htThe registered nurse (RN) on a medical-surgical unit is working with a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP). hich hi ch tasks tas ks are ar e most mos t appropria approp riate te to assign to the LPN! Select all that apply. apply. 1.
Administering a scheduled analgesic to a client with chronic back pain currently rated 8/10
2.
Assessing fuid volume status o a client with heart ailure who is scheduled or discharge
.
Assisting with bathing! eeding! and dressing a client with multiple sclerosis
".
#erorming wound care and sterile dressing change or a client with a stasis ulcer
$.
#roviding incontinence care and linen change or a client with diarrhea
%ou % ou answered this
)ime *pent(
+, *econds
&uest &ue stio ion n incorrectly. 'orre 'orrect ct answe an swerr is( is ( 1,4 $0- o people answered this &uestion correctly.
Explanation
ast updated(
/1/201$
mo st appropriat approp riate e tasks to assign to Wound Wou nd car c are e and routine routi ne medication medica tion administratio adminis tration n are the most per"o rm sterile procedures and cleanse and dress wounds "or which there the LPN. The LPN can per"orm is an esta#lished prescription plan (Option 4) . . Pain rated at $%&' is an epected "inding in a client with chronic #ack pain pain and the oral analgesic anal gesic ma* #e administered admini stered as scheduled #* # * the LPN (Option . +" this client were eperiencing new-onset uneplained pain re,uiring intravenous analgesic 1) . administration the client would need assessment #* the RN. LPN ma* per"orm speci"ic assessments #ut evaluating the "luid volume status o" a (Option 2) The LPN heart "ailure client is a comprehensive assessment involving multiple #od* s*stems (eg heart and lung sounds peripheral edema ade,uac* o" urine output). This client will will also re,uire discharge education on home management o" heart "ailure which is the responsi#ilit* o" the RN. and knowledge to meet clients elimination (Options 3 and ) UAP have the appropriate skills and h*giene and com"ort needs. Although these tasks could #e sa"el* carried out #* an LPN underutiliing UAP would #e an ine""ective use o" resources. !ducational o"#ecti$e% LPNs ma* sa"el* per"orm sterile procedures and routine medication administration. The RN is responsi#le "or discharge discharge planning and per"orming comprehensive clinical assessments. The nurse should also consider appropriate use o" resources when making assignments or delegating tasks. tps(//www.uworld.com/'/3emo/4)est.htm
mo st appropriat approp riate e tasks to assign to Wound Wou nd car c are e and routine routi ne medication medica tion administratio adminis tration n are the most per"o rm sterile procedures and cleanse and dress wounds "or which there the LPN. The LPN can per"orm is an esta#lished prescription plan (Option 4) . . Pain rated at $%&' is an epected "inding in a client with chronic #ack pain pain and the oral analgesic anal gesic ma* #e administered admini stered as scheduled #* # * the LPN (Option . +" this client were eperiencing new-onset uneplained pain re,uiring intravenous analgesic 1) . administration the client would need assessment #* the RN. LPN ma* per"orm speci"ic assessments #ut evaluating the "luid volume status o" a (Option 2) The LPN heart "ailure client is a comprehensive assessment involving multiple #od* s*stems (eg heart and lung sounds peripheral edema ade,uac* o" urine output). This client will will also re,uire discharge education on home management o" heart "ailure which is the responsi#ilit* o" the RN. and knowledge to meet clients elimination (Options 3 and ) UAP have the appropriate skills and h*giene and com"ort needs. Although these tasks could #e sa"el* carried out #* an LPN underutiliing UAP would #e an ine""ective use o" resources. !ducational o"#ecti$e% LPNs ma* sa"el* per"orm sterile procedures and routine medication administration. The RN is responsi#le "or discharge discharge planning and per"orming comprehensive clinical assessments. The nurse should also consider appropriate use o" resources when making assignments or delegating tasks. tps(//www.uworld.com/'/3emo/4)est.htm
The nurse is caring "or an older client admitted due to s*ncope on eertion and d*spnea. The client has a histor* o" aortic stenosis. +denti"* the area where the nurse would #est auscultate this clients murmur.
You answered this question incorrectly. 25% of people answered this question correctly.
