20 U/L (0.33 µkat/L) to 80 U/L (1.34 µkat/L)
2. High-density lipoprotein cholesterol from 48 mg/dL (1.24 mmol/L) to 30 mg/dL (0.78 mmol/L)
3. Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L)
4. Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L)
5. Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L)
Omitted
Correct answer
3,4,5
Answered correctly
50% Time: 2 seconds
Updated: 03/13/2017
Explanation:

Statins (rosuvastatin, atorvastatin, simvastatin) are the most preferred agents to reduce low-density lipoprotein (LDL) cholesterol, total cholesterol, and triglyceride levels. This client’s LDL level has decreased to a target range (diabetic client <100 mg/dL [2.6 mmol/L]), total cholesterol has decreased to a normal range (adult <200 mg/dL [5.2 mmol/L]), and triglyceride level has decreased to a normal range (adult <150 mg/dL [1.7 mmol/L)); all these changes indicate a therapeutic response (Options 3, 4, and 5). (Option 1) The adult therapeutic range of alanine aminotransferase (ALT) is 10-40 U/L (0.17-0.68 µkat/L). Increased aspartate aminotransferase (AST) and ALT may indicate hepatic dysfunction, a potential adverse effect of statin medication. (Option 2) The therapeutic range of high-density lipoprotein (HDL) cholesterol for adult men is >40 mg/dL (1.04 mmol/L). HDL is good cholesterol. This client’s HDL level is below the therapeutic range, indicating a nontherapeutic response.

Educational objective:
A therapeutic response to statin medication includes a decrease in a client’s LDL cholesterol, total cholesterol, and triglyceride levels to within normal range. An increase in HDL cholesterol to within normal range is also an expected outcome. Potential adverse effects include hepatic dysfunction and muscle injury.

Block Time Remaining: 00:01:05
TUTOR
Test Id: 80937794
QId: 30458 (921666)
29 of 53
A A A
A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client?1. Alprazolam [9%]
2. Dextromethorphan [32%]
3. Lisinopril [10%]
4. Valsartan [47%]
Omitted
Correct answer
4
Answered correctly
47% Time: 1 seconds
Updated: 04/26/2017
Explanation:

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.

Block Time Remaining: 00:01:06
TUTOR
Test Id: 80937794
QId: 31915 (921666)
30 of 53
A A A
A 45-year-old client with atrial fibrillation has been prescribed diltiazem. Which client outcome would best indicate that the medication has had its intended effect?1. Atrial fibrillation is converted to sinus rhythm [42%]
2. Blood pressure is 126/78 mm Hg [17%]
3. No signs or symptoms of stroke [4%]
4. Ventricular rate decreased from 158/min to 88/min [35%]
Omitted
Correct answer
4
Answered correctly
35% Time: 1 seconds
Updated: 05/29/2017
Explanation:

Atrial fibrillation is characterized by disorganized electrical activity in the atria due to multiple ectopic foci. It leads to loss of effective atrial contraction and places the client at risk for embolic stroke as a result of the thrombi formed in the atria. During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension).

The treatment goals are to reduce the ventricular rate to <100/min and prevent stroke. Ventricular rate control is the priority. Medications used for rate control include calcium channel blockers (ie, diltiazem), beta blockers (ie, metoprolol), and digoxin.

(Option 1) Diltiazem is unlikely to convert atrial fibrillation to sinus rhythm. Antiarrhythmic medications such as amiodarone or ibutilide will be used for conversion of the rhythm.

(Option 2) Calcium channel blockers such as diltiazem may reduce blood pressure, but the nurse is not evaluating this client in atrial fibrillation for this outcome. In this case, diltiazem is being used for ventricular rate reduction.

(Option 3) Having no signs or symptom of stroke is a positive outcome in this client; however, it is not a specific outcome of diltiazem. Anticoagulants (eg, warfarin, dabigatran, rivaroxaban, apixaban) are used for this purpose.

Educational objective:
The nurse should monitor for a reduction in ventricular rate in the client with atrial fibrillation who is receiving diltiazem, metoprolol, or digoxin. Anticoagulants are used to prevent embolic complications.

Exhibit

A client is admitted to the cardiac care unit with atrial fibrillation. Vital signs are shown in the exhibit. Which prescription should the nurse perform first? Click on the exhibit button for additional information.

1. Administer diltiazem 20 mg IVP [69%]
2. Administer rivaroxaban 20 mg PO [8%]
3. Draw blood for a thyroid function test [2%]
4. Send the client for echocardiogram [19%]
Omitted
Correct answer
1

Updated: 01/04/2017
Explanation:

Atrial fibrillation is characterized by a disorganization of electrical activity in the atria due to multiple ectopic foci. It results in loss of effective atrial contraction and places the client at risk for embolic stroke due to thrombi formed in the atria from stasis of blood. During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response (pulse rate) can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension).

Ventricular rate control is a priority in clients with atrial fibrillation. This client has an irregular heart rate of 140/min and is not currently hypotensive. However, if the high ventricular response is allowed to continue, it is likely that the client will begin to show signs and symptoms of decreased cardiac output such as hypotension. Therefore, giving the client diltiazem (a calcium channel blocker) is the priority as its purpose is to decrease the ventricular response rate to <100/min. Other medications such as beta blockers (metoprolol) or digoxin may also be used to control the ventricular rate.

(Option 2) Anticoagulants (eg, rivaroxaban [Xarelto], dabigatran [Pradaxa], apixaban [Eliquis], and warfarin) are used for long-term prevention of atrial thrombus and embolic complications. This is not a priority.

(Option 3) The HCP will investigate possible causes of the atrial fibrillation; one of these is an overactive thyroid gland (hyperthyroidism). The thyroid function test would be useful for confirmation, but it is not a priority.

(Option 4) An echocardiogram can be obtained once the rate is controlled, but it is not a priority.

Educational objective:
Ventricular rate control is a priority in the client with atrial fibrillation; therefore, the nurse should administer the medication (diltiazem, metoprolol, or digoxin) that will accomplish this first.

The nurse is discharging a client hospitalized for a new diagnosis of heart failure. The discharge medications include lisinopril 10 mg and spironolactone 25 mg. The client has also been started on a 2000 mg low-sodium diet. Which statement by the client indicates teaching on discharge instructions has been effective?

1. “I will be sure to take my medications before bedtime.” [5%]
2. “I will eat more fresh fruits like bananas and oranges.” [12%]
3. “I will limit my intake of cheeses, breads, and canned foods.” [67%]
4. “I will use a salt substitute to season my food.” [14%]
Omitted
Correct answer
3

Explanation:

Poor adherence to a low-sodium diet (Choice 3) and failure to take prescribed medications as directed (Choice 1) are the most common reasons for readmission of heart failure clients to the hospital setting. The edema associated with heart failure is often treated by dietary restriction of sodium. The nurse or dietician should assess the client’s diet history, teach how to read food labels and plan for dining out, and develop an overall diet plan. Diet recommendations should be individualized and culturally sensitive for the client to make the needed changes successfully.

The Dietary Approaches to Stop Hypertension (DASH) diet is widely used for clients with heart failure. All foods high in sodium (>400 mg/serving) should be avoided.

General principles of a low-sodium diet are as follows:

Do not add salt or seasonings containing sodium when preparing meals
Do not use salt at the table
Avoid high-sodium foods (eg, canned soups, processed meats, cheese, frozen meals)
Limit milk products to 2 cups daily
(Option 1) Medications such as spironolactone are diuretics. Taking them at bedtime would cause the client to have nocturia. Spironolactone should be taken in the morning.

(Option 2) Hyperkalemia is a side effect of angiotensin-converting enzyme (ACE) inhibitors such as lisinopril. Spironolactone is a potassium-sparing diuretic. Although fresh fruit is a good option for a low-sodium diet, bananas and oranges are high in potassium, which could put this client at increased risk for hyperkalemia.

(Option 4) Many salt substitutes are high in potassium. This client is already at risk for hyperkalemia due to the ACE inhibitor lisinopril and the potassium-sparing diuretic spironolactone. The nurse should encourage the client to substitute lemon juice or other spices for salt or a salt substitute.

Educational objective:
The client in heart failure on a low-sodium diet should be encouraged to limit the intake of such foods as processed meats, cheese, canned soups and vegetables, frozen meals, breads, and milk products.

Exhibit

The nurse prepares to administer 9:00 AM medications to a client. Which data should the nurse evaluate prior to administration? Select all that apply. Click the exhibit button for additional information.

1. Blood pressure
2. Blood sugar
3. Heart rate
4. International Normalized Ratio
5. Potassium level
Omitted
Correct answer
1,3,5

Explanation:

Beta blockers (eg, metoprolol, carvedilol) and angiotensin-converting enzyme (ACE) inhibitors (eg, quinapril, lisinopril, enalapril) are antihypertensive medications. The nurse should assess blood pressure prior to administration (Option 1).

Beta blockers lower heart rate by blocking the action of beta receptors that increase heart rate and contractility. The nurse should assess blood pressure and heart rate prior to administration (Option 3).

ACE inhibitors increase serum potassium by decreasing urinary potassium excretion. The nurse should assess blood pressure and serum potassium levels prior to administration (Option 5).

(Option 2) Clients with diabetes require blood sugar checks, but administration of beta blockers, ACE inhibitors, or antiplatelet medications will not require monitoring of blood sugar.

(Option 4) Aspirin, an antiplatelet medication, reduces clot formation and can increase the risk for bleeding. The nurse assesses for bruising, bleeding gums, blood in stool, and gastrointestinal upset. International Normalized Ratio should be monitored in clients taking warfarin.

Educational objective:
Beta blockers lower blood pressure and heart rate. Angiotensin-converting enzyme inhibitors lower blood pressure and increase potassium. Aspirin, an antiplatelet medication, increases the risk for bleeding.

The nurse teaches the client taking atorvastatin to call the health care provider (HCP) if experiencing which symptom associated with a serious adverse effect of atorvastatin?

1. Diarrhea [3%]
2. Headache [5%]
3. Muscle aches [66%]
4. Numbness in the feet [24%]
Omitted
Correct answer
3
Answered correctly
66% Time: 1 seconds
Updated: 02/19/2017
Explanation:

Atorvastatin (Lipitor) is a statin drug, or HMG-CoA reductase inhibitor, prescribed to lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease. A serious adverse effect of statins, including atorvastatin and rosuvastatin (Crestor), is myopathy with ongoing generalized muscle aches and weakness.

A client who develops muscle aches while on a statin drug should call the HCP who will then obtain a blood sample to assess the creatine kinase (CK) level. If myopathy is present, CK will be significantly elevated (≥10x normal), and the drug will then be discontinued.

(Option 1) Diarrhea is not a side effect of statin drugs. Colchicine used for gout and acute pericarditis commonly leads to diarrhea. Many antibiotics can induce diarrhea, and some may cause Clostridium difficile infection.

(Option 2) Headache is not a serious side effect of statin drugs. It is often a bothersome side effect of nitrates and calcium channel blockers as they dilate intracranial vessels; however, tolerance usually develops over time.

(Option 4) Numbness in the feet (neuropathy) is not a common side effect of statin drugs. It is commonly associated with isoniazid, amiodarone, and chemotherapy agents (eg, vincristine, cisplatin).

Educational objective:
The client taking a statin such as atorvastatin or rosuvastatin should be taught to call the HCP if generalized muscle aches develop as this may be a symptom of myopathy, a serious adverse effect of this type of medication.

A client diagnosed with stable angina is being discharged home on the cholesterol-lowering drug rosuvastatin. The nurse should teach the client to report which side effect to the health care provider (HCP) immediately?

1. Abdominal discomfort [5%]
2. Insomnia [1%]
3. Morning headache [5%]
4. Muscle aches or weakness [86%]
Omitted
Correct answer
4
Explanation:

Rosuvastatin (Crestor) is a strong statin drug that can cut LDL drastically and reduce total cholesterol and triglycerides. It also increases HDL. A serious complication associated with statin medication is rhabdomyolysis. Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances can be harmful to the kidney and often cause kidney damage. The client should immediately report any signs of muscle aches or weakness to the HCP. These could be early signs of rhabdomyolysis, which can be fatal.

(Options 1, 2, and 3) These can also be considered side effects of rosuvastatin calcium, but they are minor and do not need to be reported to the HCP immediately. If they persist, the client should consider reporting them.

Educational objective:
The nurse should teach all clients taking statin drugs (eg, atorvastatin, rosuvastatin) to immediately report any muscle aches or weakness, as these can lead to rhabdomyolysis, a muscle disintegration that can cause serious kidney injury.

A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client?

1. Avoid consuming high-sodium foods [4%]
2. Change positions slowly to prevent dizziness [47%]
3. Don’t stop taking this medication abruptly [46%]
4. Use an oral moisturizer to relieve dry mouth [1%]
Omitted
Correct answer
3

Explanation:

Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation.

Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death.

(Option 1) Avoiding high-sodium foods is important for blood pressure control but is not the most important advice for this client as consumption of these is not immediately life-threatening.

(Option 2) Dizziness is a side effect of clonidine. The nurse should teach the client to change positions slowly and sit for a few minutes before rising to prevent falls. Drowsiness is also quite common with clonidine. Clients should not use it with alcohol or central nervous system depressants. However, dizziness and drowsiness should diminish with continued use of the medication.

(Option 4) Dry mouth is a side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may be helpful for clients with dry mouth.

Educational objective:
Clonidine is a very potent antihypertensive. Abrupt discontinuation can result in serious rebound hypertensive crisis. Other common side effects of clonidine include dizziness, drowsiness, and dry mouth (the 3 Ds). Beta blockers, another class of blood pressure medications, can result in withdrawal symptoms if discontinued suddenly.

The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse would indicate that the new medication is having the desired effect?

1. Blood glucose of 95 mg/dL (5.3 mmol/L) [1%]
2. Potassium level of 4.2 mEq/L (4.2 mmol/L) [76%]
3. Reduction in dizziness [10%]
4. Sodium level of 138 mEq/L (138 mmol/L) [12%]
Omitted
Correct answer
2

Explanation:

Spironolactone, amiloride, triamterene, and eplerenone are potassium-sparing diuretics. In general, these are very weak diuretics and antihypertensives and are used mainly in combination with thiazide diuretics to reduce potassium (K+) loss.

The K+ level of 4.2 mEq/L (4.2 mmol/L) would indicate that this medication has been effective in preventing hypokalemia in a client receiving a thiazide diuretic such as hydrochlorothiazide or chlorthalidone.

(Option 1) Blood glucose levels can be increased by thiazide diuretics but are not affected by potassium-sparing diuretics.

(Option 3) All diuretics, including spironolactone, have the potential to cause dizziness.

(Option 4) Potassium-sparing diuretics exchange sodium for potassium in the kidneys; potassium is saved but sodium is lost. Therefore, a normal sodium level is not a desired side effect.

Educational objective:
Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene, eplerenone) are often combined with thiazide diuretics to reduce potassium loss during hypertension treatment.

A male client with hypertension was prescribed amlodipine. Which of these adverse effects is most important to teach the client to watch for?

1. Erectile dysfunction [22%]
2. Dizziness [42%]
3. Dry cough [16%]
4. Leg edema [18%]
Omitted
Correct answer
2

Explanation:

Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure.

The most important adverse effects of calcium channel blockers include dizziness (Option 2), flushing, headache, peripheral edema (Option 4), and constipation. The reduced blood pressure may initially cause orthostatic hypotension. The client should be taught to change positions slowly to prevent falls. Leg elevation and compression can help to reduce the edema. Constipation should be prevented with daily exercise and increased intake of fluids, fruits/vegetables, and high-fiber foods.

(Option 3) Angiotensin-converting enzyme (ACE) inhibitors prevent the breakdown of bradykinin, which may produce a nonproductive cough in susceptible individuals. Discontinuation of the medication stops the cough.

(Option 1) Adverse effects of beta-blockers include bradycardia, bronchospasm, depression, and decreased libido with erectile dysfunction.

Educational objective:
Calcium channel blockers are utilized to treat hypertension and chronic stable angina. Adverse effects of these medications include dizziness, flushing, headache, peripheral edema, and constipation.

.

A A A
The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching?1. “I will call my health care provider if I notice red urine or blood in my stool.” [11%]
2. “I will not stop taking dabigatran even if I get a stomachache.” [56%]
3. “I will place capsules in my pill box so I will not forget to take a dose.” [26%]
4. “I will swallow the capsule whole with a full glass of water.” [5%]
Omitted
Correct answer
3

Explanation:

Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk of clot formation and stroke in clients with chronic atrial fibrillation. The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush, shaving with an electric razor). Dabigatran capsules should be kept in their original container or blister pack until time of use to prevent moisture contamination (Option 3).

(Option 1) Red urine or blood in the stool may indicate internal bleeding caused by thrombin inhibitors. The client should report these symptoms to the health care provider.

(Option 2) Thrombin inhibitors should only be stopped under the direction of the health care provider. The nurse should educate the client that stopping dabigatran will increase the risk for stroke. Taking the medication with food will not affect how much is absorbed, and food or a full glass of water may prevent gastrointestinal side effects (eg, nausea, indigestion).

(Option 4) Thrombin inhibitor capsules should not be crushed or opened as crushing pills increases absorption and risk of bleeding.

Educational objective:
Thrombin inhibitors such as dabigatran reduce the risk for clots and stroke in clients with chronic atrial fibrillation. The nurse should teach the client to use bleeding precautions and monitor for symptoms of bleeding, swallow capsules whole with a full glass of water, and keep capsules in their original container until time of use.

A client recently diagnosed with heart failure is being discharged with a prescription for lisinopril. Which client teaching related to this new medication is important to review at discharge?

1. Instruct client to report for monthly blood work to monitor drug levels [1%]
2. Review foods high in potassium that client should include in diet [5%]
3. Teach client to count own pulse for 1 minute; hold medication if pulse <60/min [17%]
4. Teach client to rise slowly and sit on side of bed for several minutes before rising [76%]
Omitted
Correct answer
4

Explanation:

Angiotensin converting enzyme (ACE) inhibitors (eg, captopril, enalapril, lisinopril, ramipril) prevent the pathological enlargement of the left ventricle of the heart. They work by blocking a crucial step in the renin-angiotensin-aldosterone system, the main hormonal mechanism involved in blood pressure regulation.

Interrupting this step of the renin-angiotensin-aldosterone system has following effects:

A shortage of angiotensin II results in an absence of the vasoconstrictive responses (orthostatic reflex, renal blood flow regulation) causing orthostatic hypotension. Clients may be more prone to experiencing orthostatic hypotension early in treatment with ACE inhibitors and should be taught ways to prevent it.
A shortage of aldosterone causes hyperkalemia. Aldosterone Saves Sodium and Pushes Potassium out of the body.
ACE inhibitors are contraindicated in pregnancy due to teratogenic effects on the fetus (eg, oligohydramnios, fetal kidney injury).
The other important side effects of ACE inhibitors, cough and angioedema, are thought to be due to the accumulation of bradykinin.