Explanation
Time Spent: Last updated:
63 Seconds !"#!2$"5
+n aortic stenosis& there is a narrowing o" the valve opening #etween the le"t ventricle and aorta. /n auscultation a loud s*stolic e0ection murmur (heard "ollowing the 1&) is heard over the aortic area "ound at the right sternal "order& second intercostal space . 2alvular disorders (eg stenosis regurgitation prolapse) are #est heard over their respective areas. These include3 •
•
•
The pulmonic area - auscultated over the le"t sternal #order at the second intercostal space 4r#s point (where 15 is #est heard) - auscultated at the le"t sternal #order in the 6rd intercostal space The tricuspid area - located at the le"t lower sternal #order (at the 7th or 8th intercostal space)
•
The mitral area - auscultated at the le"t mid-clavicular line at the 8th intercostal space
!ducational o"#ecti$e% 9isorders o" the aortic valve are #est auscultated over the aortic area ( right sternal "order& second intercostal space).
A client is admitted to the emergenc* room with right lower ,uadrant pain and suspected acute appendicitis. hich health care provider prescription should the nurse implement 'irst! 1.
Administer $52$ mg hydrocodone/acetaminophen #6 or pain
2.
3raw blood or complete blood count and electrolyte levels
.
6btain urine specimen or urinalysis
".
*tart intravenous 79: line with normal saline 100 m/hr
%ou answered this &uestion correctly.
)ime *pent(
$ *econds
100- o people answered this &uestion ast updated( correctly.
Explanation
/0/201$
hen in'ected or o"structed #* a "oreign #od* or "ecal material the appendi #ecomes in'lamed causing acute appendicitis. The appendi ma* rupture i" le"t untreated placing the client at risk "or peritonitis a potentiall* "atal in"ection o" the peritoneum. hen prioritiing multiple prescriptions the nurse should "irst address issues o" airwa* #reathing circulation and then vital signs. +nitial interventions "or acute appendicitis ma* include the "ollowing3 &. 4nsure patent airay and administer o*gen i" h*poic 5. /#tain * access and administer prescri#ed "luids (Option 4) 6. 9raw "lood samples "or complete #lood count (:;:) electrol*te levels clotting studies and t*pe and cross as prescri#ed (Option 2) 7. +nsert indwelling urinary catheter and o#tain urine sample "or urinal*sis i" prescri#ed (Option 3) 8. +nsert a nasogastric (N+) tu"e i" necessar*
(Option 1) :lients with acute appendicitis are at risk "or rupture o' the appendi, and ma* re,uire emergency surgery. There"ore the nurse should ensure NPO status is maintained. Pain medications will #e administered intravenousl*. +n addition circulation takes priorit* over the pain medication. !ducational o"#ecti$e% The nurse must prioritie issues o" airwa* #reathing circulation and changes in vital signs a#ove other prescriptions. A client with acute appendicitis is at risk "or a ruptured appendi. This could result in peritonitis which is a potentiall* "atal in"ection.
A client with o#esit* is diagnosed with pulmonar* em#olism (P4). hich assessment data would the nurse epect to "ind! Select all that apply. 1.
;radycardia
2.
'hest pain
.
'hills and ever
".
$.
)achypnea
.
)racheal deviation
%ou answered this &uestion incorrectly. 'orrect answer is( 2,4,5
+$- o people answered this &uestion correctly.
Explanation
)ime *pent( 8 *econds
ast updated( /2/201$
A pulmonar* em#olus is a "lood clot that usuall* originates "rom the deep veins o" the legs (<='>) travels to the pulmonar* circulation and o"structs a pulmonary artery or one o" its #ranches resulting in decreased per"usion in relation to ventilation and impaired gas e,change (h*poemia). :lients are at risk "or "ormation o" venous throm#oem#olism (2T4) when the conditions detailed in 2irchows Triad are present. :lients at risk "or P4 include those with prolonged immo"ili-ation (eg during hospitaliation i" not am#ulator*) o#esit* recent surger* varicose veins smoking heart "ailure advanced age or histor* o" 2T4. The assessment data most characteristic o" P4 include3 •
yspnea ($8>)
•
Pleuritic chest pain (?'>)
•
/achycardia
•
/achypnea
•
0ypo,emia (impaired gas echange decreased per"usion with normal alveolar ventilation shunting)
•
Apprehension and aniet*
A more at*pical presentation can #e associated with a larger sied P4 and ma* include mani"estations o" cardiopulmonar* compromise and hemodynamic insta"ility (eg right ventricular d*s"unction pulmonar* h*pertension s*stemic h*potension s*ncope loss o" consciousness distended neck veins). (Option 1) A classic mani"estation o" P4 is tach*cardia to compensate "or h*poemia (not #rad*cardia). (Option 3) :hills and "ever can indicate the presence o" an in"ection and are not characteristic o" P4. @owever a low-grade "ever without chills can occur &-5 weeks a"ter P4 due to in"lammation. (Option ) Tracheal deviation is a s*mptom o" tension pneumothora. The trachea deviates "rom midline toward the una""ected side awa* "rom the collapsed lung. !ducational o"#ecti$e% :lassic clinical mani"estations o" P4 include d*spnea pleuritic chest pain tach*cardia tach*pnea h*poemia and "eelings o" apprehension and aniet*. Risk "actors "or P4 include those detailed in 2irchows Triad (eg h*percoagula#ilit* venous stasis and endothelial damage). assive P4 can cause s*ncope and hemod*namic insta#ilit*.
An elderl* client with pneumonia has a temperature o" &'5.5 B (6= :) #lood pressure =$%?? mm @g pulse &&8%min and respirations 6'%min. Assessment reveals crackles in the right lower lo#e dusk* nail #eds and dr* mucus mem#ranes. Arrange the nursing actions chronologicall* to prioritie care. ll options must "e used. nordered &ptions ;lood cultures 5 "or temperature <&'5 B (6$.= :) Normal saline (N1) solution at &58 mL%hr Levo"loacin C8' mg intravenous (+2) ever* 57 hours /*gen per nasal cannula at 7 L%min Teaching incentive spirometer use
Your 'esponse!(orrect 'esponse /*gen per nasal cannula at 7 L%min Normal saline (N1) solution at &58 mL%hr ;lood cultures 5 "or temperature <&'5 B (6$.= :) Levo"loacin C8' mg intravenous (+2) ever* 57 hours Teaching incentive spirometer use
You answered this question correctly.
Time Spent:
5$% of people answered this question correctly.
Last updated:
)6 Seconds 3!3$!2$"5
Explanation
The nurse priorities nursing actions "or the hospitalied client with pneumonia in the "ollowing order3 &. O,ygen per nasal cannula at 4 Lmin D This client is in respirator* distress (respirations 6'%min dusk* nail #eds). /*gen administration is the priorit* action.
5. NS at 12 mLhr D ost elderl* clients with pneumonia present with deh*dration (dr* mucus mem#ranes low #lood pressure). +nitiation o" +2 "luids is important to thin secretions "acilitate epectoration o" mucus and provide access "or anti#iotic therap*. 6. lood cultures , 2 'or temperature 5162 7 (38.9 :) D :ultures should alwa*s #e drawn #e"ore anti#iotic administration as these can #e inaccurate i" drawn a"terward. +denti"*ing the causative pathogen is necessar* to ensure that the appropriate anti#iotic is prescri#ed. :ultures are drawn 5 ("rom 5 di""erent venipuncture sites) to rule out contaminants. 7. Le$o'lo,acin ;6 mg * e$ery 24 hours D Levo"loacin (Leva,uin) is a "luoro,uinolone anti#iotic recommended "or the treatment o" pneumococcal pneumonia. Anti#iotics should #e administered as soon as possi#le a"ter the pneumonia diagnosis is made and cultures have #een drawn. 8. ncenti$e spirometer e$ery 2 hours D 9eep #reathing can #e per"ormed a"ter the initiation o" anti#iotics. +ncentive spirometr* increases alveolar epansion "acilitates removal o" secretions and prevents atelectasis. !ducational o"#ecti$e% The nurse must prioritie nursing actions appropriatel* #* identi"*ing the clients current health status and acuit* level threats to survival (airwa* #reathing circulation) sa"et* issues (in"ection) and desired outcomes.
A ?-month-old is admitted with #acterial meningitis. hich action is the priority o" care! 1.
Administering antibiotics
2.
Avoiding environmental stimuli
.
nitiating sei>ure precautions
".
?easuring head circumerence
%ou answered this &uestion correctly.
+- o people answered this &uestion correctly.
)ime *pent(
ast updated(
8 *econds
/2+/201$
Explanation
acterial meningitis occurs when in"ection causes in"lammation in the meninges o" the #rain and spinal cord. This in"lammation ma* lead to h*drocephalus and increased intracranial pressure (+:P). 9ue to the risk "or severe complications "rom meningitis and increased +:P (eg hearing loss permanent #rain damage death) the priority o" care is immediate anti"iotic therapy . Lum"ar puncture (LP) with cere#rospinal "luid culture is per"ormed to determine the causative organism. Anti#iotic choice ma* #e ad0usted later #ased on LP results. The client should remain on isolation precautions "or a minimum o" 57 hours "ollowing initiation o" anti#iotic therap*.