(Option 1) Renal function (blood urea nitrogen, creatinine) is commonly checked during the first week of treatment. Regular measurements to ensure therapeutic drug levels are required for lithium, phenytoin, and digoxin.

(Option 2) A common side effect of ACE inhibitor is mild hyperkalemia, which may require a lower intake of foods high in potassium. Clients taking loop diuretics (eg, furosemide) will need to increase their intake of foods high in potassium.

(Option 3) ACE inhibitors do not directly affect the heart rate. Clients prescribed digoxin are taught to take their pulse and hold their medication if the heart rate is <60/min.

Educational objective:
Client education after initiation of an angiotensin converting enzyme inhibitor (eg captopril, lisinopril) includes a discussion on development of a dry cough, taking several minutes to get out of bed, possible allergic reactions (rash, angioedema), and the teratogenic effects of the drug.

A client with chronic stable angina is reporting chest pain. The nurse notices that the transdermal nitroglycerin patch that was applied 1 hour ago has peeled off. The client’s vital signs are stable. What is the nurse’s priority action? Click the exhibit button for additional information.

1. Administer PRN morphine [5%]
2. Administer PRN sublingual nitroglycerin [51%]
3. Apply a new transdermal nitroglycerin patch [25%]
4. Obtain a 12-lead electrocardiogram [17%]
Omitted
Correct answer
2

Explanation:

Angina is chest pain due to myocardial ischemia. A client with chronic stable angina experiences intermittent chest pain relieved with rest or administration of nitroglycerin. The priority action for acute angina is administration of rapid-acting (1-3 minutes) sublingual nitroglycerin to restore cardiac perfusion. Nitroglycerin is a vasodilator that decreases cardiac workload (decreasing oxygen consumption), reduces preload, and increases myocardial perfusion. Onset and duration of action of nitroglycerin varies with route of administration.

(Option 1) Morphine sulfate relieves pain and has a mild vasodilator effect that decreases cardiac workload. Morphine is given if nitroglycerin does not relieve chest pain.

(Option 3) Transdermal nitroglycerin patches have a delayed onset of action (40-60 minutes) and are not effective in the treatment of acute anginal pain. If a patch is accidentally removed, a new one may be applied after the nurse first administers sublingual nitroglycerin.

(Option 4) A client with known stable angina is expected to have exertional chest pain if the pain is not prevented with nitroglycerin (eg, transdermal patch, prophylactic sublingual dose). Restoration of myocardial perfusion with sublingual nitroglycerin should not be delayed to obtain an electrocardiogram (ECG). The nurse should consider obtaining an ECG and implementing emergency measures if the pain does not resolve after 3 doses of sublingual nitroglycerin (unstable angina).

Educational objective:
Acute stable angina is managed with nitroglycerin, which causes vasodilation and restores myocardial perfusion. Sublingual nitroglycerin has a rapid onset and is used to treat acute angina by increasing myocardial perfusion; transdermal patches have a delayed onset and are used prophylactically.

t

A nurse receives an electrocardiogram of a client with type 2 diabetes, heart failure, and hypothyroidism. Based on the findings, which of the following medications should the nurse suspect as the most likely cause? Click the exhibit button for more information.

1. Captopril [19%]
2. Carvedilol [60%]
3. Glimepiride [5%]
4. Levothyroxine [13%]
Omitted
Correct answer
2

Explanation:

The client has sinus bradycardia, which can be caused by:

Drugs (eg, beta blockers, calcium channel blockers, digoxin). Consider withholding beta blockers if systolic blood pressure <100 mm Hg or heart rate <60 and notify the provider.

Vagal stimulation (eg, carotid sinus massage, Valsalva maneuver)

Diseases (eg, hypothyroidism, myocardial infarction, increased intracranial pressure)

The clinical significance of sinus bradycardia depends on how the client tolerates the effect of slow heart rate on cardiac output. Sinus bradycardia is usually asymptomatic. However, symptomatic bradycardia can manifest as pale, cool skin; hypotension; weakness; confusion; dyspnea; chest pain; and syncope.

(Options 1, 3, and 4) The side effects of these drugs include tachycardia (Table).

Educational objective:
Sinus bradycardia may be caused by drugs (eg, beta blockers), vagal stimulation, hypothyroidism, inferior wall myocardial infarction, and increased intracranial pressure. It is normal in some people (eg, trained athletes).

The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement would require further teaching about digoxin?

1. “I will call the health care provider (HCP) if I don’t feel like eating.” [33%]
2. “I will call the HCP if I feel dizzy and lightheaded.” [10%]
3. “I will call the HCP if I have trouble reading.” [13%]
4. “I will take my blood pressure before taking my medicine.” [42%]
Omitted
Correct answer
4

Explanation:

Digoxin (Lanoxin) is a cardiac glycoside with positive inotropic and negative chronotropic effects. It is used to treat atrial fibrillation because at therapeutic levels (0.5-2.0 ng/mL) it decreases conduction through the sinoatrial node (SA) and ventricular heart rate. However, drug toxicity is common due to digoxin’s narrow therapeutic range. Clients are instructed to recognize and report signs and symptoms of digoxin toxicity. These include the following:

Gastrointestinal symptoms, including anorexia, nausea, vomiting, and abdominal pain, are frequently the earliest symptoms (Option 1)
Neurologic manifestations – lethargy, fatigue, weakness, and confusion
Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness (Option 3)
Cardiac arrhythmias are the most dangerous symptoms. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness. Clients are instructed to check their pulse and tell the HCP if it is low or has skipped beats (Option 2).
(Option 4) There is no need to routinely check blood pressure before taking the medicine. Clients should check their pulse.

Educational objective:
Clients receiving digoxin are instructed to measure their pulse before taking the medication and withhold digoxin if the heart rate is <60/min. Clients should also be taught to recognize and report gastrointestinal (eg, anorexia, nausea, diarrhea), neurologic, and cardiac symptoms and visual changes (eg, altered color vision, scotomas) that suggest

The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse?

1. Client reports a headache [11%]
2. Current blood pressure is 160/88 mm Hg [12%]
3. Heart rate has dropped from 70/min to 60/min [17%]
4. Slight wheezes auscultated during inspiration [58%]
Omitted
Correct answer
4

Explanation:

Propranolol is a nonselective beta-blocker that inhibits beta1 (heart) and beta2 (bronchial) receptors. It is used for many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heart rate. Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess for any history of asthma or respiratory problems with this client and notify the health care provider (HCP).

(Option 1) A headache is a common occurrence with hypertension. The nurse may administer an analgesic as needed.

(Option 2) This is the first dose of propranolol that the client has received. It may take several days of treatment for the blood pressure to reduce to a more normal reading.

(Option 3) A reduction in heart rate is expected with a beta-blocker. The nurse should continue to monitor it for further reduction.

Educational objective:
The nurse should be concerned about the presence of wheezing in a client taking a nonselective beta-blocker like propranolol. Wheezing may indicate bronchoconstriction or bronchospasm. The nurse should assess for any history of asthma or other respiratory problems and report to the HCP.

The nurse is performing discharge teaching for the parents of a 4-year-old with heart failure. Which statement by the parents indicates the need for further teaching related to the administration of digoxin?

1. “If our child vomits after a dose, we won’t give a second one.” [9%]
2. “Symptoms of nausea and vomiting should be reported to our health care provider (HCP).” [6%]
3. “We will hold the dose if our child’s heart rate is above 90/min.” [79%]
4. “We will not mix the medication with other foods or liquids.” [4%]
Omitted
Correct answer
3

Explanation:

Digoxin is a cardiac glycoside given to infants and children in heart failure. It is given to increase myocardial contraction, which increases cardiac output and improves circulation and tissue perfusion. Digoxin is a potentially dangerous drug due to its narrow margin of safety in dosage. Parents should receive thorough education and in return demonstrate appropriate administration procedures for this medication.

Parent teaching for administration of digoxin includes the following:

Inform parents of the pulse rate at which to hold the medication based on HCP prescription. In general, digoxin is held if pulse <90-110/min for infants and young children or <70/min for an older child.
Administer oral liquid in the side and back of the mouth
Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication (Option 4)
If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule.
If more than 2 doses are missed, notify the HCP
If the child vomits, do not give a second dose (Option 1). Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP (Option 2).
Give water or brush the client’s teeth after administration to remove the sweetened liquid
Educational objective:
Nausea, vomiting, or slow pulse rate can indicate digoxin toxicity. General guidelines are to hold digoxin for pulse <90-110/min in infants and young children and <70/min in older children.

The nurse is preparing to administer medications to an 84-year-old client with dementia, agitation, and heart failure. Knowing that this client does not like to take pills and often allows only a few to be administered, the nurse prioritizes the oral medications by importance to the client’s well-being. Which medications would be most important for the client to receive? Select all that apply.

1. Aripiprazole
2. Calcium carbonate
3. Donepezil
4. Furosemide
5. Lisinopril
Omitted
Correct answer
1,4,5

Explanation:

Aripiprazole (Abilify) is an atypical antipsychotic that acts as a dopamine system stabilizer. It helps stabilize mood and control symptoms such as agitation and hallucinations in clients with dementia, making it an important drug for this client (Option 1).

The combination of lisinopril (an ACE inhibitor) and furosemide (Lasix, a loop diuretic) is normally used to control heart failure symptoms, particularly in clients with fluid overload. If these medications are not taken, the client will be at risk for exacerbation of heart failure and hospitalization. Therefore, these medications are also high priority (Options 4 and 5).

(Options 2 and 3) Medications used for their preventive benefits are lower priority and so would be administered after the medications more critical to the client’s short-term well-being.

Donepezil (Aricept) is used to prevent worsening of symptoms in Alzheimer dementia, and it does not decrease agitation. It is a preventive medication and so would be a lower priority.

Calcium carbonate is used as a calcium supplement for osteoporosis. It would be the lowest priority.

Educational objective:
Some clients with dementia may not want to take medications. It is common for these clients to take a few pills and then decide they do not want any more. Therefore, it is important to administer the highest priority medications first. Those that provide an immediate physiologic and symptomatic benefit, including those used to control behavioral issues and heart problems, should be the highest priority.

The nurse has just completed discharge teaching about sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching?

1. “I will call 911 if my chest pain isn’t relieved by NTG.” [4%]
2. “If I have chest pain, I can take up to 3 pills 5 minutes apart.” [5%]
3. “I’ll call my doctor if I start having chest pain at night.” [26%]
4. “I’ll keep one bottle in the house and one in the car.” [62%]
Omitted
Correct answer
4

Explanation:

NTG is a vasodilator used to treat stable angina. It is a sublingual tablet or spray that is placed under the client’s tongue. It usually relieves pain in about 3 minutes and lasts 30-40 minutes. The recommended dose is 1 tablet or 1 spray taken sublingually for angina every 5 minutes for a maximum of 3 doses (Option 2). If symptoms are unchanged or worse 5 minutes after the first dose, emergency medical services (EMS) should be contacted (Option 1). Previously, clients were taught to call EMS after the third dose was taken, but newer studies suggest that this leads to a significant delay in treatment.

The NTG should be easily accessible at all times. Tablets are packaged in a light-resistant bottle with a metal cap. They should be stored away from light and heat sources, including body heat, to protect from degradation. Clients should be instructed to keep the tablets in the original container. Once opened, the tablets lose potency and should be replaced every 6 months. The car is not a good place to store NTG due to heat (Option 4).

(Option 3) Waking up at night with chest pain can signify that angina is occurring at rest and is no longer considered stable angina. This should be reported to the health care provider.

Educational objective:
Education about sublingual NTG should include placing the tablet or spray under the tongue; repeating the dose every 5 minutes, with up to 3 total doses if angina is not relieved; notifying EMS if the first dose does not improve the symptoms; keeping the tablets in the original container away from light and heat; and replacing the bottle every 6 months once opened.

Exhibit

The nurse reviews the medication administration record and daily laboratory report of a client with atrial fibrillation. Which laboratory results should the nurse monitor when giving these medications? Select all that apply. Click the exhibit button for more information.

1. Complete blood count
2. Digoxin level
3. Glucose
4. International Normalized Ratio
5. Serum potassium
Omitted
Correct answer
1,2,3,5

Explanation:

The complete blood count (CBC) should be assessed periodically with the administration of enoxaparin, an anticoagulant. The nurse would want to assess the hemoglobin, hematocrit, and platelet count levels. If these levels are low, the client will be at risk for increased bleeding.

Digoxin levels are not often prescribed unless there is suspicion of digoxin toxicity. However, if this value is available, the nurse should assess it. Digoxin toxicity can be seen with levels >2 ng/mL. Potassium levels should also be monitored in the client receiving digoxin. Hypokalemia can potentiate digoxin toxicity.

Prednisone is a glucocorticoid that can increase glucose levels. Glucose levels should be monitored periodically for clients receiving this medication.

(Option 4) Low-molecular-weight heparins, such as enoxaparin, produce a stable response at recommended dosages and negate the need for frequent monitoring of activated partial thromboplastin time (aPTT) or International Normalized Ratio (INR) levels. aPTT is monitored when administering unfractionated heparin. INR is monitored if the client is receiving warfarin.

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

Exhibit

A home health nurse visits a client 2 weeks after discharge from the hospital. The client experienced an acute myocardial infarction and subsequent heart failure. Home medications are listed in the exhibit. Which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information.

1. Bruising easily, especially on arms [34%]
2. Fatigue [3%]
3. Feeling depressed [3%]
4. Muscle cramps in legs [58%]
Omitted
Correct answer
4

Explanation:

The nurse would be most concerned with the client’s report of muscle cramps in the legs. This could be a sign of hypokalemia caused by use of the diuretic furosemide or possibly a reaction from the statin medication atorvastatin.

Hypokalemia may manifest as muscle cramps, weakness, or paralysis and typically starts with the leg muscles. Hypokalemia could be dangerous in this client due to possible arrhythmias in the presence of existing cardiac dysfunction. The client may need to be started on supplemental potassium and a high-potassium diet if the serum potassium level is low. If the potassium level is normal, atorvastatin may be responsible for muscle cramps.

(Option 1) Bruising, especially on the upper extremities, is common with the use of antiplatelet agents such as aspirin and clopidogrel. The nurse should teach the client to monitor for other, more severe signs of bleeding, such as blood in the stool.

(Option 2) The myocardial infarction and heart failure have most likely reduced the client’s functional capacity and can cause fatigue. Beta blockers such as metoprolol can also cause fatigue. This will improve with time, and the nurse should talk to the client about possible cardiac rehabilitation.

(Option 3) Feeling depressed is common after an acute health-related event such as a myocardial infarction. The client needs to be evaluated further and may need an antidepressant. However, feelings of depression are not immediately life-threatening unless the client exhibits suicidal ideation.

Educational objective:
The nurse should recognize muscle cramps in the legs as a possible sign of hypokalemia in the client taking diuretics. Muscle cramps should be reported to the health care provider in anticipation of checking a potassium level, adding a potassium supplement, and instructing the client to eat potassium-rich foods.

A A A
ExhibitA nurse in the cardiac intermediate care unit is caring for a client with acute decompensated heart failure (ADHF). The client also has a history of coronary artery disease and peripheral vascular disease. The nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication? Click on the exhibit button for additional information.

1. Aspirin [14%]
2. Atorvastatin [18%]
3. Furosemide [13%]
4. Metoprolol [53%]
Omitted
Correct answer
4

Explanation:

Beta blockers, or “lols” (metoprolol, carvedilol, bisoprolol, atenolol), are the mainstay of therapy for clients with chronic heart failure as these improve survival rates for both systolic and diastolic heart failure. However, in certain situations beta blockers can worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility.

In this client with acute decompensated heart failure (ADHF), marginally low blood pressure (BP), crackles in the lungs, low oxygen saturation, jugular venous distension (JVD), and peripheral edema, the administration of beta blockers can cause the client to further deteriorate. Beta blockers at low doses may be able to be restarted after this client has stabilized and exacerbation of ADHF has resolved with diuresis.

(Options 1 and 2) Aspirin is contraindicated if the client has evidence of bleeding. Statins are contraindicated if there is evidence of severe liver or muscle injury. It is appropriate to administer both of these medications to this client who has coronary artery disease and peripheral vascular disease.

(Option 3) This client has crackles, JVD, and peripheral edema, indicating the need for furosemide (Lasix). Therefore, the nurse should continue to monitor the client’s BP with the administration of furosemide as it can lower BP. When excess fluid is removed through diuresis, the heart will be able to pump more effectively, which will increase cardiac output and BP.

Educational objective:
The nurse should question administration of beta blockers in a client with symptoms of acute ADHF due to the possibility of further clinical deterioration. Beta blockers are most useful for chronic heart failure.

The nurse is preparing to administer 160 mg of furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect?

1. Bradycardia [16%]
2. Hypokalemia [49%]
3. Nephrotoxicity [15%]
4. Ototoxicity [18%]
Omitted
Correct answer
4
Answered correctly

Explanation:

IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the dose above, use the following formula:

(160 mg) / (4 mg/min) = 40 min
(Option 1) Bradycardia is an adverse effect of beta blockers (eg, metoprolol, atenolol), calcium channel blockers (eg, verapamil), and digoxin. It is not an adverse effect of furosemide.

(Option 2) Hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic. However, slower infusion is unlikely to prevent this adverse effect.

(Option 3) Although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of administration.

Educational objective:
High doses of IV furosemide should be administered slowly to prevent ototoxicity.

e is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? Select all that apply.

1. Assess for bruising
2. Assess for tarry stools
3. Monitor intake and output
4. Monitor liver function tests
5. Monitor platelets
Omitted
Correct answer
1,2,5
Answered correctly

Explanation:

Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenic purpura, so platelets should be monitored periodically (Option 5).

(Option 3) Monitoring intake and output is indicated while a client is on diuretic medications (eg, furosemide, torsemide, bumetanide) but not for antiplatelet agents.

(Option 4) Baseline liver enzymes are obtained for clients taking statins (eg, rosuvastatin, atorvastatin) and isoniazid (for tuberculosis). Elevated liver enzymes are an infrequent side effect of clopidogrel, and regular monitoring is usually not required in clients without hepatic impairment.

Educational objective:
Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) can pose a risk for serious bleeding. Clients should be monitored for bruising, signs of bleeding (eg, tarry stools, hematuria), and decreased platelet counts.

The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering? Click on the exhibit for more information.