(Option 2) :lients with meningitis are o"ten ver* sensiti$e to stimuli (eg #right lights noise). Although environmental stimuli should #e reduced as much as possi#le the priorit* o" care is initiating anti#iotic therap*. (Option 3) 1eiures ma* occur in in"ants with #acterial meningitis and are o"ten accompanied #* a shrill& high
hich o" the "ollowing "indings re"lect concerning vital signs that re,uire "urther nursing assessment and intervention! Select all that apply. ". 2. 3. 8. 5. You answered this
*fter al+uterol administration, 5-year-old client reports tremor and has pulse "2$!min *fter hydromorphone " m intra/enous push 014, decreases from "3$!)$ mm to ""$!#$ mm (lient recei/in +lood transfusion7 pre-infusion: "2$!)$ mm and pulse )$!min7 now: $!#$ mm and "$$!min 9etal heart rate monitored durin la+or chanes from "8$!min to "$$!min with decelerations urse preparin to administer prescri+ed nifedipine7 +lood pressure is $!6$ mm Time Spent:
" Seconds
question correctly. "$$% of people answered this Last updated:
3!2#!2$"5
question correctly.
Explanation
cute hemolytic reaction during a #lood trans"usion usuall* develops within the 'irst 1 minutes . 1igns%s*mptoms include chills "ever lower #ack pain ("rom damaged cells in the kidne*s) tach*cardia tach*pnea and h*potension. Acute hemol*tic reaction is an emergency that re,uires the nurse to stop the trans'usion and treat shock.
Normal "etal heart tones are &&'-&?'%min. 9ecrease in heart rate with decelerations could indicate uteroplacental insu''iciency and must #e assessed. Ni"edipine (Procardia) is a potent calcium channel #locker antih*pertensive. +t should not #e administered when the clients ;P is on the lower end o" the accepta#le range as this ma* result in hypotension.
(Option 1) Al#uterol (2entolin) is a #ronchodilator #eta-adrenergic agonist. 4pected side e""ects include tremor tach*cardia and palpitation. Normal pulse rate in a 8-*ear-old can #e C'-&5'%min and averages &''%min. This is the upper limit o" epected "indings. (Option 2) This is the upper normal dosing limit "or initial +2P administration o" h*dromorphone (9ilaudid) a potent narcotic. @*potension and #rad*cardia are epected adverse e""ects. /rthostatic h*potension occurs most o"ten with am#ulation or positioning in the semi-Bowlers position. :lients are not ordinaril* allowed to #e am#ulator* "or 5'-6' minutes a"ter +2P administration o" narcotics. This one-time reading is not signi"icant enough to re,uire emergenc* intervention. !ducational o"#ecti$e% ;eta-adrenergic agents have an epected side e""ect o" tremor or palpitations and narcotics can cause mild h*potension or #rad*cardia. +ntervention is not necessar* unless the values are signi"icant or the client #ecomes s*mptomatic.
The client had surger* "or possi#le cancer. The positive #iops* result is #ack in the medical record #ut the client has not #een told that the #iops* showed malignanc*. The client asks the nurse EAm + going to die!E hat is the #est wa* "or the nurse to initially handle the situation! 1.
@veryone will die one day! but good treatment is available or most cancers today.@
2.
@ can understand your an=iety about the situation. et me call your health care provider 7<'#:.@
.
@*hare with me your thoughts and eelings about the situation.@
".
@)he biopsy result came back as malignant! but that doesnt mean the cancer is not treatable.@
%ou answered this )ime *pent(
$, *econds
&uestion incorrectly. $- o people answered this ast updated(
1/2/201$
&uestion correctly.
Explanation
The nurse must "irst assess the clients knowledge and "eelings a#out the situation. Use o" therapeutic communication techni,ues including listening re"lection and "ocusing allow the nurse to determine the clients needs at that time. /"ten the client is 0ust seeking an empathetic listener. (Option 1) Under the ethical principle o" $eracity the nurse should not lie or o''er 'alse reassurance. +t is unclear at this time what the prognosis or treatment options are "or this client and automatic responses (eg Eever*one will die one da*E) and "alse reassurance (eg Egood treatment is availa#le "or most cancers toda*E) are t*pes o" nontherapeutic communication. (Option 2) Although contacting the @:P ma* #e necessar* the nurse should "irst eplore the clients thoughts and "eelings to determine the clients current needs.
(Option 4) The news o" the positive #iops* result should #e given #* the @:P so that "actual in"ormation as well as prognosis and treatment options can #e provided at that time. There is no ethical or legal o#ligation "or the nurse to reveal a clients results the moment the results are availa#le. !ducational o"#ecti$e% hen asked #* a client a#out results or d*ing respond #* assessing the clients understanding o" the situation and%or "eelings a#out the topic using therapeutic communication skills.