1. Furosemide [68%]
2. Glipizide [8%]
3. Levofloxacin [6%]
4. Potassium chloride [16%]
Omitted
Correct answer
1

Explanation:

The nurse should question the prescription for furosemide (Lasix), a potent loop diuretic, before administering the medication. The client has a significant decrease in systolic blood pressure (50 mm Hg), a negative fluid balance of 2000 mL for 24 hours, hypernatremia (normal sodium, 135-145 mg/dL [135-145 mmol/L]), and a potassium level that is trending downward. These parameters indicate hypotonic dehydration, which is often caused by diuretic use. If the diuretic were administered, the fluid volume deficit would increase further.

(Option 2) Glipizide, an oral sulfonylurea drug used to control blood sugar, is prescribed once or twice a day 30 minutes before meals. The client’s blood sugar is within normal limits (70-99 mg/dL [3.9-5.5 mmol/L]), so there is no need for the nurse to question the prescription.

(Option 3) Antibiotic therapy with levofloxacin (Levaquin) is appropriate for a client with a urinary tract infection, so there is no need for the nurse to question the prescription.

(Option 4) Potassium chloride is usually prescribed with a diuretic to prevent hypokalemia. The potassium is within normal limits (normal, 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) but is trending downward. A further decrease in potassium from the diuretic would increase the risk for cardiac dysrhythmias associated with hypokalemia. Most clients need a potassium level of around 4.0 mEq/L (4.0 mmol/L) to prevent arrhythmias. If the furosemide is discontinued, the health care provider and nurse should check serum potassium levels the next day to determine whether further dosing is necessary.

Educational objective:
Decrease in blood pressure, increase in pulse rate, output greater than intake, hypernatremia, and decrease in serum potassium are manifestations that can indicate hypotonic dehydration in a client receiving diuretic therapy.

Block Time Remaining: 00:00:07
TUTOR
Test Id: 80941960
QId: 31324 (921666)
1 of 53
A A A
The nurse is preparing to administer IV cefazolin to a client who is newly admitted with cellulitis. The client’s allergies include amoxicillin, ciprofloxacin, and sulfa drugs. What should the nurse do first?1. Administer the medication as ordered [10%]
2. Clarify the order with the health care provider (HCP) [48%]
3. Get more information from the client about the client’s allergies [31%]
4. Notify the pharmacy that the drug is inappropriate for this client [9%]
Omitted
Correct answer
3
Answered correctly
31% Time: 7 seconds
Updated: 01/08/2017
Explanation:

The nurse should find out more about this client’s allergies before giving the medication. Specifically, the nurse must learn what type of reaction the client had to amoxicillin, a penicillin antibiotic. With a history of anaphylaxis to penicillin, cephalosporins (eg, cefazolin) are contraindicated. Penicillin-cephalosporin cross-sensitivity occurs due to the structural similarity between the cephalosporin and penicillin molecules.

If this client’s reaction to amoxicillin was only a rash or other mild reaction that was not life-threatening, the cephalosporin can be safely administered. However, if the client had an anaphylactic reaction to penicillin, the HCP will need to prescribe a different antibiotic.

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

(Option 2) The nurse does not have enough information to determine whether the HCP needs to be called.

(Option 4) The nurse does not have enough information to determine whether the medication is appropriate.

Educational objective:
A client with a penicillin allergy may be allergic to cephalosporin antibiotics. Cephalosporins may be safely administered to clients with a history of mild allergic reaction, such as rash, but they are contraindicated in clients with a history of penicillin anaphylaxis.

Block Time Remaining: 00:00:08
TUTOR
Test Id: 80941960
QId: 31336 (921666)
2 of 53
A A A
A client has been on long-term therapy with esomeprazole. What is essential for the nurse to ask the client?1. “Are you drinking plenty of water with the medication?” [21%]
2. “Are you taking the medication after meals?” [21%]
3. “Have you had a bone density test recently?” [45%]
4. “Have you had your blood pressure taken regularly?” [10%]
Omitted
Correct answer
3
Answered correctly
45% Time: 1 seconds
Updated: 01/19/2017
Explanation:

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.

Block Time Remaining: 00:00:13
TUTOR
Test Id: 80941960
QId: 31830 (921666)
3 of 53
A A A
A client in the intensive care unit is receiving IV vancomycin and gentamicin. The nurse should monitor for which potential complication with the administration of these medications?1. Blood in nasogastric tube drainage [1%]
2. Decrease in red blood cell (RBC) count [5%]
3. Increase in serum creatinine level [71%]
4. Onset of muscle aches and cramping [21%]
Omitted
Correct answer
3
Answered correctly
71% Time: 5 seconds
Updated: 04/17/2017
Explanation:

Vancomycin and aminoglycosides (eg, gentamicin, amikacin, tobramycin) are strong antibiotics that can cause nephrotoxicity and ototoxicity. The client receiving these medications simultaneously would be at an even higher risk for these adverse reactions. The nurse should monitor the client’s renal function by assessing blood urea nitrogen (BUN) and creatinine levels and measuring urinary output. Increased levels of BUN and creatinine may indicate kidney damage. The health care provider should be notified before continuing these medications.

(Option 1) Blood in the nasogastric tube could be a complication of peptic ulcer disease and the use of nonsteroidal anti-inflammatory drugs and corticosteroids.

(Option 2) A decrease in the RBC count may be evidence of bone marrow suppression that can occur with use of certain cancer drugs (eg, methotrexate).

(Option 4) Muscle cramping can occur occasionally with use of gentamicin but is not an indication to stop the infusion. Muscle aching and cramping that may signify a complication occur with the use of statins (eg, atorvastatin, rosuvastatin) and fibrates (eg, gemfibrozil, fenofibrate).

Educational objective:
The nurse should recognize that the risk of nephrotoxicity and ototoxicity is potentiated when vancomycin and aminoglycosides (eg, gentamicin) are administered together. Kidney and hearing functions should be closely monitored in these clients.

Block Time Remaining: 00:00:14
TUTOR
Test Id: 80941960
QId: 33899 (921666)
4 of 53
A A A
The nurse reinforces teaching to a female client about taking misoprostol to prevent stomach ulcers. Which statement by the client would prompt further instruction?1. “I can take this medication with food if it hurts my stomach.” [7%]
2. “I must use a reliable form of birth control while taking this medication.” [10%]
3. “I should continue to take my ibuprofen as prescribed.” [44%]
4. “I will take this medicine with an antacid to decrease stomach upset.” [37%]
Omitted
Correct answer
4
Answered correctly
37% Time: 1 seconds
Updated: 05/15/2017
Explanation:

Misoprostol (Cytotec) is a synthetic prostaglandin that protects against gastric ulcers by reducing stomach acid and promoting mucus production and cell regeneration. It is often prescribed to prevent gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug (NSAID) therapy.

Antacids, especially those that contain magnesium (eg, Gaviscon), can increase the adverse effects of misoprostol (eg, diarrhea, dehydration). If clients require therapy with antacids, they should choose one that does not contain magnesium (eg, calcium carbonate [Tums]) and contact the health care provider if adverse effects occur (Option 4).

(Option 1) Taking misoprostol with food can help decrease gastrointestinal side effects (eg, abdominal pain, cramping, diarrhea).

(Option 2) Misoprostol is also used for labor induction and is classified as a pregnancy category X drug. Women of childbearing age must be educated on using reliable birth control and the possible sensation of uterine cramping while taking misoprostol. Clients who suspect they are pregnant must stop taking the medication and contact their health care provider immediately.

(Option 3) The client can continue taking ibuprofen (an NSAID) with misoprostol because misoprostol is designed to reduce side effects of ibuprofen.

Educational objective:
Misoprostol prevents gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug therapy. It should not be taken with antacids but can be taken with food to reduce gastrointestinal upset. Women of childbearing age should be educated on using reliable birth control methods as misoprostol can induce labor.

Block Time Remaining: 00:00:14
TUTOR
Test Id: 80941960
QId: 33899 (921666)
4 of 53
A A A
The nurse reinforces teaching to a female client about taking misoprostol to prevent stomach ulcers. Which statement by the client would prompt further instruction?1. “I can take this medication with food if it hurts my stomach.” [7%]
2. “I must use a reliable form of birth control while taking this medication.” [10%]
3. “I should continue to take my ibuprofen as prescribed.” [44%]
4. “I will take this medicine with an antacid to decrease stomach upset.” [37%]
Omitted
Correct answer
4
Answered correctly
37% Time: 1 seconds
Updated: 05/15/2017
Explanation:

Misoprostol (Cytotec) is a synthetic prostaglandin that protects against gastric ulcers by reducing stomach acid and promoting mucus production and cell regeneration. It is often prescribed to prevent gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug (NSAID) therapy.

Antacids, especially those that contain magnesium (eg, Gaviscon), can increase the adverse effects of misoprostol (eg, diarrhea, dehydration). If clients require therapy with antacids, they should choose one that does not contain magnesium (eg, calcium carbonate [Tums]) and contact the health care provider if adverse effects occur (Option 4).

(Option 1) Taking misoprostol with food can help decrease gastrointestinal side effects (eg, abdominal pain, cramping, diarrhea).

(Option 2) Misoprostol is also used for labor induction and is classified as a pregnancy category X drug. Women of childbearing age must be educated on using reliable birth control and the possible sensation of uterine cramping while taking misoprostol. Clients who suspect they are pregnant must stop taking the medication and contact their health care provider immediately.

(Option 3) The client can continue taking ibuprofen (an NSAID) with misoprostol because misoprostol is designed to reduce side effects of ibuprofen.

Educational objective:
Misoprostol prevents gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug therapy. It should not be taken with antacids but can be taken with food to reduce gastrointestinal upset. Women of childbearing age should be educated on using reliable

Block Time Remaining: 00:00:16
TUTOR
Test Id: 80941960
QId: 31862 (921666)
6 of 53
A A A
A client with ulcerative colitis is prescribed the drug sulfasalazine. Which information should the nurse discuss with the client concerning this drug? Select all that apply.1. Drinking 8 glasses of water daily
2. Stopping the medicine if blood is present in stool
3. Stopping the medicine if urine turns an orange-yellow color
4. Taking folic acid supplements
5. Wearing sunscreen when outdoors
Omitted
Correct answer
1,4,5
Answered correctly
37% Time: 1 seconds
Updated: 05/05/2017
Explanation:

Sulfasalazine (Azulfidine) is a sulfonamide (salicylate and sulfa antibiotic) and nonbiologic disease-modifying antirheumatic drug (DMARD) used for mild to moderate chronic inflammatory rheumatoid arthritis (RA) and inflammatory bowel disease (eg, ulcerative colitis). It inhibits the production of prostaglandin, a mediator in the body’s inflammatory response.

Most “sulfa” medications (eg, trimethoprim, sulfamethoxazole) share common side effects, including:

Crystalluria causing kidney injury – client should drink 8 glasses of water daily to maintain adequate urine output (eg, 1200-1500 mL/day)
Photosensitivity and risk for sunburn – client should avoid sun exposure and apply sunscreen
Folic acid deficiency (megaloblastic anemia and stomatitis) – client should eat folate-rich foods and take 1 mg/day folic acid supplement
Rarely life-threatening agranulocytosis (leukopenia) – client should be monitored for complete blood count at the start of therapy and report fever or sore throat immediately
Stevens-Johnson syndrome – client should stop the medicine if rash develops
(Option 2) Ulcerative colitis is characterized by bloody diarrhea, and the medication is taken to reduce this effect.

(Option 3) Urine and skin can turn an orange-yellow color but will return to normal when the drug is discontinued. This is an expected finding.

Educational objective:
Sulfasalazine (Azulfidine) is used for mild to moderate chronic inflammatory RA and inflammatory bowel disease. Important adverse effects include crystalluria with kidney injury, yellow-orange skin and urine discoloration, folic acid deficiency, and photosensitivity.

.

Block Time Remaining: 00:00:17
TUTOR
Test Id: 80941960
QId: 30257 (921666)
7 of 53
A A A
A client has nausea, abdominal cramping, and persistent mucus-like, watery diarrhea that is positive for Clostridium difficile. The nurse anticipates the client will be prescribed which medication to treat this condition?1. Ceftriaxone [46%]
2. Fluconazole [8%]
3. Metronidazole [43%]
4. Pantoprazole [2%]
Omitted
Correct answer
3
Answered correctly
43% Time: 1 seconds
Updated: 05/04/2017
Explanation:

C difficile is often associated with antibiotic therapy but can also be a nosocomial hospital-acquired infection. Antibiotics, especially broad-spectrum, reduce normal bacteria in the body. This allows other bacteria, such as C difficile, to take over and cause a superinfection. It grows in the intestinal tract and causes antibiotic-associated diarrhea.

Metronidazole (Flagyl) is an anti-infective drug commonly used to treat C difficile. For severe C difficile infection, oral vancomycin may be used; intravenous vancomycin is ineffective.

(Option 1) Ceftriaxone (Rocephin) is a cephalosporin antibiotic; its use could cause C difficile infection.

(Option 2) Fluconazole (Diflucan) is a broad-spectrum antifungal agent; it is not indicated to treat C difficile.

(Option 4) Pantoprazole (Protonix) is a proton pump inhibitor agent; its use has been associated with development of C difficile infection.

Educational objective:
Antibiotics reduce normal bacteria in the body, allowing other bacteria or fungi, such as C difficile, to take over. C difficile is a toxin-producing microorganism that grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) and oral vancomycin are commonly used to treat this condition.

Block Time Remaining: 00:00:18
TUTOR
Test Id: 80941960
QId: 30863 (921666)
8 of 53
A A A
A client has a deep vein thrombosis and is receiving a heparin drip. The client’s activated partial thromboplastin time (aPTT) has been in the therapeutic range for the past 24 hours. The most recent laboratory value shows that the current aPTT equals the control value. What explanation should the nurse consider?1. The client became tolerant to heparin [34%]
2. The client consumed spinach [13%]
3. The client developed thrombocytopenia [23%]
4. The client’s intravenous (IV) line is infiltrated [27%]
Omitted
Correct answer
4
Answered correctly
27% Time: 1 seconds
Updated: 05/25/2017
Explanation:

With a heparin drip infusion, the goal is to reach the therapeutic range of the drug’s effect and not the “normal” or “control value.” Once the therapeutic effect range has been reached (usually 1.5-2.0 times the control value), it usually remains within this range without titrating the heparin infusion rate.

Heparin has a short duration (approximately 2-6 hours IV). Therefore, if it is not being infused, the aPTT level will go back to the control value (aPTT level without administration of anticoagulants). In addition, the volume of heparin being infused is small (because the standard concentration is 100 units/mL) so it is possible to miss an infiltration.

(Option 1) Clients do not develop tolerance to heparin. However, tolerance is typically seen with other medications such as nitroglycerine and opioids.

(Option 2) Consumption of dark-green leafy vegetables is an issue related to therapeutic levels of warfarin (Coumadin). These foods have vitamin K, the antagonist for warfarin. However, this is not an issue related to heparin administration.

(Option 3) Low platelets (heparin-induced thrombocytopenia) are a risk for clients on heparin; this can typically result in clot formation rather than bleeding (paradoxic effect) but has no effect on aPTT.

Educational objective:
PTT is used to measure the therapeutic effect of heparin IV infusion (should be 1.5-2.0 times the control value). Due to the short half-life, the possibility of infiltration should be assessed if the PTT level suddenly drops despite heparin administration.

Block Time Remaining: 00:00:19
TUTOR
Test Id: 80941960
QId: 30924 (921666)
9 of 53
A A A
A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs?1. Blurred vision [46%]
2. Dark-colored urine [4%]
3. Difficulty hearing [25%]
4. Yellow skin [23%]
Omitted
Correct answer
1
Answered correctly
46% Time: 1 seconds
Updated: 04/09/2017
Explanation:

Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination.

(Options 2 and 4) Dark-colored urine and yellow skin can indicate the presence of hepatotoxicity, which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, rifampin). However, hepatotoxicity is not common with ethambutol.

(Option 3) Difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to streptomycin. Streptomycin, an aminoglycoside antibiotic, is a second-line drug sometimes used to treat multi-drug-resistant tuberculosis, with ototoxic and nephrotoxic adverse effects.

Educational objective:
Clients taking ethambutol must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect.

Block Time Remaining: 00:00:20
TUTOR
Test Id: 80941960
QId: 30354 (921666)
10 of 53
A A A
A client is receiving a blood transfusion. Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 to 84/50 mm Hg. The client reports “feeling a little cold.” Based on this assessment, in what order should the nurse complete the following actions? All options must be used.Your Response/ Incorrect Response
Correct Response
Stop the blood transfusion
Using new tubing, infuse normal saline into the vein
Administer prescribed vasopressor
Collect urine specimen
Document the occurrence
Omitted
Correct answer
4,5,1,2,3
Answered correctly
69% Time: 1 seconds
Updated: 02/15/2017
Explanation:

It is important for the nurse to remain with the client for 15 minutes after starting a blood transfusion to monitor for signs of a reaction. These signs include fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. The client may report a variety of symptoms ranging from none to a feeling of impending doom. If signs of a transfusion reaction occur, the nurse should:

Stop the transfusion immediately (Option 4).
Using new tubing, infuse normal saline to keep the vein open (Option 5).
Continue to monitor hemodynamic status and notify the health care provider and blood bank.
Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids (Option 1).
Collect a urine specimen to be assessed for a hemolytic reaction (Option 2).
Document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis (Option 3).
Educational objective:
If signs or symptoms of a blood transfusion reaction occur, the nurse should stop the infusion immediately and use new tubing to keep the vein open with normal saline. The nurse should continue to monitor the client’s hemodynamic status, and administer prescribed drugs. The nurse should also collect a urine specimen to be assessed for a hemolytic reaction.

ved.

Block Time Remaining: 00:00:22
TUTOR
Test Id: 80941960
QId: 32035 (921666)
11 of 53
A A A
A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection (UTI). The nurse instructs the client to observe for and notify the health care provider (HCP) immediately about which of the following?1. Brown-colored urine [6%]
2. Hearing and balance problems [66%]
3. Pain in the Achilles tendon area [23%]
4. Sunburn [3%]
Omitted
Correct answer
3
Answered correctly
23% Time: 2 seconds
Updated: 12/23/2016
Explanation:

Use of fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin), especially ciprofloxacin, places clients at increased risk for tendinitis and tendon rupture that most often occur in the Achilles tendon. This class of antibiotics carries a black box warning about this risk. The Food and Drug Administration recommends that at the first sign of tendon pain or swelling, clients should stop taking the fluoroquinolone, abstain from moving the affected area, and contact their HCP promptly for further evaluation and a change of antibiotic.

(Option 1) Turning urine into a harmless brown color is a common side effect of nitrofurantoin, another antibiotic commonly used for UTI treatment.

(Option 2) Hearing and balance problems (vertigo) result from aminoglycoside ototoxicity (eg, gentamicin).

(Option 4) Ciprofloxacin can cause photosensitivity. The client should be instructed to avoid sun exposure and use sunscreen while taking the medication.

Educational objective:
Fluoroquinolones (ciprofloxacin) carry a black box warning citing an increased risk of tendinitis and rupture, especially of the Achilles tendon.

Block Time Remaining: 00:00:23
TUTOR
Test Id: 80941960
QId: 31846 (921666)
12 of 53
A A A
A client has received a new prescription for nystatin to treat oral candidiasis. Which instructions should the nurse give this client?1. Apply the ointment inside the mouth with a cotton-tipped applicator [12%]
2. Chew, then swallow the lozenge [0%]
3. Swish liquid in mouth for as long as possible, then spit it out [47%]
4. Swish liquid in mouth for several minutes, then swallow it [38%]
Omitted
Correct answer
4
Answered correctly
38% Time: 1 seconds
Updated: 04/23/2017
Explanation:

Nystatin is used to treat oral candidiasis, or thrush, that can be caused by medications such as antibiotics, corticosteroids, or oral contraceptive pills. Medical conditions that make oral candidiasis more likely include HIV, immunosuppression, uncontrolled diabetes, denture use, and hormonal changes during pregnancy.

Nystatin is available in the form of powders, suspensions, creams, ointments, and lozenges. Oral suspensions are the more common form of nystatin used for oral candidiasis. The client should be directed to swish the solution within the mouth, making contact with all the mucous membranes, and then swallow the solution after several minutes. Swallowing would help to clear any unseen esophageal candidiasis.

(Option 1) Ointments are used on Candida infections of the skin.

(Option 2) Lozenges are available for oral candidiasis but should be allowed to dissolve in the mouth.

(Option 3) The liquid should be swallowed, not spit out.

Educational objective:
The nurse should teach the client taking nystatin solution for oral candidiasis to swish it in the mouth for several minutes and then swallow the solution. Swallowing would help to clear any unseen esophageal candidiasis.

Block Time Remaining: 00:00:25
TUTOR
Test Id: 80941960
QId: 30954 (921666)
13 of 53
A A A
A child with cystic fibrosis is to receive a dose of pancrelipase at 12:00 PM. The client states that he is not hungry and will eat his lunch in an hour. Which action is appropriate for the nurse to take?1. Administer the prescribed pancrelipase [13%]
2. Hold the pancrelipase until the client eats [83%]
3. Notify the health care provider [3%]
4. Skip this dose of the pancrelipase [0%]
Omitted
Correct answer
2
Answered correctly
83% Time: 2 seconds
Updated: 05/10/2017
Explanation:

Cystic fibrosis affects the pancreatic excretion of digestive enzymes. Without these enzymes, the client is unable to absorb fats, starches, and some proteins from the diet. Pancrelipase provides these enzymes to the client and must be given with every snack and meal so that the client can digest and absorb the nutrients eaten. If the client is not eating when the medication is scheduled, there are no nutrients to digest. Therefore, the dose should be held until the client eats.

Educational objective:
Pancrelipase is a medication containing lipase, protease, and amylase. In cystic fibrosis, the client’s pancreas does not excrete these necessary enzymes. To prevent malabsorption syndrome, the enzymes must be taken with every snack and every meal.

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Block Time Remaining: 00:00:26
TUTOR
Test Id: 80941960
QId: 31844 (921666)
14 of 53
A A A
A parent calls the after-hours triage nurse about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse?1. Acetaminophen being given every 4 hours for fever [17%]
2. Bismuth subsalicylate being used for nausea [52%]
3. Ibuprofen being given every 6 hours for body aches [20%]
4. Popsicles and gelatin desserts being used for hydration [10%]
Omitted
Correct answer
2
Answered correctly
52% Time: 1 seconds
Updated: 04/21/2017
Explanation:

The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains a salicylate (same class as aspirin) and could possibly cause Reye syndrome. Reye syndrome can develop in children with a recent viral illness such as varicella or influenza. It can cause acute encephalopathy and hepatic dysfunction. Children with viral infections should not be given aspirin or products containing salicylates.

(Options 1 and 3) Acetaminophen and ibuprofen are being used appropriately.

(Option 4) Sufficient fluids are important to maintain hydration in the child with influenza. Water and fluids should be offered frequently; popsicles and gelatin desserts (eg, Jell-O) provide a palatable means of getting children to ingest fluids.

Educational objective:
The nurse should tell the parent not to administer any product containing aspirin or salicylates to a child with a viral infection (eg, influenza, varicella) to prevent Reye syndrome.

Block Time Remaining: 00:00:27
TUTOR
Test Id: 80941960
QId: 31816 (921666)
15 of 53
A A A
The nurse provides teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?1. Need for an eye examination [13%]
2. Need for sunblock [10%]
3. Risk for infection [50%]
4. Risk for kidney injury [25%]
Omitted
Correct answer
3
Answered correctly
50% Time: 1 seconds
Updated: 03/15/2017
Explanation:

Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis.

Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Leukopenia and its immunosuppressant effects can increase susceptibility to infection. Clients should be educated about obtaining routine killed (inactivated) vaccines (eg, influenza, pneumococcal) and avoiding crowds and persons with known infections. Live vaccines (eg, herpes zoster) are contraindicated in clients receiving immunosuppressants, such as methotrexate.

Alcohol should be avoided in clients taking methotrexate as it is hepatotoxic and drinking alcohol increases the client’s risk for hepatotoxicity.

(Option 1) Regular eye examinations every 6 months are indicated for clients prescribed the nonbiological DMARD antimalarial hydroxychloroquine (Plaquenil) as it can cause retinal damage. Ethambutol, used to treat tuberculosis, also requires frequent eye examinations.

(Options 2 and 4) Photosensitivity (common with tetracycline, thiazide diuretics, and sulfonamides) and nephrotoxicity (common with aminoglycosides, vancomycin, and nonsteroidal anti-inflammatory drugs) can occur, but immunosuppression is more likely and potentially fatal.

Educational objective:
Methotrexate is a nonbiologic disease-modifying antirheumatic drug used to treat rheumatoid arthritis. The major adverse effects associated with its use include bone marrow suppression, hepatotoxicity, and gastrointestinal .

Block Time Remaining: 00:00:28
TUTOR
Test Id: 80941960
QId: 31867 (921666)
16 of 53
A A A
A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, “Because I’m not depressed!” What is the nurse’s most appropriate response?1. “Depression is common with fibromyalgia, but a low dose of this drug can prevent it.” [12%]
2. “It can relieve your chronic pain and help you sleep better at night.” [58%]
3. “It helps to relieve the adverse effects of your other prescribed drugs.” [11%]
4. “You have the right to refuse. I will notify your health care provider (HCP).” [17%]
Omitted
Correct answer
2
Answered correctly
58% Time: 1 seconds
Updated: 05/05/2017
Explanation:

Fibromyalgia (FM) results from abnormal central nervous system pain transmission and processing. It is characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances.

Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well (Option 2). Other effective drugs to treat the chronic pain associated with FM include pregabalin and amitriptyline (Elavil), an older tricyclic antidepressant drug.

(Option 1) Although depression often accompanies chronic pain, duloxetine can be prescribed specifically to treat the chronic pain associated with FM.

(Option 3) Duloxetine is prescribed for major depressive disorder and to relieve pain associated with diabetic neuropathy and FM. It is not given to relieve the adverse effects of other drugs.

(Option 4) A client has the right to refuse any drug. However, the nurse should first explain the purpose of the drug to the client before notifying the HCP.

Educational objective:
Medications such as duloxetine, pregabalin, and amitriptyline have neuropathic pain-relieving effects. They are commonly used for treating pain associated with diabetic neuropathy and FM. Duloxetine is particularly effective for treating both depression and pain.

Block Time Remaining: 00:00:31
TUTOR
Test Id: 80941960
QId: 31874 (921666)
17 of 53
A A A
A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication?1. Blood cultures [18%]
2. Creatinine levels [63%]
3. Magnesium levels [1%]
4. White blood cell (WBC) count [16%]
Omitted
Correct answer
2
Answered correctly
63% Time: 3 seconds
Updated: 05/19/2017
Explanation:

Vancomycin can cause nephrotoxicity, which occurs most often in clients who already have some degree of renal impairment. Serum creatinine levels should be monitored daily during IV vancomycin treatment to look for an increase in level over a few days. If an increasing trend is identified, the nurse should consult with the health care provider (HCP) and/or pharmacist before administering the dose.

(Option 1) Blood cultures may be checked periodically during vancomycin therapy, but they are not likely to change this quickly.

(Option 3) Magnesium levels are typically not affected by vancomycin therapy.

(Option 4) The WBC count may be helpful in determining the effectiveness of vancomycin therapy in treating infection. However, this laboratory result is unlikely to influence the nurse’s decision on whether to administer the dose. Therefore, it is not the highest priority.

Educational objective:
Creatinine levels should be closely monitored for signs of nephrotoxicity in the client receiving IV vancomycin. If increasing creatinine is identified, the nurse should hold the dose and consult with the HCP and/or pharmacist before administration.

Block Time Remaining: 00:00:31
TUTOR
Test Id: 80941960
QId: 31874 (921666)
17 of 53
A A A
A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication?1. Blood cultures [18%]
2. Creatinine levels [63%]
3. Magnesium levels [1%]
4. White blood cell (WBC) count [16%]
Omitted
Correct answer
2
Answered correctly
63% Time: 3 seconds
Updated: 05/19/2017
Explanation:

Vancomycin can cause nephrotoxicity, which occurs most often in clients who already have some degree of renal impairment. Serum creatinine levels should be monitored daily during IV vancomycin treatment to look for an increase in level over a few days. If an increasing trend is identified, the nurse should consult with the health care provider (HCP) and/or pharmacist before administering the dose.

(Option 1) Blood cultures may be checked periodically during vancomycin therapy, but they are not likely to change this quickly.

(Option 3) Magnesium levels are typically not affected by vancomycin therapy.

(Option 4) The WBC count may be helpful in determining the effectiveness of vancomycin therapy in treating infection. However, this laboratory result is unlikely to influence the nurse’s decision on whether to administer the dose. Therefore, it is not the highest priority.

Educational objective:
Creatinine levels should be closely monitored for signs of nephrotoxicity in the client receiving IV vancomycin. If increasing creatinine is identified, the nurse should hold the dose and consult with the HCP and/or pharmacist before administration.

Block Time Remaining: 00:00:32
TUTOR
Test Id: 80941960
QId: 31851 (921666)
18 of 53
A A A
A client with chronic rheumatoid arthritis (RA) says, “I am so frustrated, tired, and stiff. I just can’t keep up with my young children anymore.” The client is prescribed adalimumab, a tumor necrosis factor (TNF) inhibitor. What is the priority nursing diagnosis (ND) for this client regarding the new prescription?1. Disturbed body image [2%]
2. Hopelessness [9%]
3. Impaired physical mobility [35%]
4. Risk for infection [53%]
Omitted
Correct answer
4
Answered correctly
53% Time: 1 seconds
Updated: 04/28/2017
Explanation:

Infection is a major adverse effect of TNF inhibitors (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) as these drugs interfere with the body’s normal immune response and cause immunosuppression. This increases the risk for a new infection or reactivation of a previous infection (eg, latent tuberculosis, hepatitis B virus).

Nursing interventions should focus on preventing infection (eg, reducing risk factors, promoting wellness) as it can be life-threatening in the setting of immunosuppression. This ND poses the greatest threat to the client’s survival and is therefore the priority diagnosis (Option 4).

(Option 1) Disturbed body image related to physical and psychological changes secondary to chronic RA is an appropriate ND. Nursing interventions should focus on client adaptation and acceptance of changes due to the illness. However, this does not pose the greatest risk to the client’s survival and is not the priority ND.

(Option 2) Hopelessness related to activity restriction and worsening physiological status secondary to chronic RA is an appropriate ND. Interventions should focus on setting short-term goals to change behaviors and promoting a more positive attitude. However, this is not the priority ND.

(Option 3) Impaired physical mobility related to decreased physical endurance and joint stiffness secondary to chronic RA is an appropriate ND. Interventions should focus on improving joint function and resuming the client’s usual activities. However, this is not the priority ND.

Educational objective:
TNF inhibitors (eg, etanercept, infliximab, adalimumab) interfere with the body’s normal immune response and cause immunosuppression. This increases the risk for a new infection or reactivation of a previous infection (eg, latent tuberculosis, hepatitis B virus).

Block Time Remaining: 00:00:33
TUTOR
Test Id: 80941960
QId: 31753 (921666)
19 of 53
A A A
A client comes to the emergency department following a bee sting. The client has a diffuse rash, hypotension, and throat tightness. One injection of IM epinephrine does not improve the client’s condition. What action should the nurse take next?1. Administer IV fluid bolus [7%]
2. Administer methylprednisolone [20%]
3. Prepare for emergency cricothyrotomy [14%]
4. Repeat IM epinephrine injection [57%]
Omitted
Correct answer
4
Answered correctly
57% Time: 1 seconds
Updated: 04/09/2017
Explanation:

Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). Circulatory failure and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine), can lead to cardiac/respiratory arrest.

The management of anaphylactic shock includes:

Ensure patent airway, administer oxygen
Remove insect stinger if present
IM epinephrine is the drug of choice and should be given to this client. Epinephrine stimulates both alpha- and beta-adrenergic receptors and dilates bronchial smooth muscle (beta 2) and provides vasoconstriction (alpha 1). The IM route (mid anterior lateral thigh) is better than the subcutaneous route. Repeat dose every 5-15 minutes.
Place in recumbent position and elevate legs
Maintain blood pressure with IV fluids, volume expanders or vasopressors
Bronchodilator (inhaled beta agonist) such as albuterol is administered to dilate the small airways and reverse bronchoconstriction
Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus
Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction
Anticipate cricothyrotomy or tracheostomy with severe laryngeal edema
(Option 1, 2, and 3) These are appropriate responses that should come after a repeat dose of epinephrine has been given.

Educational objective:
IM epinephrine is the single most important medication to be given in anaphylactic shock. The dose should be repeated every 5-15 minutes if symptoms are still present. Antihistamines, corticosteroids, and IV fluids are other supportive treatments.

.

Block Time Remaining: 00:00:34
TUTOR
Test Id: 80941960
QId: 30373 (921666)
20 of 53
A A A
A client is receiving chemotherapy for acute myeloid leukemia. The health care provider prescribes allopurinol to prevent tumor lysis syndrome (TLS). Which laboratory value indicates a therapeutic response to the medication?1. Serum calcium 9.5 mg/dL (2.38 mmol/L) [11%]
2. Serum phosphate 4.0 mg/dL (1.29 mmol/L) [5%]
3. Serum potassium 4.5 mEq/L (4.5 mmol/L) [13%]
4. Serum uric acid level 6.0 mg/dL (357 µmol/L) [69%]
Omitted
Correct answer
4
Answered correctly
69% Time: 1 seconds
Updated: 03/17/2017
Explanation:

A potential complication of chemotherapy is acute tumor lysis syndrome (TLS), a rapid release of intracellular components into the bloodstream. Massive cell lysis releases intracellular ions (potassium and phosphorus) and nucleic acids into the bloodstream. Catabolism of the nucleic acids produces uric acid, resulting in severe hyperuricemia. Released phosphorus binds calcium, producing calcium phosphate mixture but lowering serum calcium levels. Both calcium phosphate and uric acid are deposited into the kidneys, causing renal injury.

Allopurinol (Zyloprim) blocks the nucleic acid catabolism and prevents hyperuricemia but would not affect potassium, phosphate, and calcium levels. Chronic gout and uric acid calculi also require the administration of allopurinol to decrease uric acid accumulation. A normal blood uric acid level for an adult male is 4.4-7.6 mg/dL (262-452 µmol/L) and female is 2.3-6.6 mg/dL (137-393 µmol/L).

(Option 1) The normal calcium level for adults is 8.6-10.2 mg/dL (2.15-2.55 mmol/L). The client with this complication would experience hypocalcemia.

(Option 2) The normal phosphate level for adults is 2.4-4.4 mg/dL (0.78-1.42 mmol/L). In this condition, the phosphate level would show hyperphosphatemia.

(Option 3) The normal potassium level for adults is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Hyperkalemia is usually present in a client with this chemotherapy-induced complicatin.

Educational objective:
The therapeutic effect of allopurinol (Zyloprim) is to decrease hyperuricemia caused by TLS. Laboratory values of significance in TLS include rising blood uric acid, potassium, and phosphate levels, with decreasing calcium levels.

Block Time Remaining: 00:00:35
TUTOR
Test Id: 80941960
QId: 31934 (921666)
21 of 53
A A A
A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. Which intervention related to the drug’s adverse effects should the nurse include in the teaching plan?1. Have an ophthalmologic examination every 6 months [52%]
2. Take the medication on an empty stomach [6%]
3. Take vitamin D and calcium supplements [26%]
4. Wear a MedicAlert bracelet [15%]
Omitted
Correct answer
1
Answered correctly
52% Time: 1 seconds
Updated: 12/10/2016
Explanation:

Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent.

Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12 months (Option 1).

(Option 2) Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (common side effect).

(Option 3) Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation is not required.

(Option 4) There are no effects of hydroxychloroquine that would require wearing a MedicAlert bracelet.

Educational objective:
Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of SLE. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required.

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Block Time Remaining: 00:00:39
TUTOR
Test Id: 80941960
QId: 31831 (921666)
22 of 53
A A A
The nurse is caring for a client receiving IVPB azithromycin. Which client data obtained by the nurse should be reported to the health care provider (HCP) prior to administering any additional doses?1. Currently nauseated and vomited once [10%]
2. Decreased white blood cell (WBC) count [17%]
3. Prolonged QT interval [61%]
4. Temperature of 101.4 F (38.6 C) [11%]
Omitted
Correct answer
3
Answered correctly
61% Time: 4 seconds
Updated: 12/09/2016
Explanation:

All macrolide antibiotics (eg, azithromycin, erythromycin, clarithromycin) can cause a prolonged QT interval, which may lead to sudden cardiac death due to torsades de pointes. Therefore, an electrocardiogram (ECG) should be monitored. Concurrent use of macrolide antibiotics with other drugs that prolong QT interval (eg, amiodarone, sotalol, haloperidol, ziprasidone, azole antifungals) will further increase this risk.

Macrolides can also cause hepatotoxicity when taken in high doses or in combination with other hepatotoxic medications such as acetaminophen, phenothiazines, and sulfonamides. Elevation of aspartate transaminase and alanine transaminase levels (liver enzymes) may indicate that hepatotoxicity is occurring, and the nurse should report these results to the HCP.