The nurse is caring "or a client who is in active la#or at 6= weeks gestation and receiving a continuous intravenous (+2) in"usion o" o*tocin. The nurse notes "re,uent and persistent late decelerations on the "etal monitor. hat actions should the nurse take! Select all that apply. 1.
Administer o=ygen via a nonrebreather ace mask
2.
'hange the maternal position to the lateral side
.
3iscontinue o=ytocin inusion
".
otiy the health care provider 7<'#:
$.
#erorm a nitra>ine test
%ou answered this &uestion correctly.
)ime *pent(
"" *econds
100- o people answered this &uestion ast updated(
/0/201$
correctly.
Explanation
This client is eperiencing late decelerations. Nurses ma* use the mnemonic E24AL :@/PE to help recall the di""erent causes o" change in "etal heart rate tracings. Late decelerations indicate uteroplacental insu''iciency and are a sign o" 'etal intolerance to la#or. +nterventions are directed at correcting the cause o" late decelerations and deliver* ma* #e necessar*.
Nursing actions to improve "etal per'usion and o,ygenation include3 &. 9iscontinue uterotonic drugs (eg o*tocin FPitocinG) to reduce uterine activit*H 7=S/ action 5. :hange the maternal position to the le't side to relieve compression o" the in"erior vena cava 6. Administer o,ygen at $-&' L%min via nonre#reather "ace mask 7. Iive prescri#ed intravenous (+2) "olus o" lactated Ringers or normal saline 8. Noti"* the @:P
(Option ) The "ern and nitraine paper tests are used to assess "or the presence o" lea>ing amniotic 'luid. The "ern paper test is positive when a "erning pattern o" dried amniotic "luid is visualied under a microscope. Nitraine paper tests the p@ o" vaginal secretions (acidic with p@ o" 7.8-8.8). This test is positive when the p@ strip turns #lue which indicates the presence o" amniotic "luid (#asic with p@ o" C.'-C.8). These tests would #e epected to #e positive as this client is in active la#or. !ducational o"#ecti$e% Late decelerations indicate uteroplacental insu''iciency and are a sign o" "etal intolerance to la#or. These are treated #* discontinuing or decreasing o*tocin in"usion ( 7=S/ action) changing the maternal position to the lateral side administering $-&' L%min o*gen via a nonre#reather "ace mask and giving an +2 "luid #olus.
A health care provider (@:P) prescri#es ce"uroime 6' mg%kg%da* P/ divided in e,ual doses ever* &5 hours "or a child with a urinar* tract in"ection. The child weighs 65 l#. ;ased on the ce"uroime la#el how man* milliliters would the nurse administer per dose! =ecord your anser using one decimal place . :lic> the e,hi"it "utton 'or additional in'ormation . Answer3
(mL)
A client is #eing admitted to the health care "acilit* with a new diagnosis o" Clostridium difficile colitis. hich elements o" in"ectious disease precautions are necessar* when providing routine care "or this client! Select all that apply. *lcohol-+ased saniti;ers for hand cleanin
". (lient in sinle-room 0pri/ate4 isolation
2. urse usin 5 respirator 3. urse usin sterile lo/es 8. urse usin surical mas< 5. urse wearin disposa+le own
6. !,planation%
Clostridium difficile re,uires
contact precautions under the guidelines pu#lished #* the :enters "or 9isease :ontrol and Prevention. •
•
Place the client in single
C difficile -in"ected
All sur"aces within 6 "eet o" the #ed are considered contaminated
•
Personal protective e,uipment ( gon and glo$es ) must #e discarded #e"ore leaving the room
•
@and h*giene must #e per"ormed with soap and ater
•
•
Alcohol-#ased hand sanitiers do not kill
C difficile spores
(Option 1)
9edicated medical e,uipment (stethoscope #lood pressure cu"") should remain in the room
(Option 3) Bor client care involving air#orne precautions a class N=8 or higher grade respirator must #e used in lieu o" a surgical mask to avoid potential eposure to aerosolied particles. 1urgical masks are rated "or #arrier protection "or droplet splashing and "iltration o" large respirator* particles onl*. (Option 4) Regular clean gloves (not sterile) are needed. (Option ) 1urgical masks are rated "or #arrier protection "rom droplet-#ased disease transmission and provide onl* "iltration "or large respirator* particles. asks are re,uired during an* activit* with the possi#ilit* o" "luids splashing (suctioning wound care). !ducational o"#ecti$e% Clostridium difficile re,uires contact-#ased precautions - private isolation room pre"erred disposa#le gown and nitrile gloves. C difficile re,uires the use o" soap and ater not alcohol-#ased hand sanitiers to prevent transmission.