(Option 1) Nausea and vomiting can be side effects of azithromycin. They are not as concerning as the adverse reaction of prolonged QT interval.

(Option 2) A decrease in the WBC count would be expected as infection is resolving.

(Option 4) Fever may be present in a client with an infection. The nurse should use as-needed acetaminophen cautiously in a client also receiving azithromycin due to the risk of hepatotoxicity.

Educational objective:
Macrolide antibiotics (eg, erythromycin, azithromycin, clarithromycin) can cause QT prolongation, which can lead to life-threatening arrhythmias (eg, torsades de pointes). They can also be hepatotoxic; therefore, the nurse should monitor liver function tests and an ECG and report

Block Time Remaining: 00:00:40
TUTOR
Test Id: 80941960
QId: 34498 (921666)
23 of 53
A A A
The nurse is reviewing new prescriptions for assigned clients. Which prescription would require further clarification from the health care provider?1. Alteplase for an ischemic stroke in a client with a blood pressure of 192/112 mm Hg [16%]
2. Amoxicillin for a respiratory infection in a client who is 20 weeks pregnant [28%]
3. Fentanyl for moderate to severe pain in a client post appendectomy with an allergy to codeine [19%]
4. Sodium chloride 3% infusion for a client with syndrome of inappropriate antidiuretic hormone [34%]
Omitted
Correct answer
1
Answered correctly
16% Time: 1 seconds
Updated: 04/19/2017
Explanation:

Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) are often prescribed to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive pulmonary embolism). They are recombinant plasminogen activators that activate the blood fibrinolytic system and dissolve thrombi.

Thrombolytic agents are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood pressure >180/110 mm Hg). Therefore, the health care provider should be consulted for clarification. Administering alteplase in the presence of these conditions can cause hemorrhage, including life-threatening intracerebral hemorrhage (Option 1).

(Option 2) Most penicillin derivates (eg, ampicillin, amoxicillin) and cephalosporins (eg, cephalexin, ceftriaxone) are generally considered safe for use by women who are pregnant or lactating.

(Option 3) Fentanyl is appropriate in postoperative clients with moderate to severe pain, even those with a history of allergies to codeine. Both drugs have opiate agonist effects but are chemically different. Codeine is a derivative of natural opiates (eg, morphine), whereas fentanyl is completely synthetic.

(Option 4) Syndrome of inappropriate antidiuretic hormone (SIADH) secretion results in water retention and dilutional hyponatremia. Clients with SIADH often require hypertonic saline for sodium repletion to increase serum sodium levels with a minimal infused volume of water.

Educational objective:
Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) place clients at risk for bleeding. Therefore, they are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension.

.

Block Time Remaining: 00:00:42
TUTOR
Test Id: 80941960
QId: 31228 (921666)
24 of 53
A A A
A client with deep vein thrombosis (DVT) is receiving a continuous infusion of unfractionated heparin. The client asks the nurse what the heparin is for. How should the nurse respond?1. “Heparin is a blood thinner that will help to dissolve the clot in your leg.” [27%]
2. “Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs.” [6%]
3. “Heparin will keep the current clot from getting bigger and help prevent new clots from forming.” [65%]
4. “I’m sorry. This is something that your health care provider (HCP) can answer better upon arriving.” [0%]
Omitted
Correct answer
3
Answered correctly
65% Time: 2 seconds
Updated: 03/18/2017
Explanation:

Venous thrombosis involves the formation of a thrombus (clot) and the inflammation of the vein. Anticoagulant therapy such as heparin does not dissolve the clot. The clot will be broken down by the body’s intrinsic fibrinolytic system over time. The heparin slows the time it takes blood to clot, thereby keeping the current clot from growing bigger and preventing new clots from forming.

(Option 1) Anticoagulants do not dissolve clots. Thrombolytic agents (fibrinolytics), such as tissue plasminogen activator (tPA), are used to break the clots, but they also carry the risk of serious intracranial hemorrhage and are used only for acute life-/organ-threatening conditions. The body will break down the clot over a period of time.

(Option 2) Heparin does not prevent the clot from breaking off but will deter the clot from growing larger.

(Option 4) The nurse should be able to answer client questions regarding medications being administered. The HCP can answer any further questions the client may have.

Educational objective:
The nurse should teach the client that the purpose of unfractionated heparin infusion in the treatment of DVT is to slow the time it takes blood to clot, thereby keeping the current clot from getting bigger and preventing new clots from forming.

Block Time Remaining: 00:00:43
TUTOR
Test Id: 80941960
QId: 30433 (921666)
25 of 53
A A A
Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome?1. Bladder scan showing 500 mL urine [32%]
2. Hemoglobin of 11 g/dL (110 g/L) [9%]
3. History of cataracts [32%]
4. Reporting frequent diarrhea today [25%]
Omitted
Correct answer
1
Answered correctly
32% Time: 1 seconds
Updated: 12/11/2016
Explanation:

Dicyclomine hydrochloride (Bentyl) is an anticholinergic medication. Anticholinergics are used to relax smooth muscle and dry secretions. Anticholinergic side effects include pupillary dilation, dry mouth, urinary retention, and constipation. Therefore, the classic contraindications are closed-angle glaucoma, bowel ileus, and urinary retention.

The urge to urinate is normally present at 300 mL; pain is usually felt around 500 mL. This client has urinary retention and should not have the bladder smooth muscle further relaxed.

(Option 2) Anticholinergic drugs do not affect the blood count. The normal reference range for hemoglobin is 11.7-15.5 g/dL (117-155 g/L) for females and 13.2-17.3 g/dL (132-173 g/L) for males.

(Option 3) The common eye contraindication is narrow-angle glaucoma as it could worsen the condition. Cataracts are a clouding of the lens and are not related to drainage flow.

(Option 4) Diarrhea is an expected finding with irritable bowel syndrome or other increased peristalsis and is a common reason for the drug to be prescribed. Anticholinergic drugs are contraindicated in the presence of a bowel ileus or atony as constipation is a side effect and further relaxation of the intestines could worsen these conditions.

Educational objective:
Anticholinergic drugs are contraindicated when smooth muscle relaxation is already a concern. Commonly cited contraindications include narrow-angle glaucoma, urinary retention (including benign prostatic hyperplasia), and bowel ileus/obstruction.

Block Time Remaining: 00:00:43
TUTOR
Test Id: 80941960
QId: 30367 (921666)
26 of 53
A A A
A client with latent tuberculosis has been taking oral isoniazid (INH) 300 mg daily for 2 months. The client tells the nurse that for the past week she has had numbness, a burning sensation, and tingling in her hands and feet. Additional intake of which of the following would most likely have prevented this?1. Folic acid [14%]
2. Vitamin B6 [43%]
3. Vitamin B12 [29%]
4. Vitamin D [12%]
Omitted
Correct answer
2
Answered correctly
43% Time: 0 seconds
Updated: 04/26/2017
Explanation:

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 B6 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.

Block Time Remaining: 00:00:43
TUTOR
Test Id: 80941960
QId: 31968 (921666)
27 of 53
A A A
The nurse is caring for a client who started receiving chemotherapy 10 days ago. Today, the health care provider prescribes filgrastim. Which of the following is an expected outcome of this medication?1. Decrease in serum uric acid [12%]
2. Increase in hemoglobin level [8%]
3. Increase in neutrophil count [63%]
4. Increase in platelet count [15%]
Omitted
Correct answer
3
Answered correctly
63% Time: 0 seconds
Updated: 12/12/2016
Explanation:

Chemotherapy can cause suppression of rapidly reproducing cells, including bone marrow suppression. This can result in decreased red blood cells, white blood cells, and platelets, all manufactured in the bone marrow. It is most likely to be seen with chemotherapy (versus radiation), with the lowest counts (the nadir) usually at 7-10 days after therapy initiation. Leukopenia is a decrease in total circulating white blood cell count (<4,000/mm3) and neutropenia is a decrease in circulating neutrophils (usually <1500/mm3).

Filgrastim (Neupogen) and pegfilgrastim (Neulasta) stimulate neutrophil production and are given prophylactically or if the client has an infection and more neutrophils are needed to fight it (Option 3).

(Option 1) Cancer chemotherapy causes cell lysis, which results in tumor lysis syndrome due to massive release of nucleic acid and its metabolic product, uric acid. Uric acid deposition leads to acute kidney injury. Medications such as allopurinol or rasburicase and aggressive IV hydration are used to prevent this complication.

(Option 2) Anemia is also common with chemotherapy. Epoetin (Procrit), a form of erythropoietin, stimulates the body to make additional red blood cells.

(Option 4) Low platelet count is not considered an urgent need until it is at <50,000/mm3. Usually, platelet transfusions are given.

Educational objective:
Bone marrow suppression from chemotherapy can cause decreased red blood cells, white blood cells, and platelets. Erythropoietin is used to increase red blood cell production, and filgrastim is administered to stimulate neutrophil production.

Block Time Remaining: 00:00:43
TUTOR
Test Id: 80941960
QId: 31541 (921666)
28 of 53
A A A
The emergency department nurse prepares a male client for surgery. The client was admitted with a traumatic open fracture of the femur, hematocrit of 36% (0.36), and hemoglobin of 12 g/dL (120 g/L). Which prescription should the nurse validate with the health care provider before administration?1. Cefazolin [8%]
2. Enoxaparin [75%]
3. Morphine [4%]
4. Tetanus toxoid [10%]
Omitted
Correct answer
2
Answered correctly
75% Time: 0 seconds
Updated: 03/19/2017
Explanation:

The Joint Commission Surgical Improvement Project CORE measure set has shown that preventives (eg, heparin, enoxaparin, aspirin) in select surgical procedures, given 24 hours before and after surgery, reduce the risk of venous thromboembolism. However, the estimated blood loss in a client with a fracture can be significant depending on the site (eg, 250-1200 mL). Although this client’s admission hematocrit (36% [0.36]) and hemoglobin (12 g/dL [120 g/L]) are only slightly low for an adult male (normal: 39%-50% [0.39-0.50], 13.2-17.3 g/dL [132-173 g/L]), the blood loss may not yet be evident. Therefore, the nurse would validate the prescription for enoxaparin (Lovenox) with the health care provider before administration.

Medications commonly prescribed for a client with an open fracture include:

Cefazolin (Ancef), a bone-penetrating cephalosporin antibiotic that is active against skin flora (Staphylococcus aureus); it is given prophylactically before and after surgery to prevent infection (Option 1)

Cyclobenzaprine (Flexeril), a central and peripheral muscle relaxant given to treat pain associated with muscle spasm; carisoprodol (Soma) or methocarbamol (Robaxin) can also be prescribed

Tetanus and diphtheria toxoid, an immunization given prophylactically to prevent infection (Clostridium tetani) if immunizations are not up to date (>10 years), unavailable, or unknown (Option 4)

Ketorolac (Toradol), a nonsteroidal anti-inflammatory drug given to decrease inflammation and pain

Opioids (eg, morphine, hydrocodone [Vicodin]), given for analgesia (Option 3)

Educational objective:
Medications commonly prescribed for a client with an open fracture to prevent infection and treat pain and muscle spasm include cefazolin (Ancef), tetanus toxoid, ketorolac (Toradol), opioids, and cyclobenzaprine (Flexeril).

Block Time Remaining: 00:00:43
TUTOR
Test Id: 80941960
QId: 30032 (921666)
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A client who has been on long-term omeprazole therapy for gastroesophageal reflux disease is admitted to the hospital for a urinary tract infection. The nurse recognizes that this client is at highest risk for which complication due to omeprazole use?1. Clostridium difficile infection [61%]
2. Gait disturbance [13%]
3. Jaw necrosis [7%]
4. Tremor [18%]
Omitted
Correct answer
1
Answered correctly
61% Time: 0 seconds
Updated: 06/02/2017
Explanation:

Long-term use of proton pump inhibitors (PPIs) is common as these medications are available over the counter. PPIs impair intestinal calcium absorption and therefore are associated with decreased bone density, which increases the possibility of fractures of the spine, hip, and wrist. PPIs cause acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias.

PPI use may also increase the risk for clostridium difficile-associated diarrhea (CDAD); currently the cause is unclear. A safety alert has been issued by the US Food and Drug Administration (FDA) advising health care providers to consider CDAD for unresolved diarrhea in PPI users. This client would be receiving antibiotics for a urinary tract infection, further increasing the risk for C difficile infection (Option 1).

(Option 2) Gait disturbance (ataxia) is commonly seen with phenytoin toxicity.

(Option 3) Jaw necrosis is associated with long-term bisphosphonate (eg, alendronate, risedronate) therapy.

(Option 4) Tremor is seen with lithium toxicity and albuterol (short-acting beta agonist) use.

Educational objective:
Long-term use of PPIs (Prazoles – omeprazole, lansoprazole, pantoprazole, rebeprazole) has been associated with decreased bone density (calcium malabsorption) and increased risk for C difficile-associated diarrhea and pneumonia.

Block Time Remaining: 00:00:44
TUTOR
Test Id: 80941960
QId: 35142 (921666)
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A community health nurse evaluates several clients’ vaccination status. Which clients would the nurse recommend receive the influenza vaccine injection? Select all that apply.1. 9-month-old with no known medical conditions
2. 5-year-old with congenital heart defect
3. 23-year-old recently diagnosed with HIV
4. 45-year-old caretaker of elderly parent
5. 75-year-old with end-stage renal failure
Omitted
Correct answer
1,2,3,4,5
Answered correctly
5% Time: 1 seconds
Updated: 01/31/2017
Explanation:

Influenza is a respiratory illness common during the cooler months of the year. Each year, a new influenza vaccine is created to help protect against specific viral strains. The Centers for Disease Control and Prevention and Public Health Agency of Canada recommend that all clients age ≥6 months receive the influenza vaccine annually unless the client has a life-threatening allergy to the vaccine or one of its ingredients. Special emphasis should be placed on vaccinating the following high-risk individuals:

Clients with chronic conditions (eg, asthma, heart failure, cancer) may experience exacerbation of symptoms if infected (Options 2 and 5).
Immunocompromised clients (eg, HIV) have decreased ability to fight infection (Option 3).
Health care workers and caretakers are at greater risk for acquiring and transmitting infection to other clients (Option 4).
Healthy children age 6-23 months and clients age ≥65 are at greatest risk for serious, flu-related complications (eg, pneumonia, dehydration) (Option 1).
Pregnant women are at increased risk for premature labor/delivery or influenza complications due to pregnancy-related physiologic changes.
Please note: The NCLEX now includes multiple-response questions with all options correct.

Educational objective:
Annual vaccination during influenza season is recommended for all clients age ≥6 months without life-threatening allergy to the vaccine or its ingredients. High-risk groups include clients who have chronic conditions, those who work in health care or as caretakers, those age 6-23 months or ≥65, and pregnant women.

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Test Id: 80941960
QId: 31840 (921666)
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The nurse provides teaching about methotrexate to a 28-year-old client with rheumatoid arthritis. Which client statement indicates the need for further instruction regarding this drug?1. “I know my resistance to germs will be lower, so I should get a flu shot this year.” [23%]
2. “I should take precautions to prevent pregnancy while I take this medicine.” [16%]
3. “I will have an eye examination every 6 months to check for damage caused by my medication.” [38%]
4. “It will be a difficult change for me, but I will not have wine with dinner anymore.” [21%]
Omitted
Correct answer
3
Answered correctly
38% Time: 1 seconds
Updated: 04/24/2017
Explanation:

Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) to treat rheumatoid arthritis and psoriasis.

The client’s statement about getting an eye examination every 6 months indicates that further teaching is necessary as these examinations are not indicated for clients prescribed methotrexate (Option 3). However, frequent eye examinations are required for clients prescribed the nonbiologic antimalarial DMARD hydroxychloroquine (Plaquenil) as it can cause retinal damage.

(Option 1) Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection. They should avoid crowded places and individuals with known infection and should receive appropriate killed (inactivated) vaccines (eg, influenza, pneumococcal). Live vaccines (eg, herpes zoster) are contraindicated.

(Option 2) Clients should not become pregnant while taking methotrexate or for at least 3 months after it is discontinued as the drug is teratogenic and can cause congenital abnormalities and fetal death.

(Option 4) Clients taking methotrexate should avoid alcohol as the prescription drug is hepatotoxic and drinking alcohol increases the risk for hepatotoxicity.

Educational objective:
Methotrexate is a disease-modifying antirheumatic drug used to treat rheumatoid arthritis and psoriasis. The major adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity, congenital abnormalities, and fetal death.

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Test Id: 80941960
QId: 31557 (921666)
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The nurse is caring for a client with an inflammatory bowel disease exacerbation. The client is prescribed sulfasalazine. Which finding would require a priority follow-up by the nurse?1. Elevated erythrocyte sedimentation rate [33%]
2. Hemoglobin 10.5 g/dL (105 g/L) [27%]
3. Urine with yellow-orange discoloration [6%]
4. Urine specific gravity 1.035 [32%]
Omitted
Correct answer
4
Answered correctly
32% Time: 1 seconds
Updated: 01/17/2017
Explanation:

Sulfasalazine (Azulfidine) contains sulfapyridine and aspirin (5-ASA) and is used as a topical gastrointestinal anti-inflammatory and immunomodulatory agent in inflammatory bowel disease (IBD). When the 5-ASA is combined with the sulfa preparation, the drug does not become absorbed until it reaches the colon. Dehydration is a risk with IBD as the client can have up to 20 diarrheal stools a day. The client usually does not feel thirsty until after there is a fluid volume deficit. Sulfa can crystallize in the kidney if the client is dehydrated.

Normal urine specific gravity is 1.003-1.030. Elevated specific gravity can indicate concentrated urine and be a sign of dehydration (Option 4).

(Option 1) Due to the inflammatory nature of IBD, erythrocyte sedimentation rate, C-reactive protein, and white blood cells can be elevated. This is an expected finding during an exacerbation.

(Option 2) Mild to moderate anemia (normal hemoglobin 13.2-17.3 g/dL [132-173 g/L] for males, 11.7-15.5 g/dL [117-155 g/L] for females) is common with most chronic inflammatory conditions (eg, rheumatoid arthritis, IBD) as the body cannot use the available iron in bone marrow with active inflammation. In addition, IBD exacerbation usually includes bloody stools, resulting in blood loss iron deficiency anemia. This needs follow-up but is not a priority.

(Option 3) Yellow-orange discoloration of the client’s skin and urine is an expected side effect from the drug.

Educational objective:
Dehydration is a concern with sulfasalazine and most other “sulfa” medications due to the risk of crystal formation in the kidney. It is also a potential complication of inflammatory bowel disease.

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Test Id: 80941960
QId: 30961 (921666)
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The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client. The nurse knows that the parent understands the teaching when the parent does which of the following?1. Allows the client to sip the medication from a cup [0%]
2. Expels the medication from a dropper onto the back of the tongue [13%]
3. Mixes the medication in the infant’s bottle of formula [1%]
4. Using a syringe, administers the medication in small amounts into the back of the cheek [83%]
Omitted
Correct answer
4
Answered correctly
83% Time: 1 seconds
Updated: 04/08/2017
Explanation:

Using a syringe to measure the medication is the most accurate technique to ensure that the proper amount of medication is being administered. The correct procedure for administering oral medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk for choking and ensures that all the medication is consumed.

(Option 1) Although cup feeding may be a method used to feed infants in specific cases, medication administration requires a more accurate measurement. A syringe can provide an accurate measurement and decrease the risk of waste due to the infant’s spitting or drooling.

(Option 2) Infants have a decreased gag reflex. Dispensing medication onto the back of the tongue would increase the risk for aspiration of the medication.

(Option 3) It is very important for the infant to receive the entire dose of the medication. Medication should never be mixed in a bottle of formula as the infant may not consume the entire amount.

Educational objective:
The extrusion reflex and a decreased gag reflex in infants less than 4 months old increase the risk for choking and aspiration. Instilling the medication using a syringe at the back of the cheek decreases the risk for choking and ensures that the correct amount of medication is consumed.

Block Time Remaining: 00:00:48
TUTOR
Test Id: 80941960
QId: 34034 (921666)
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A nurse is observing a nursing student reinforce teaching to a client on how to take sucralfate. Which statement made by the student would require intervention by the nurse?1. “Take this in the morning 1 hour before breakfast.” [18%]
2. “Take this with your other stomach medications.” [61%]
3. “Take your heart medication 2 hours after sucralfate.” [12%]
4. “You might experience constipation while taking this.” [7%]
Omitted
Correct answer
2
Answered correctly
61% Time: 1 seconds
Updated: 03/25/2017
Explanation:

Sucralfate is an oral medication that forms a protective layer in the gastrointestinal mucosa, which provides a physical barrier against stomach acids and enzymes. It doesn’t neutralize or reduce acid production. It is prescribed to treat and prevent both stomach and duodenal ulcers. This medication is generally prescribed 1 hour before meals and at bedtime and, for effective results, is administered on an empty stomach with a glass of water (Option 1).

Sucralfate also binds with many other medications (eg, digoxin, warfarin, phenytoin) and reduces their bioavailability. Therefore, all other medications are generally administered at least 1-2 hours before or after sucralfate administration (Option 3). Constipation is a common side effect of this medication (Option 4).

(Option 2) Sucralfate forms a better protective layer at low pH. Therefore, antacids or other acid-reducing medications (eg, proton pump inhibitors or H2 blockers) should not be taken 30 minutes before or after taking sucralfate to avoid altered absorption.

Educational objective:
Sucralfate should be taken on an empty stomach with a glass of water. Sucralfate forms a better protective layer at low pH. Therefore, acid-reducing agents (eg, antacids, proton pump inhibitors, H2 blockers) should be avoided 30 minutes before and after administration to avoid altered absorption. Other medications should be administered 1-2 hours before or after sucralfate.

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Test Id: 80941960
QId: 32209 (921666)
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The nurse reviews the medication administration records and laboratory results for assigned clients. Which medication requires that the health care provider be notified before administration?1. Calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L) [11%]
2. Clopidogrel for a client with a platelet count of 70,000/mm3 (70 × 109/L) [72%]
3. Magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.5 mmol/L) [8%]
4. Metformin for a client with a glycosylated hemoglobin level of 11% [7%]
Omitted
Correct answer
2
Answered correctly
72% Time: 1 seconds
Updated: 02/17/2017
Explanation:

Clopidogrel (Plavix) is a platelet aggregation inhibitor used to prevent blood clot formation in clients with recent myocardial infarction, acute coronary syndrome, cardiac stents, stroke, or peripheral vascular disease. Because it can cause thrombocytopenia and increase the risk for bleeding, the nurse should notify the health care provider (HCP) of the low platelet count (normal: 150,000-400,000/mm3 [150-400 × 109/L]) before administering clopidogrel.

(Option 1) Calcium acetate (PhosLo) is used to control hyperphosphatemia in clients with end-stage kidney disease by binding to phosphate in the intestines and excreting it in the stool. Because the phosphate level is high (normal adult: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]), it is not necessary to notify the HCP.

(Option 3) Magnesium sulfate is used to correct hypomagnesemia and treat torsades de pointes and seizures associated with eclampsia. Because the magnesium level is low (normal adult: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), it is not necessary to notify the HCP.

(Option 4) Metformin (Glucophage) is a first-line drug for the control of blood sugar in clients with type 2 diabetes mellitus. Glycosylated hemoglobin (A1C) measures the total hemoglobin that has glucose attached to it, expressed as a percentage. Glucose remains attached to the red blood cell for the life of the cell (about 120 days) and reflects glycemic control over an extended period. The recommended A1C level for a client with diabetes is <7%. Although the A1C level is elevated, the medication would be administered regardless of the result (unless the client is hypoglycemic), so it is not necessary to notify the HCP.

Educational objective:
Clopidogrel (Plavix) can cause thrombocytopenia (platelet count <150,000/mm3 [150 × 109/L]) and increase a client’s risk for bleeding.

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Test Id: 80941960
QId: 34029 (921666)
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The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs further investigation?1. “I am taking an antibiotic for a urinary tract infection.” [41%]
2. “I had a negative tuberculosis skin test 2 weeks ago.” [8%]
3. “I just received my yearly flu shot a week ago.” [10%]
4. “I will continue taking naproxen at night to help with pain.” [39%]
Omitted
Correct answer
1
Answered correctly
41% Time: 1 seconds
Updated: 03/27/2017
Explanation:

Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that suppress the inflammatory response in autoimmune diseases such as rheumatoid arthritis, Crohn disease, and psoriasis. Due to the immunosuppressive action of TNF inhibitors, clients taking these drugs are at increased risk for infection. A client with current, recent, or chronic infection should not take a TNF inhibitor (Option 1).

(Option 2) The immunosuppressive action of TNF inhibitors can activate latent tuberculosis (TB). Therefore, a tuberculin skin test (TST) should be administered prior to beginning TNF inhibitor therapy, and clients who test positively for latent TB must also undergo treatment for TB before starting therapy. Clients should have a TST every year while receiving the drug.

(Option 3) Clients taking immunosuppressive TNF inhibitors (eg, adalimumab) should receive an annual inactivated (injectable) influenza vaccine to reduce the risk of contracting the flu virus. Clients taking TNF inhibitors or other immunosuppressants are at risk for infection and therefore should not receive live attenuated vaccines.

(Option 4) Many clients with rheumatoid arthritis use nonsteroidal anti-inflammatory medications (eg, celecoxib, naproxen) in conjunction with antirheumatic and/or targeted therapies (eg, methotrexate, adalimumab, etanercept) to effectively treat pain and minimize inflammation.

Educational objective:
Clients with infection should not take tumor necrosis factor (TNF) inhibitors (eg, infliximab, adalimumab, etanercept) as these suppress the immune response. Before starting drug therapy, clients should be tested for tuberculosis and receive the inactivated (injectable) influenza vaccine. Clients taking TNF inhibitors should avoid live vaccines.

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TUTOR
Test Id: 80941960
QId: 30649 (921666)
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A client is being discharged on enoxaparin therapy following total knee replacement surgery. Which teaching instruction does the nurse include in the teaching plan?1. “Eliminate green, leafy, vitamin K-rich vegetables from your diet.” [18%]
2. “Mild bruising or redness may occur at the injection site.” [44%]
3. “You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort.” [4%]
4. “You will need PT/INR assessments at regular intervals while on enoxaparin therapy.” [31%]
Omitted
Correct answer
2
Answered correctly
44% Time: 1 seconds
Updated: 03/21/2017
Explanation:

Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) that may be prescribed for up to 10-14 days following hip and knee surgery to prevent deep venous thrombosis. Discharge teaching for the client on enoxaparin therapy includes:

Pinch an inch of skin upwards and insert the needle at a 90-degree angle into the fold of skin.
Continue to hold the skin fold throughout the injection and then remove the needle at a 90-degree angle.
Mild pain, bruising, irritation, or redness of the skin at the injection site is common. Do NOT rub the site with the hand. Using an ice cube on the injection site can provide relief (Option 2).
Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements (Ginkgo biloba, vitamin E) without health care provider approval as these can increase the risk of bleeding (Option 3).
Monitor complete blood count to assess for thrombocytopenia.
(Option 1) Vitamin K-rich foods do not need to be eliminated from the diet during enoxaparin therapy; prothrombin time (PT) and international normalized ratio (INR) are not affected. However, PT and INR are decreased when a vitamin K antagonist (eg, warfarin [Coumadin]) is taken with vitamin K-rich foods.

(Option 4) Routine coagulation studies (eg, PT, INR, partial thromboplastin time [PTT]) do not need to be monitored in a client who is taking enoxaparin. However, periodic assessment of complete blood count (CBC) is usually required to monitor for hidden bleeding and thrombocytopenia (especially in older clients with renal insufficiency).

Educational objective:
LMWH (Enoxaparin) requires monitoring of CBC (thrombocytopenia) but not coagulation studies. Administration of unfractionated heparin requires monitoring with PTT, whereas warfarin requires PT/INR monitoring. Clients on these medications should avoid aspirin and NSAIDs.

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Test Id: 80941960
QId: 30932 (921666)
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The nurse develops a teaching plan for a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis (TB). Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include?1. Notify the health care provider if your urine is red [16%]
2. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication [9%]
3. Wear eyeglasses instead of soft contact lenses while taking this medication [70%]
4. You can stop taking the medications as soon as one sputum culture comes back normal [3%]
Omitted
Correct answer
3
Answered correctly
70% Time: 0 seconds
Updated: 05/28/2017
Explanation:

Active TB is treated with combination drug therapy. Isoniazid causes hepatotoxicity and peripheral neuropathy. Rifampin (Rifadin) also causes hepatotoxicity. Therefore, baseline liver function tests should be obtained. Clients should be advised to watch for signs and symptoms of hepatotoxicity (eg, jaundice, anorexia). Ethambutol causes ocular toxicity, and clients will need frequent eye examinations.

A teaching plan for a client prescribed rifampin includes these additional instructions:

Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. Tears can turn red, making contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenses while taking this medication.
Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of oral contraceptives.
(Option 1) Red urine is an expected finding with rifampin use; clients should not be concerned.

(Option 2) Clients should be advised to not consume alcohol and drugs that can increase the risk for hepatotoxicity (eg, acetaminophen) during long-term use of this drug.

(Option 4) The effectiveness of treatment for active TB is determined by 3 negative sputum cultures and chest x-ray. If the entire course of therapy (6-9 months) is not completed, reinfection, spread to others, and development of resistant strains of TB bacteria can result.

Educational objective:
Common potential side effects of rifampin include hepatotoxicity, red-orange discoloration of body fluids, and increased metabolism of some drugs (eg, oral contraceptives, hypoglycemics, warfarin).
.

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TUTOR
Test Id: 80941960
QId: 31764 (921666)
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The health care provider prescribes amoxicillin/clavulanate (liquid) twice a day for a child with acute sinusitis. What instructions are most important for the parents? Select all that apply.1. Administer it with food if nausea or diarrhea develops
2. Complete the medication course even if the child is better
3. Expect a rash, which is normal, as a side effect
4. Shake the medicine well before use
5. Use a household spoon to measure the dose
Omitted
Correct answer
1,2,4
Answered correctly
60% Time: 1 seconds
Updated: 04/20/2017
Explanation:

Amoxicillin/clavulanate belongs to aminopenicillin group and is often used to treat respiratory infections. Instructions for parents about amoxicillin include:

The medication may be taken with or without food as food does not affect absorption
The most common side effects of this medication are nausea, vomiting, and diarrhea. If nausea or diarrhea develops, the medicine may be administered with food to decrease the gastrointestinal side effects (Option 1).
Shake the liquid well prior to administration. Administer at evenly spaced intervals throughout the day to maintain therapeutic blood levels (Option 4).
Ensure that the child receives the full course of therapy; do not discontinue the medication if the child is feeling better or symptoms have resolved (Option 2).
(Option 3) Rash, itching, dyspnea, or facial/laryngeal edema may indicate an allergic reaction, and the medication should be discontinued.

(Option 5) Pediatric liquid medications are often dispensed with a measuring device designed to administer the exact dose prescribed. The following calibrated devices may be included: dropper, oral syringe, plastic measuring cup, or measuring spoon.

Educational objective:
Amoxicillin/clavulanate in liquid form should be shaken well prior to administration; the correct dose is administered using a calibrated measuring device. It is taken with or without food, at evenly spaced intervals, and until all the medication is consumed. If nausea or diarrhea develops, the medication may be administered with food.

.

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TUTOR
Test Id: 80941960
QId: 31758 (921666)
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The nurse is caring for a client on IV heparin infusion and oral warfarin. Current laboratory values indicate that the client’s aPTT is 5 times the control value and the PT/INR is 2 times the control value. What action does the nurse anticipate?1. Clarify vegetable consumption with client [7%]
2. Decrease the heparin rate [63%]
3. Decrease the warfarin dose [5%]
4. Obtain an order for vitamin K injection [24%]
Omitted
Correct answer
2
Answered correctly
63% Time: 0 seconds
Updated: 04/03/2017
Explanation:

The anticoagulant heparin has to be administered intravenously or subcutaneously. The duration is 2-6 hours intravenously and 8-12 hours subcutaneously. It is measured by the aPTT (activated partial thromboplastin time) laboratory value. Warfarin (Coumadin) is taken orally, with onset/therapeutic effects reached after 2-7 days. It is measured by prothrombin time (PT) or International Normalized Ratio (INR).

The therapeutic range for aPTT or PT/INR is generally 1.5-2.0 times the control value (up to 3 times the control value at times). An aPTT value above the therapeutic range places the client at risk for excess bleeding. The heparin administration would need to be stopped or decreased.

(Option 1) Clients on warfarin must eat the same amount of dark green leafy vegetables because these foods contain vitamin K and will alter the effects of warfarin. The PT/INR is at therapeutic level so there is no concern related to this client’s diet.

(Option 3) The warfarin dose has achieved the therapeutic range for PT/INR and does not need adjustment.

(Option 4) Vitamin K is the antidote for warfarin; the antidote for heparin is protamine sulfate. However, due to the short half-life of heparin, usually the dose is just held instead of administering an antidote when the values are too high.

Educational objective:
The therapeutic effect from heparin or warfarin (Coumadin) is 1.5-2.0 times the control value. Heparin is measured with aPTT and warfarin is measured with PT/INR. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.

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TUTOR
Test Id: 80941960
QId: 31848 (921666)
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The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment?1. C-reactive protein (CRP) [46%]
2. Prothrombin time (PT) [29%]
3. Serum LDL cholesterol [3%]
4. Tuberculin skin test (TST) [20%]
Omitted
Correct answer
4
Answered correctly
20% Time: 0 seconds
Updated: 04/28/2017
Explanation:

TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies.

Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these drugs. Otherwise, TB reactivation would occur (Option 4).

(Option 1) CRP is a non-specific test used to detect acute or chronic inflammation in the body. CRP can be used to evaluate the effectiveness of medications that decrease inflammation. An elevation would be expected in clients with RA, especially during a flare, but it is not the most important test result to check before initiating therapy.

(Options 2 and 3) LDL cholesterol and PT are unrelated to the administration of these medications.

Educational objective:
Major adverse effects of biologic disease-modifying TNF inhibitor drugs (eg, etanercept, infliximab, adalimumab) include severe infections and bone marrow suppression. TB reactivation is a major concern. Therefore, all clients must receive a TST to rule out latent TB.

Block Time Remaining: 00:00:53
TUTOR
Test Id: 80941960
QId: 30874 (921666)
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ExhibitA client with cancer is to receive a third dose of cisplatin. The client’s laboratory results are shown in the exhibit. Which factor would be important for the nurse to assess before confirming the dose with the health care provider? Click on the exhibit button for additional information.

1. Blood pressure [7%]
2. Capillary refill [1%]
3. Skin turgor [1%]
4. Urine output [88%]
Omitted
Correct answer
4
Answered correctly
88% Time: 1 seconds
Updated: 03/15/2017
Explanation:

Urine output is a good indicator of renal function. Cisplatin is an antineoplastic medication that can cause renal toxicity. The client’s elevated BUN (normal 6-20 mg/dL [2.1-7.1 mmol/L]) may be due to dehydration (prerenal disease) or decreased kidney function. The creatinine is also elevated (normal 0.6-1.3 mg/dL [53-115 µmol/L]), an indication of kidney injury. In addition to laboratory results, the health care provider will also need to know urine output. The medication dosage may then be adjusted or discontinued.

(Option 1) Blood pressure may be part of the assessment of kidney function, but multiple disorders can cause changes in blood pressure. Urine output is a better indicator of renal function.

(Option 2) Capillary refill is used to assess the circulatory system and is not a good indicator of a decrease in renal function.

(Option 3) Skin turgor is important in assessing hydration status. However, this client’s laboratory results indicate the possibility of renal toxicity from the cisplatin. Urine output is a better indicator of renal function.

Educational objective:
Cisplatin is an antineoplastic drug that may cause kidney injury. Assessment of renal function includes laboratory values and urine output.

Block Time Remaining: 00:00:55
TUTOR
Test Id: 80941960
QId: 32020 (921666)
43 of 53
A A A
The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next?1. Check vital signs [38%]
2. Maintain IV access with normal saline [54%]
3. Notify the health care provider [6%]
4. Recheck identification labels and numbers [0%]
Omitted
Correct answer
2
Answered correctly
54% Time: 1 seconds
Updated: 03/13/2017
Explanation:

Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions include:

Stop transfusion immediately and disconnect tubing at the catheter hub.
Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse (Option 2).
Notify health care provider (HCP) and blood bank.
Monitor vital signs.
Recheck labels, numbers, and the client’s blood type.
Treat client’s symptoms according to the HCP’s prescription.
Collect blood and urine specimens to evaluate for hemolysis.
Return blood and tubing set to the blood bank for additional testing.
Complete necessary facility paperwork to document the reaction.
(Option 1) Monitoring vital signs would be the step after ensuring IV access, administering normal saline, and notifying the HCP.

(Option 3) The nurse should ensure continued IV access before notifying the HCP. The HCP will likely prescribe IV medications (eg, vasopressors, antihistamines, corticosteroids) to treat the transfusion reaction, so a patent IV is critical.