The nurse auscultates rhonchi in a client with a tracheostom* tu#e and per"orms endotracheal suctioning to clear the secretions. hich nursing interventions are most appropriate to limit the risks associated with suctioning! Select all that apply. Apply suction only while withdrawing catheter
1. nstill sterile normal saline to loosen secretions
2. imit aspiration time to 10 seconds with each suction pass
. ?aintain sterile techni&ue throughout suctioning procedure
". #re5o=ygenate with 100- o=ygen
$. !,planation%
!ndotracheal suctioning is per"ormed to maintain a patent airwa* i" a client cannot mo#ilie secretions independentl*. +nserting a catheter into the airwa* compromises the sterilit* o" the lower airwa* and increases the risk "or in'ection. 1uctioning removes o*gen in addition to secretions placing the client at risk "or hypo,emia. @igh suction levels or the contact o" the catheter with the trachea can cause trauma such as #arotrauma damage to tracheal mucosa and microatelectasis. +n order to decrease the occurrence o" these complications3 •
Use strict sterile techni?ue throughout suctioning process.
•
Pre
o*gen (h*pero*genation) "or 6-7 #reaths.
•
Aspirate during withdrawal o" catheter onl* limiting each suction pass to 16 seconds.
•
Allow client 7-8 recover* #reaths #etween suction passes to replenish o,ygen.
(Option 2) +nstilling 8-&' mL o" sterile normal saline solution (N11) is thought to help loosen thick secretions and stimulate cough. Although saline lavage is a common practice in some "acilities the
installation o" N11 into the airwa* prior to suctioning is not recommended. +t can dislodge #acteria causing increased #acterial coloniation and can stimulate ecessive coughing. !ducational o"#ecti$e% 4ndotracheal suctioning increases risks "or pulmonar* in"ection h*poemia microatelectasis and mucosal tissue damage. To decrease these suctioning-associated risks use sterile techni,ue preo*genate appl* suction onl* while withdrawing catheter and limit aspiration time. Avoid the use o" saline lavage and "re,uent suction passes without ade,uate rest #etween. A client with dia#etes and an in"ected heel ulcer is trans"erred to the intensive care unit #ecause o" deteriorating condition. ;ased on the admission assessment what does the nurse identi"* as the most li>ely condition! :lic> the e,hi"it "utton 'or additional in'ormation.
2ital signs at &'''
Temperature
&'5.$ B ( 6=.6 : )
;lood pressure
$'%?' mm @g
@eart rate
&&'%min
Respirations
6?%min la#ored
1p/
$=>
5
Admission notes
&'''
:lient is lethargic and di""icult to arouse. Large amount o" purulent drainage noted "rom le"t heel ulcer. ound culture positive "or 1taph*lococcus aureus and serum lactate level elevated. 1econd "luid challenge '.=> normal saline solution in"using at &''' mL%hr. :2P 5 mm @g PAP 6 mm @g. ill continue to monitor. JJJJJJJJJJJJJJJJJJJ RN
A client with dia#etes and an in"ected heel ulcer is trans"erred to the intensive care unit #ecause o" deteriorating condition. ;ased on the admission assessment what does the nurse identi"* as the most li>ely condition! :lic> the e,hi"it "utton 'or additional in'ormation . =ultiple oran dysfunction syndrome 0=&>S4 ?8%@ ".
Sepsis ?2$%@ 2. Septic shoc< ?62%@
3. Systemic inflammatory response syndrome 0S1'S4 ?"$%@ 8. !,planation%
The presence o" in"ection with a gram-positive wound culture increases the risk "or developing sepsis and septic shock. Sepsis.@ @*potension and inade,uate tissue per"usion (ie elevated serum lactate level) despite "luid resuscitation and decreased central venous pressure (ie decreased circulating volume) and pulmonar* arter* wedge pressure (ie decreased preload) indicate the presence o" septic shock in this client. ;ased on the alterations in hemod*namic parameters septic shock is the most likel* condition in this client. (Option 1) /91 is the "ailure o" 5 or more #od* organs (eg acute kidne* in0ur* acute respirator* distress s*ndrome). 1eptic shock can progress to multiorgan d*s"unction (ie severe end o" sepsis and septic shock). @owever the assessment data do not indicate that it is the most likel* condition at this time. (Option 2) Sepsis is a s*stemic in"lammator* response (ie increased heart rate respirations temperature and decreased s*stolic #lood pressure) to a documented or suspected in'ection and is present in this client. @owever it is not the most likel* condition #ecause the assessment data support progression along the sepsis continuum to septic shock.