(Option 4) Mislabeling blood and administering the wrong blood type are the most common causes of a transfusion reaction. However, maintaining IV access takes priority over investigating a potential clinical error.

Educational objective:
During a blood transfusion reaction, the nurse should immediately stop the transfusion and initiate normal saline to maintain IV access and prevent hypotension and vascular collapse.

Block Time Remaining: 00:00:56
TUTOR
Test Id: 80941960
QId: 31368 (921666)
44 of 53
A A A
A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What interventions should the nurse implement? Select all that apply.1. Continue heparin infusion and recheck aPTT in 6 hours
2. Prepare to administer vitamin K
3. Redraw blood for laboratory tests
4. Review guidelines for administration of protamine
5. Stop infusion of heparin and notify the health care provider (HCP)
Omitted
Correct answer
4,5
Answered correctly
34% Time: 1 seconds
Updated: 02/06/2017
Explanation:

Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2.0 times the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin).

(Option 1) Continuing the heparin infusion will put the client at risk for a severe bleeding episode.

(Option 2) Vitamin K is the reversal agent for warfarin.

(Option 3) There is no reason to redraw blood for laboratory workup at this time as the abnormal aPTT result is consistent with the client’s bleeding. Laboratory studies may need to be redone within 1 hour of stopping the infusion or giving a reversal agent.

Educational objective:
The nurse should stop the infusion of heparin when there is evidence of bleeding. The HCP should be notified immediately and the nurse should be prepared to give protamine if ordered.

Block Time Remaining: 00:00:58
TUTOR
Test Id: 80941960
QId: 34410 (921666)
45 of 53
A A A
The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the health care provider?1. “I don’t have much interest in sex lately.” [1%]
2. “I feel like I might be getting a cold.” [46%]
3. “My periods have been heavy lately.” [39%]
4. “These hot flashes are occurring a lot.” [12%]
Omitted
Correct answer
3
Answered correctly
39% Time: 2 seconds
Updated: 05/22/2017
Explanation:

Selective estrogen receptor modulators (eg, tamoxifen) have differential action in different tissues (mixed agonist/antagonist). In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of estrogen-receptive breast cancer cells.

However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in premenopausal woman or any bleeding in postmenopausal women can be a sign of endometrial cancer (Option 3). Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein thrombosis).

Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. Therefore, monitoring for life-threatening side effects is very important.

(Options 1 and 4) Because tamoxifen blocks estrogen receptors, it can cause symptoms of menopause. Vaginal dryness, hot flashes, and decreased libido (sexual dysfunction) are common and would be discussed after addressing more concerning symptoms.

(Option 2) Tamoxifen is not associated with significant immunosuppression although it may rarely cause leukopenia.

Educational objective:
Tamoxifen has mixed agonist and antagonist activity on estrogen receptors in various tissues. It is used for several years in estrogen-responsive breast cancer. However, it is associated with increased risk of endometrial cancer and venous thromboembolism. Menopausal symptoms (eg, vaginal dryness, hot flashes) are the most common side effect.

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TUTOR
Test Id: 80941960
QId: 32043 (921666)
46 of 53
A A A
The nurse is caring for a client who had surgery yesterday. When administering omeprazole, the client asks “What is that for? I don’t take it at home.” Which reply by the nurse is most appropriate?1. “Omeprazole helps prevent nausea by making your stomach empty faster.” [6%]
2. “Omeprazole helps prevent you from developing an ulcer due to the stress of surgery.” [64%]
3. “Omeprazole protects you from getting an infection while on antibiotics.” [2%]
4. “This medication will treat your gastroesophageal reflux disease (GERD).” [26%]
Omitted
Correct answer
2
Answered correctly
64% Time: 1 seconds
Updated: 12/20/2016
Explanation:

Omeprazole is a proton pump inhibitor (PPI) that suppresses the production of gastric acid by inhibiting the proton pump in the parietal cells of the stomach. In most hospitalized clients without a history of GERD or ulcers, PPIs are prescribed to prevent stress ulcers from developing during surgery or a major illness.

Although evidence has shown that two-thirds of clients who receive PPIs do not need them, these medications are still widely prescribed in hospitalized clients. PPIs can be identified by their “-prazole” ending (eg, pantoprazole, lansoprazole, esomeprazole).

(Option 1) Metoclopramide (Reglan) is not a PPI. It decreases postoperative nausea by promoting gastric emptying.

(Option 3) PPIs may be associated with an increased risk of Clostridium difficile infection with antibiotic use.

(Option 4) The client does not take this medication at home. The nurse is assuming that the client has a history of GERD rather than assessing for this condition first.

Educational objective:
PPIs such as omeprazole are often prescribed to hospitalized clients without GERD or ulcers to prevent stress ulcers from developing during surgery or a major illness.

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TUTOR
Test Id: 80941960
QId: 31752 (921666)
47 of 53
A A A
The nurse is caring for a client with cirrhosis who has hepatic encephalopathy. The client is prescribed lactulose. Which assessment by the nurse will most likely indicate that the medication has achieved the desired therapeutic effect?1. Higher potassium level [2%]
2. Improved mental status [70%]
3. Looser stool consistency [13%]
4. Reduced abdominal distension [13%]
Omitted
Correct answer
2
Answered correctly
70% Time: 1 seconds
Updated: 04/30/2017
Explanation:

Hepatic encephalopathy in cirrhosis results from higher serum ammonia levels that cause neurotoxic effects, including mental confusion. Oral lactulose is given to reduce the ammonia by trapping it in the gut and then expelling it with a laxative effect. Improved mental status implies reduction of ammonia levels.

(Option 1) Clients with cirrhosis typically have hypokalemia due to hyperaldosteronism (as aldosterone is not metabolized by the damaged liver). Hypokalemia can also result from diuretics used to treat the fluid retention and ascites. Lactulose is not intended to treat this pathology.

(Option 3) Lactulose is a laxative. In cirrhosis, constipation (which allows more ammonia to be absorbed) and hard stool (which irritates hemorrhoids) are to be avoided. However, the main purpose of lactulose is expelling the ammonia, with resulting benefits.

(Option 4) Abdominal distension (ascites) in cirrhosis is treated with diuretics (eg, furosemide, spironolactone) and paracentesis. Lactulose does not influence this pathology or symptom.

Educational objective:
Lactulose is a laxative used to trap and expel ammonia in clients with cirrhosis who have hepatic encephalopathy. Elevated ammonia levels cause mental confusion.

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TUTOR
Test Id: 80941960
QId: 31527 (921666)
48 of 53
A A A
Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply.1. Black cohosh
2. Garlic
3. Ginger
4. Ginkgo biloba
5. Hawthorn
Omitted
Correct answer
2,3,4
Answered correctly
40% Time: 1 seconds
Updated: 04/02/2017
Explanation:

Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to elective surgery, but they may not know that some herbal supplements can increase bleeding risk. The nurse should question the client specifically about the use of herbal supplements.

Herbal supplements that can increase risk for bleeding include:

Gingko biloba
Garlic
Ginseng
Ginger
Feverfew
(Option 1) Black cohosh is used for treatment of menopausal symptoms. The main side effect is liver injury.

(Option 5) Hawthorn extract is used to control hypertension and mild to moderate heart failure. Hawthorn use does not increase the risk of bleeding.

Educational objective:
Use of herbal supplements such as ginkgo biloba, garlic, ginseng, ginger, and feverfew should be reported to the health care provider before surgery as they may increase the risk of bleeding.

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TUTOR
Test Id: 80941960
QId: 31850 (921666)
49 of 53
A A A
The home health nurse reviews the laboratory results for 4 clients. Which laboratory value is most important for the nurse to report to the health care provider?1. Client with Clostridium difficile infection receiving metronidazole has a white blood cell count of 15,000/mm3 (15.0 x 109/L) [7%]
2. Client with liver cirrhosis has an International Normalized Ratio of 1.5 [19%]
3. Client with mild asthma exacerbation receiving prednisone has a blood glucose of 250 mg/dL (13.9 mmol/L) [39%]
4. Client with rheumatoid arthritis taking adalimumab has a white blood cell count of 14,000/mm3 (14.0 x 109/L) [33%]
Omitted
Correct answer
4
Answered correctly
33% Time: 1 seconds
Updated: 04/02/2017
Explanation:

Adalimumab (Humira) is a tumor necrosis factor (TNF) inhibitor, a biologic disease-modifying antirheumatic drug (DMARD) classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade]) and include immunosuppression and infection (eg, current, reactivated). An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately.

(Option 1) This client with Clostridium difficile infection will have an elevated white blood cell count. The client is receiving appropriate therapy (eg, metronidazole, oral vancomycin). The nurse will need to monitor the white cell count and, if it keeps increasing, report it.

(Option 2) The liver produces most blood clotting factors. Clients with liver cirrhosis will lose this ability and are at risk for bleeding. This client’s International Normalized Ratio is mildly elevated (normal 0.75-1.25), which is expected with cirrhosis.

(Option 3) Corticosteroids increase blood glucose. This is expected, and the client may need treatment if the glucose levels are markedly increased for a prolonged period. Most clients with asthma exacerbation are expected to take a 5- to 7-day course of steroids.

Educational objective:
Adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) are common tumor necrosis factor inhibitor, biologic disease-modifying antirheumatic drugs. Major adverse effects include immunosuppression and infection.
.

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TUTOR
Test Id: 80941960
QId: 30008 (921666)
50 of 53
A A A
A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediately to the health care provider? Select all that apply.1. Excess blinking of eyes
2. Dry mouth
3. Dull headache
4. Lip smacking
5. Puffing of cheeks
Omitted
Correct answer
1,4,5
Answered correctly
30% Time: 1 seconds
Updated: 04/30/2017
Explanation:

Metoclopramide (Reglan) is prescribed for the treatment of delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects, including tardive dyskinesia (TD). This is especially common in older adults with long-term use. The client should call the health care provider immediately if TD symptoms develop, including uncontrollable movements such as:

Protruding and twisting of the tongue
Lip smacking
Puffing of cheeks
Chewing movements
Frowning or blinking of eyes
Twisting fingers
Twisted or rotated neck (torticollis)
(Options 2 and 3) Common side effects of metoclopramide such as sedation, fatigue, restlessness, headache, sleeplessness, dry mouth, constipation, and diarrhea need not be reported to the health care provider.

Educational objective:
Both antipsychotic medication and metoclopramide use can be associated with significant extrapyramidal side effects (eg, tardive dyskinesia). The nurse should teach the client the importance of immediately communicating these to the health care provider.

Block Time Remaining: 00:01:05
TUTOR
Test Id: 80941960
QId: 34086 (921666)
51 of 53
A A A
A client in the emergency department is being discharged with a prescription for trimethoprim-sulfamethoxazole. Which statement by the client would indicate a need for further evaluation?1. “I developed a whole-body rash while on glyburide.” [47%]
2. “I drink at least 5 large bottles of water daily.” [3%]
3. “I had to stop using lisinopril due to a bad cough.” [19%]
4. “I have a birth control implant in place.” [29%]
Omitted
Correct answer
1
Answered correctly
47% Time: 2 seconds
Updated: 02/27/2017
Explanation:

Trimethoprim-sulfamethoxazole (Bactrim) is a sulfonamide antibiotic, commonly referred to as a sulfa drug. These antibiotics are prescribed to treat bacterial infections (eg, urinary tract infections). Contraindications include hypersensitivity to sulfa drugs, and pregnancy or breastfeeding.

Glyburide is a sulfonylurea and has the potential to cause a sulfa cross-sensitivity reaction. Commonly used diuretics (eg, thiazides, furosemide) are also sulfa derivatives and can cause cross-sensitivity reaction. Although this reaction is uncommon, an alternate antibiotic, if possible, can be prescribed by the health care provider.

(Option 2) Crystalluria is a potential adverse effect of sulfa medications. Clients should drink at least 2-3 L of water daily to prevent crystalluria.

(Option 3) Angiotensin-converting enzyme inhibitors (eg, lisinopril) can produce an intractable cough. The only way to relieve this adverse effect is to discontinue the medication. There is no cross-reactivity with sulfa medications.

(Option 4) Birth control implants (eg, IMPLANON, NEXPLANON) are progestin rods placed subdermally in the upper arm that provide contraception for up to 3 years. They are not contraindicated with concurrent trimethoprim-sulfamethoxazole use.

Educational objective:
Clients prescribed sulfa antibiotics (eg, trimethoprim-sulfamethoxazole [Bactrim]) should be assessed for allergies to sulfa drugs and sulfonylurea medications, such as glyburide, due to potential cross-sensitivity reactions.

.

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TUTOR
Test Id: 80941960
QId: 30675 (921666)
52 of 53
A A A
A client diagnosed with trichomonal vaginal infection (trichomoniasis) is prescribed metronidazole. Which of the following is essential for the nurse to teach? Select all that apply.1. Avoid alcohol while taking this medication
2. Perform vaginal douche for 7-10 days
3. Use birth control pills to prevent recurrence of infection
4. Your partner(s) must be treated simultaneously
5. Your urine can change to a deep red-brown color
Omitted
Correct answer
1,4,5
Answered correctly
47% Time: 1 seconds
Updated: 04/29/2017
Explanation:

Trichomoniasis is a sexually transmitted infection (STI). Many women with trichomoniasis are asymptomatic but can have profuse frothy gray or yellow-green vaginal discharge with a fishy odor. Small red lesions (strawberry) may be present in the vagina or cervix. Pruritus is common.

Metronidazole (Flagyl) is the initial drug of choice. Clients should avoid alcohol while taking metronidazole and for 24 hours after completion of the therapy due to a reaction that includes flushing, nausea/vomiting, and abdominal pain. The medication can cause a metallic taste and turn the urine a deep red-brown color.

It is essential to treat the partner(s) at the same time to avoid reinfection. Clients should abstain from sexual intercourse until the infection is cleared, usually about 1 week after treatment.

(Option 2) Routine vaginal douching (with a mixture of water and vinegar) is not recommended as it increases the risk of infections such as bacterial vaginosis.

(Option 3) Birth control pills do not protect against transmission of STIs. The use of condoms can help prevent the spread of infection.

Educational objective:
Trichomoniasis is an STI. Expected symptoms include yellow-green, frothy discharge with a fishy odor and an accompanying itch. Metronidazole is the initial drug of choice. Clients should avoid alcohol while on metronidazole, which can make the urine darker and cause a metallic taste. Partners must be treated simultaneously.

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TUTOR
Test Id: 80941960
QId: 30762 (921666)
53 of 53
A A A
ExhibitThe nurse is in the medication room preparing medications due at 1800 for a client who had an aortic valve replacement 5 days ago. Which action should the nurse implement first? Click on the exhibit button for additional information.

1. Assess the client’s most recent potassium level [11%]
2. Check the client’s INR [57%]
3. Measure the client’s vital signs [6%]
4. Verify the client’s name and date of birth at the bedside [24%]
Omitted
Correct answer
2
Answered correctly
57% Time: 1 seconds
Updated: 03/08/2017
Explanation:

Warfarin (Coumadin) is an anticoagulant given to clients with a mechanical valve replacement. To determine if the client is receiving an appropriate dose, the INR needs to be checked regularly. A therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. The nurse should not administer warfarin without checking the INR first. If the INR is >3.5, the nurse should hold the dose and contact the health care provider for further direction.

(Option 1) Although the nurse should assess the client’s potassium level prior to administering supplemental potassium, this medication was scheduled at 0900 and is not indicated at this time. There is no pharmacologic interaction between potassium levels and warfarin.

(Option 3) The client’s vital signs should be measured routinely, but administration of warfarin and simvastatin are not contingent on the results.

(Option 4) Verification of the client’s name and date of birth is an important safety measure that should be performed at the bedside, immediately before medication administration.

Educational objective:
The nurse should check the client’s most recent INR level prior to administering warfarin. A therapeutic INR is 2.5-3.5 for clients with mechanical heart valves. The nurse should hold the dose and contact the health care provider if the INR is >3.5.

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TUTOR
Test Id: 80944027
QId: 30982 (921666)
1 of 54
A A A
The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider?1. “I am feeling unsteady when I walk.” [30%]
2. “I am getting up to urinate about 4 times during the night.” [4%]
3. “I have a metallic taste in my mouth when I eat.” [25%]
4. “My gums are getting so puffy and red.” [40%]
Omitted
Correct answer
1
Answered correctly
30% Time: 1 seconds
Updated: 12/08/2016
Explanation:

Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases.

Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin.

(Option 2) Nocturia is an expected side effect of diuretics but not phenytoin. Nocturia is also seen with diabetes mellitus and benign prostatic hyperplasia.

(Option 3) Metallic taste in the mouth is often seen with metronidazole but not with phenytoin.

(Option 4) Gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity. It occurs more often in clients <23 years of age who are prescribed >500 mg/day. Good oral hygiene can limit symptoms.

Educational objective:
Phenytoin, an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin drug-induced toxicity involve the central nervous system and include ataxia, nystagmus, slurred speech, and decreased alertness.

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TUTOR
Test Id: 80944027
QId: 31857 (921666)
2 of 54
A A A
A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should teach this client about which possible side effect?1. Constipation [12%]
2. Sedation [31%]
3. Sexual dysfunction [50%]
4. Weight loss [4%]
Omitted
Correct answer
3
Answered correctly
50% Time: 1 seconds
Updated: 04/29/2017
Explanation:

Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat major depression and anxiety disorders. SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) are generally well tolerated except for sexual dysfunction. Clients often underreport this side effect. However, when asked specifically, over 50% of clients taking SSRIs may be experiencing some type of sexual dysfunction. This can be a decrease in sexual desire, arousal, or orgasm and may vary by gender. The nurse should discuss this with the client. The side effect may decrease or cease after a 2- to 4-week waiting period for the therapeutic effect, or the client may be able to switch to a different antidepressant medication (eg, bupropion).

(Option 1) Constipation is uncommon with SSRIs. Drugs with anticholinergic activity (eg, tricyclic antidepressants such as amitriptyline) may result in constipation or urinary retention.

(Option 2) Sedation is a common side effect of benzodiazepines (eg, alprazolam, lorazepam, diazepam, and chlordiazepoxide), first generation antihistamines, and narcotic medications. SSRIs may cause insomnia.

(Option 4) Weight gain is a common side effect of most SSRIs, especially with long-term therapy.

Educational objective:
SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) can cause sexual dysfunction. The client should be encouraged to report this to the health care provider if they are still present 2-4 weeks after treatment initiation.