(Option 4) S=S is a generalied in"lammator* response to an in'ectious or nonin'ectious insult to the #od*. +t is o"ten di""icult to distinguish "rom earl* sepsis. hen 1+R1 is suspected a source "or sepsis should #e sought. !ducational o"#ecti$e% S=S K Ieneralied in"lammator* response to an in"ectious or nonin"ectious insult to the #od* Sepsis K Presence (pro#a#le or documented) o" in"ection along with s*stemic mani"estations o" in"ection Septic shoc> K 1epsis-induced h*potension despite ade,uate "luid resuscitation (6' mL%kg)
A#out which o" the "ollowing d*srh*thmias in a client should the nurse #e most concerned! ? ".
2%@ 2.
?8%@
3.
?66%@ ?
8.
25%@
!,planation%
*entricular 'i"rillation (*7) is a d*srh*thmia that can #e lethal and should #e treated immediatel*
with cardiopulmonar* resuscitation (:PR) and de"i#rillation. +t is characteried #* irregular wave"orms o" var*ing shapes and amplitude on the electrocardiogram (4:I). echanicall* there is no e""ective contraction cardiac output or pulse. (Option 1) Atrial "i#rillation (AB) is an a#normal heart rh*thm #ut the client usuall* has a pulse. +n
addition AB is not as concerning as 2B. (Option 2) Premature ventricular contractions (P2:s) can indicate ventricular irrita#ilit* #ut the client
has a pulse. (Option 4) 2entricular tach*cardia (2T) is a d*srh*thmia that can #e lethal. A client with 2T is
prioritied a"ter a client with 2B as it is possi#le to have a pulse in 2T. !ducational o"#ecti$e%
2B is a d*srh*thmia that can #e lethal. The client does not have a pulse and must #e treated immediatel* with :PR and de"i#rillation.
;e"ore administering medications to a client hospitalied 6 da*s ago "or acute asthma the nurse compares the morning la#orator* results with the admission data. The nurse should con"irm which prescription with the health care provider prior to administration! :lic> on the e,hi"it "utton 'or additional in'ormation. *l+uterol ne+uli;ation e/ery 8 hours ?2%@ ". AnoBaparin 8$ m su+cutaneously e/ery 28 hours ?56%@
2. =ethylprednisolone 2$ m intra/enously e/ery 6 hours ?"5%@ 3. otassium chloride 2$ mAq!L e/ery 28 hours ?28%@ 8. !no,aparin (Lo$eno,) is a low-molecular-weight heparin anticoagulant administered "or proph*lais o" deep venous throm#osis in hospitalied clients. ;leeding and throm"ocytopenia (platelet count &8''''%mm F&8' &' %LG) are possi#le complications o" anticoagulant therap*. @eparin-induced throm#oc*topenia (@+T) is a serious condition that o"ten develops rapidl* re,uiring prompt recognition and treatment. Unlike other drug-induced "orms o" throm#oc*topenia @+T can result in arterial or $enous throm"osis (eg stroke etremit* in"arction) although the eact association is unknown. This clients platelet count (=?'''%mm F=? &' %LG) has dramaticall* decreased since 6
=
6
=
admission. The nurse should note this drastic change and ,uestion the continuation o" the prescription with the health care provider #e"ore administering the medication. (Option 1) ;ronchodilators such as al#uterol and ipratropium are indicated in acute asthma and chronic o#structive pulmonar* disease eacer#ations. (Option 3) eth*lprednisolone (1olu-edrol) is an anti-in"lammator* corticosteroid drug indicated "or treatment o" lung in"lammation associated with asthmaM the route dosage and "re,uenc* are correct. This clients elevated white #lood cell count is likel* due to glucocorticoid administration and is an epected e""ect o" corticosteroids. (Option 4) Potassium chloride is an electrol*te replacement drug and is indicated #* the presence o" h*pokalemia (6.8 m4,%L F6.8 mmol%LG)M the route dosage and "re,uenc* are correct. Bre,uent use o" al#uterol likel* caused h*pokalemia in this client. !ducational o"#ecti$e% @eparin-induced throm#oc*topenia can result in arterial or venous throm#osis. Platelet counts should #e care"ull* monitored in an* client receiving anticoagulant therap*.
The nurse is caring "or a client who is in active la#or at 6= weeks gestation and receiving a continuous intravenous (+2) in"usion o" o*tocin. The nurse notes "re,uent and persistent late decelerations on the "etal monitor. hat actions should the nurse take! Select all that apply. *dminister oByen /ia a nonre+reather face mas<
". (hane the maternal position to the lateral side
2. >iscontinue oBytocin infusion
3. otify the health care pro/ider 0(4
8. erform a nitra;ine test 5. This client is eperiencing late decelerations. Nurses ma* use the mnemonic E24AL :@/PE to help recall the di""erent causes o" change in "etal heart rate tracings.