Block Time Remaining: 00:00:04
TUTOR
Test Id: 80944027
QId: 31138 (921666)
3 of 54
A A A
A client was prescribed phenytoin 100 mg orally 3 times a day a month ago. The serum phenytoin level is 32 mcg/mL and the nurse notifies the health care provider (HCP). Which action is anticipated from the HCP?1. Administer phenytoin as prescribed [11%]
2. Decrease phenytoin daily dose [72%]
3. Increase phenytoin daily dose [3%]
4. Repeat serum phenytoin level in 2 hours [12%]
Omitted
Correct answer
2
Answered correctly
72% Time: 2 seconds
Updated: 12/12/2016
Explanation:

Phenytoin (Dilantin), an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is 10-20 mcg/mL. In the presence of an elevated reference range (32 mcg/mL), if no seizure activity is observed, the nurse would anticipate the HCP to prescribe a decreased daily dose. The nurse will continue to monitor for signs of toxicity (eg, ataxia, nystagmus, slurred speech, decreased mentation).

(Options 1 and 3) The serum phenytoin level is elevated, so administering the prescribed dose or increasing the dose can raise the level and further increase the risk for drug-induced toxicity.

(Option 4) Repeating the serum phenytoin level in 2 hours will not result in a significant change as the average half-life of the drug is 22 hours.

Educational objective:
Phenytoin (Dilantin) is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin-induced toxicity involve the central nervous system (eg, nystagmus, ataxia, slurred speech, decreased mentation) and can occur when phenytoin plasma levels exceed the therapeutic reference range (10-20 mcg/mL).

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TUTOR
Test Id: 80944027
QId: 31937 (921666)
4 of 54
A A A
ExhibitThe nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? Click on the exhibit button for additional information.

1. Give all medications, including acetaminophen, and reassess in 30 minutes [10%]
2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes [14%]
3. Hold the haloperidol and notify the health care provider (HCP) immediately [61%]
4. Hold the hydrochlorothiazide and notify the HCP immediately [13%]
Omitted
Correct answer
3
Answered correctly
61% Time: 3 seconds
Updated: 01/10/2017
Explanation:

This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the “typical” antipsychotics (eg, haloperidol, fluphenazine). However, even the newer “atypical” antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome.

NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment.

(Option 1) Administering acetaminophen may be appropriate, but it is more important to discontinue the haloperidol and notify the HCP immediately.

(Option 2) Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU).

(Option 4) Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms.

Educational objective:
NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication.

Block Time Remaining: 00:00:08
TUTOR
Test Id: 80944027
QId: 31302 (921666)
5 of 54
A A A
An elderly client with depression is given trazodone. Which statement by the client indicates that additional teaching is needed?1. “I will call the health care provider if I develop a prolonged erection.” [3%]
2. “I will get up slowly, in stages, from supine to standing.” [2%]
3. “I will take this medication at night to avoid daytime drowsiness.” [3%]
4. “It is okay to drink 2 glasses of wine at night.” [90%]
Omitted
Correct answer
4
Answered correctly
90% Time: 1 seconds
Updated: 05/20/2017
Explanation:

Trazodone (Oleptro), a serotonin modulator, is used to treat major depressive disorders. In addition to affecting serotonin levels, the drug blocks alpha and histamine (H1) receptors. Blockade of alpha receptors can cause orthostatic hypotension similar to that from other alpha blockers (eg, terazosin, tamsulosin) used to treat benign prostatic hyperplasia. Blockade of H1 receptors leads to sedation. Therefore, this drug is particularly effective in treating insomnia associated with depression. However, concurrent intake of other medications or substances that cause sedation can be detrimental; these include benzodiazepines (eg, alprazolam, lorazepam, diazepam), sedating antihistamines (eg, chlorpheniramine, hydroxyzine), and alcohol (Option 4).

(Option 1) Priapism is a known serious side effect of trazodone. A client with an erection lasting several hours should go to the hospital.

(Option 2) Clients should be advised to rise from supine to standing slowly, in stages, due to the risk of orthostatic hypotension.

(Option 3) The drug should be taken at bedtime to avoid daytime sedation.

Educational objective:
Trazodone modulates serotonin levels in the brain. In addition, it blocks alpha and H1 receptors, leading to orthostatic hypotension and sedation, respectively. Priapism is another serious side effect, though rare.

Block Time Remaining: 00:00:08
TUTOR
Test Id: 80944027
QId: 32922 (921666)
6 of 54
A A A
The nurse is assessing a client diagnosed with tuberculosis who started taking rifapentine a week ago. Which statement by the client warrants further assessment and intervention by the nurse?1. “I do not want to get pregnant, so I restarted my oral contraceptive last month.” [65%]
2. “I have been taking my medications with breakfast every morning.” [11%]
3. “I should alert my health care provider if I notice yellowing of my skin.” [11%]
4. “Since I started this medicine, my saliva has become a red-orange color.” [11%]
Omitted
Correct answer
1
Answered correctly
65% Time: 0 seconds
Updated: 06/04/2017
Explanation:

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.

Block Time Remaining: 00:00:10
TUTOR
Test Id: 80944027
QId: 30691 (921666)
7 of 54
A A A
The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up?1. Client has 1 emesis of green fluid [12%]
2. Client has had no bowel movement for 2 days [18%]
3. Client falls asleep while talking to the nurse [46%]
4. Client reports experiencing pruritus [22%]
Omitted
Correct answer
3
Answered correctly
46% Time: 2 seconds
Updated: 05/19/2017
Explanation:

Pasero opioid-induced sedation scale
Level of sedation
Nursing intervention
S – Sleeping, easy to rouse
No action necessary
1 – Awake, alert
No action necessary
May increase sedation
2 – Slightly drowsy but easy to rouse
Acceptable, no action necessary
3 – Falls asleep during conversation
Unacceptable
Monitor respiratory status
Notify health care provider to decrease sedation by 25%-50%
4 – Somnolent, minimal or no response to verbal & physical stimuli
Stop sedation
Consider using naloxone
Notify health care provider
Monitor respiratory status
Respiratory depression is the most serious side effect of narcotic medication. Sedation precedes respiratory depression. Falling asleep during a conversation scores “3” on the Pasero Opioid-Induced Sedation Scale (POSS); no additional narcotics should be given to the client. Other classes of drugs (eg, non-steroidal anti-inflammatory medications) can be given if the client is still in pain.

The client will also be at increased risk for respiratory depression if the pain is completely relieved and/or it is night time. No additional narcotics should be given until the client is at level 2 sedation on POSS (eg, slightly drowsy, easily aroused).

(Option 1) Nausea or vomiting is a typical side-effect of narcotic administration, especially when it is given in a larger dose or to the opioid-naïve client. It usually lessens with time and repeat administration. Nausea or vomiting would not be a concern unless it is excessive or severe. The nurse should ensure that the client receives adequate hydration (eg, intravenous fluids, clear liquids, antiemetics).

(Option 2) Constipation is a known side effect of opioid administration and does not lessen with long-term administration. Proactive measures are needed as long as the client is on narcotics. However, large intestine peristalsis does not usually start until 2-3 days after surgery.

(Option 4) Pruritus (itching) is a known side effect of narcotic administration. It is usually treated with diphenhydramine (Benadryl) or some other antihistamine.

Educational objective:
Sedation precedes respiratory depression in narcotic administration. A client (especially if on high doses) should be assessed for sedation level. Level 3 sedation on POSS requires that no additional narcotics be administered to the client.

Block Time Remaining: 00:00:11
TUTOR
Test Id: 80944027
QId: 31829 (921666)
8 of 54
A A A
ExhibitA client with a history of degenerative arthritis is being discharged home following an exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should educate the client about which topics? Select all that apply. Click on the exhibit button for additional information.

1. Dryness of the mouth and throat may occur
2. Ringing in the ears is an expected, transient side effect
3. The albuterol canister should not be shaken before use
4. The health care provider should be notified if stools are black and tarry
5. Tiotropium capsules should not be swallowed
Omitted
Correct answer
1,4,5
Answered correctly
52% Time: 1 seconds
Updated: 02/17/2017
Explanation:

A common side effect of tiotropium (Spiriva) and other anticholinergics (eg, ipratropium, benztropine) is xerostomia (dry mouth) due to the blockade of muscarinic receptors of the salivary glands, which inhibits salivation. Sugar-free candies or gum may be used to alleviate dry mouth and throat (Option 1).

Tiotropium capsules should not be swallowed. These capsules are placed inside the inhaler device, and the capsule is pierced, allowing the client to inhale its contents (Option 5).

Glucocorticoids (eg, prednisone), when taken in combination with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen, can increase the risk of gastrointestinal ulceration and bleeding. The client should report black, tarry stools (ie, melena) to the health care provider as they could indicate gastrointestinal bleeding (Option 4).

(Option 2) Tinnitus (ie, ringing in the ears) is an uncommon side effect of NSAID (eg, naproxen) use. Tinnitus is commonly associated with toxicity related to salicylate-containing NSAIDs (eg, aspirin) or aminoglycosides (eg, gentamicin, neomycin, tobramycin); its onset should be reported by a client taking these medications. The medication may need to be discontinued to prevent permanent hearing loss.

(Option 3) The albuterol canister should be shaken prior to inhalation to ensure appropriate medication delivery.

Educational objective:
The nurse should teach the client taking glucocorticoids with aspirin or nonsteroidal anti-inflammatory drugs about the risk for gastrointestinal bleeding or ulceration. Xerostomia is a common side effect of anticholinergic drugs that can be alleviated with sugar-free candies or gum. Tiotropium capsules should not be swallowed.

Block Time Remaining: 00:00:12
TUTOR
Test Id: 80944027
QId: 30736 (921666)
9 of 54
A A A
The nurse in an ambulatory care center is teaching a client with a diagnosis of persistent depressive disorder (dysthymia) about the appropriate use of bupropion hydrochloride SR. Which statement made by the client indicates a need for further teaching?1. “If I have a sudden change in my mood, I should call my physician immediately.” [9%]
2. “If I have trouble swallowing the tablet, I can cut it in half.” [81%]
3. “If I miss a dose, I should not double the next dose to catch up.” [5%]
4. “It may take several weeks before I get better.” [3%]
Omitted
Correct answer
2
Answered correctly
81% Time: 1 seconds
Updated: 01/22/2017
Explanation:

Bupropion hydrochloride (Wellbutrin) is an atypical antidepressant used to treat depressive disorders, including major depressive disorder, seasonal affective disorder, and persistent depressive disorder (dysthymia). Preparations of bupropion hydrochloride include immediate-release, sustained release (SR), and extended-release (XL) tablets.

Any medication marked SR or XL should not be chewed, cut, or crushed due to the risk of adverse effects from too rapid absorption of the drug. No form of bupropion hydrochloride should be altered; tablets should be swallowed whole, with or without food. Seizures are of particular concern if a client takes a high or toxic dose of bupropion hydrochloride.

Clients on any kind of antidepressant need to be monitored closely for worsening depression, sudden or unusual behavior or mood changes, and the emergence of suicidal thoughts and behaviors. Clients with a diagnosis of depression and/or their family members need education and information on the increased risk of suicide (Option 1).

Additional instructions to a client about the use of bupropion hydrochloride include the following:

Limit alcohol; inform the health care provider if you are used to consuming large amounts of alcohol
Do not double up on the medication if a scheduled dose is missed (Option 3)
Take the medication at the same time each day
It may take several weeks to feel the effects of bupropion hydrochloride (Option 4)
Weight loss may occur when taking this medication
Educational objective:
No form of bupropion hydrochloride should be crushed, chewed, or cut due to the risk of seizures and other adverse effects caused by the more rapid absorption and resulting higher serum levels of the drug. No medications labeled SR or XL should be altered before they are administered. This type of medication preparation should be swallowed whole.

Block Time Remaining: 00:00:13
TUTOR
Test Id: 80944027
QId: 32021 (921666)
10 of 54
A A A
A child with attention-deficit hyperactivity disorder (ADHD) has been taking methylphenidate for a year. What are the priority nursing assessments when the client comes to the clinic for a well-child visit?1. Attention span and activity level [28%]
2. Dental health and mouth dryness [7%]
3. Height/weight and blood pressure [52%]
4. Progress with schoolwork and in making friends [11%]
Omitted
Correct answer
3
Answered correctly
52% Time: 1 seconds
Updated: 12/16/2016
Explanation:

Methylphenidate (Ritalin, Concerta) is a central nervous system stimulant used to treat ADHD and narcolepsy. It affects neurotransmitters (dopamine and norepinephrine) in the brain that contribute to hyperactivity and lack of impulse control.

A common side effect of methylphenidate is loss of appetite with resulting weight loss. Parents and caregivers should be instructed to weigh the child with ADHD at least weekly due to the risk of temporary interruption of growth and development. It is very important to compare weight/height measures from one well-child checkup to the next. If weight loss becomes a serious problem, methylphenidate can be given after meals; however, before meals is preferable.

Another side effect of methylphenidate is increased blood pressure and tachycardia. These should be monitored before and after starting treatment with stimulants.

(Option 1) Therapeutic effects of methylphenidate include increased attention span and improvement in hyperactivity. These would be important components of a well-child assessment, but not the priority.

(Option 2) Evaluating dental health is part of any well-child assessment. Dry mouth is not a common side effect of methylphenidate.

(Option 4) Expected outcomes of methylphenidate therapy include improvement in schoolwork and social relationships. These would be important components of a well-child assessment, but not the priority.

Educational objective:
Side effects of methylphenidate therapy that require on-going monitoring are delayed growth and development and increased blood pressure. Children with ADHD should be weighed regularly at home or school; weight loss trends should be reported and discussed with the health care provider. Blood pressure and cardiac function also should be monitored on an on-going basis.

Block Time Remaining: 00:00:15
TUTOR
Test Id: 80944027
QId: 34477 (921666)
12 of 54
A A A
A client diagnosed with vaginal candidiasis is instructed on self-care management techniques and proper administration of the prescribed miconazole vaginal cream. Which statement by the client indicates that further teaching is needed?1. “Each time I use the bathroom, I will wipe myself from the front to the back.” [2%]
2. “I should choose loose-fitting cotton underwear instead of nylon undergarments.” [6%]
3. “I will refrain from having sex until my partner is also tested and treated for the infection.” [67%]
4. “Prior to going to bed at night, I will apply miconazole cream using the vaginal applicator.” [23%]
Omitted
Correct answer
3
Answered correctly
67% Time: 1 seconds
Updated: 05/14/2017
Explanation:

Candida albicans (yeast) can colonize and cause infections of the vulvovaginal region. Vaginal candidiasis often causes itching and painful urination due to urine stinging the inflamed areas of the vulva. Assessment shows a thick, white, curd-like vaginal discharge and reddened vulvar lesions.

Miconazole (Monistat), an antifungal cream commonly prescribed to treat vaginal candidiasis, is inserted high into the vagina using an applicator. It is best applied at bedtime so that it will remain in the vagina for an extended period (Option 4). Sexual intercourse is avoided until the inflammation is resolved, typically for the duration of treatment, approximately 3-7 days (Option 3). However, sexual activity is not a significant cause of infection or reinfection of candida, and partner evaluation is not needed. Trichomoniasis, syphilis, gonorrhea, and HIV are mainly sexually transmitted; therefore, partners should be evaluated and treated.

Other teaching points for this client should include:

Ensuring proper hygiene of the perineum – cleansing from anterior to posterior (front to back) to prevent accidental introduction of fecal organisms (Option 1)
Wearing loosely fitted cotton underwear and avoiding synthetic undergarments to promote ventilation, decrease friction, and reduce moisture (Option 2)
Refraining from douching, which can introduce organisms higher up into the vaginal canal and cervix
Educational objective:
Miconazole cream is commonly prescribed to treat vaginal candidiasis. Miconazole is best applied at bedtime so that it will remain in the vagina longer. Clients being treated for vaginal candidiasis should wear loose-fitting cotton underwear and refrain from sexual intercourse for the duration of treatment.

Block Time Remaining: 00:00:16
TUTOR
Test Id: 80944027
QId: 30772 (921666)
13 of 54
A A A
A pediatric client is diagnosed with an acute asthma attack. Which immediate-acting medications should the nurse prepare to administer to this client? Select all that apply.1. Albuterol
2. Ibuprofen
3. Ipratropium
4. Montelukast
5. Tobramycin
Omitted
Correct answer
1,3
Answered correctly
49% Time: 1 seconds
Updated: 04/23/2017
Explanation:

Asthma is an inflammatory condition in which the smaller airways constrict and become filled with mucus. Breathing, especially on expiration, becomes more difficult. Pharmacologic treatment for acute asthma includes the following:

Oxygen to maintain saturation >90%
High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes
Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an effect.
(Option 2) Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen, indomethacin) and aspirin can worsen asthma symptoms in some clients and are not indicated unless necessary.

(Option 4) Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide) to provide long-term asthma control.

(Option 5) Tobramycin is an aminoglycoside antibiotic. It is used in aerosolized form to treat cystic fibrosis exacerbation when Pseudomonas is the predominant organism causing lung infection.

Educational objective:
Inhaled corticosteroids and leukotriene inhibitors are typically used to achieve and maintain control of inflammation for long-term management of asthma. Quick-relief medications (eg, albuterol, ipratropium) are used to treat acute symptoms and exacerbations.

Block Time Remaining: 00:00:25
TUTOR
Test Id: 80944027
QId: 32006 (921666)
15 of 54
A A A
The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?1. “I’ve felt the need for an afternoon nap most days this week.” [9%]
2. “I’ve gained 3 lb (1.36 kg) since I began taking this medication.” [11%]
3. “I’ve had the stomach flu for the past couple of days.” [55%]
4. “My mouth seems to be drier than usual lately.” [24%]
Correct Answered correctly
55% Time: 8 seconds
Updated: 01/22/2017
Explanation:

Lithium is often used in the treatment of bipolar disorder. It has expected, mild side effects as well as potentially serious ones related to drug toxicity. Drowsiness, weight gain, dry mouth, and gastrointestinal upset are expected, mild side effects.

Lithium toxicity occurs with dehydration, hyponatremia, decreased renal function, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs, thiazide diuretics). Lithium and sodium are closely related in the body. Acute viral gastroenteritis (stomach flu) presents with abrupt onset of diarrhea, nausea, vomiting, and abdominal pain. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium, increasing the risk for lithium toxicity (Option 3).

(Option 1) Drowsiness is an expected side effect. The nurse should advise the client to avoid hazardous activities and driving until the effects of lithium are known or this side effect subsides.

(Option 2) Weight gain is an expected side effect. The nurse should provide client education about healthy food choices and proper exercise and/or provide for a dietary consult.

(Option 4) Dry mouth is an expected side effect. The nurse should provide client teaching about measures to counteract this side effect (eg, ice chips, sugarless gum or candy, drinking plenty of water). However, excessive urination and polydipsia indicate nephrogenic diabetes insipidus from lithium toxicity.

Educational objective:
Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels in clients re