Late decelerations indicate uteroplacental insu''iciency and are a sign o" 'etal intolerance to la#or. +nterventions are directed at correcting the cause o" late decelerations and deliver* ma* #e necessar*.
Nursing actions to improve "etal per'usion and o,ygenation include3 &. 9iscontinue uterotonic drugs (eg o*tocin FPitocinG) to reduce uterine activit*H 7=S/ action 5. :hange the maternal position to the le't side to relieve compression o" the in"erior vena cava
6. Administer o,ygen at $-&' L%min via nonre#reather "ace mask 7. Iive prescri#ed intravenous (+2) "olus o" lactated Ringers or normal saline 8. Noti"* the @:P (Option ) The "ern and nitraine paper tests are used to assess "or the presence o" lea>ing amniotic 'luid. The "ern paper test is positive when a "erning pattern o" dried amniotic "luid is visualied under a microscope. Nitraine paper tests the p@ o" vaginal secretions (acidic with p@ o" 7.8-8.8). This test is positive when the p@ strip turns #lue which indicates the presence o" amniotic "luid (#asic with p@ o" C.'-C.8). These tests would #e epected to #e positive as this client is in active la#or. !ducational o"#ecti$e% Late decelerations indicate uteroplacental insu''iciency and are a sign o" "etal intolerance to la#or. These are treated #* discontinuing or decreasing o*tocin in"usion ( 7=S/ action) changing the maternal position to the lateral side administering $-&' L%min o*gen via a nonre#reather "ace mask and giving an +2 "luid #olus.
The nurse is caring "or a client with ;ells pals*. The nurse most li>ely epects which "inding(s) on assessment! Select all that apply. (hane in lacrimation on the affected side
". Alectric shoc<-li
3. 1na+ility to smile symmetrically
8. Se/ere facial pain alon the chee<+one
5.
ellAs palsy is peripheral& unilateral "acial paral*sis characteried #* in"lammation o" the "acial nerve (cranial nerve 2++) in the a#sence o" a stroke or other causative agent%disease. Paral*sis o" the motor "i#ers innervating the "acial muscles results in "laccidit* on the a""ected side.
1*mptoms include the "ollowing3 •
+na#ilit* to completel* close the e*e on the a""ected side
•
Blattening o" the nasola#ial "old on the side o" the paral*sis (Option 3)
•
+na#ilit* to smile or "rown s*mmetricall* (Option 4)
•
Alteration in tear production (eg decreased tearing with etreme dr*ness ecessive tearing) due to lower e*elid muscle weakness (Option 1)
Alteration in the sensor* "i#ers can cause loss o" taste on the anterior two-thirds o" the tongue. (Options 2 and ) 1evere "acial pain along the cheek#one and electric shock-like pain in the lips and gums are s*mptoms o" trigeminal neuralgia (cranial nerve 2). The trigeminal nerve ma* #ecome h*persensitive and cause "acial pain in ;ells pals* #ut this is uncommon. !ducational o"#ecti$e% ;ells pals* is a "acial paral*sis characteried #* "acial droop uns*mmetrical smile or "rown changes in tear production and ina#ilit* to close the a""ected e*e appropriatel*. Bacial pain with ;ells pals* is related to h*persensitivit* o" the trigeminal nerve and is uncommon.
A client is diagnosed with lower-etremit* deep venous throm#osis (92T) a"ter a cross-countr* road trip. hich clinical mani"estations most characteristic o" a 92T does the nurse epect to assess! Select all that apply. lue, cyanotic toes ". (alf pain
2. >ry, shiny, hairless s
8. Carmth and erythema
5.
*/ is the most common "orm o" venous throm#oem#olism and occurs most o"ten ($'>) in the proimal deep veins (iliac "emoral) o" the lower etremities. +t is a common complication o" hospitaliation surger* and immo#ilit* or inactivit*. This client is at greater risk due to prolonged inactivit* "rom traveling.
Although 92T can #e silent clinical mani"estations characteristic o" a lower-etremit* 92T include unilateral edema cal' pain or tenderness to touch armth and erythema and low-grade temperature. @omans sign is increased resistance or cal" pain that occurs on dorsi"leion o" the "oot. ;ecause it can #e caused #* conditions other than 92T (muscle in0ur*) and is o"ten "alse positive or "alse negative it is not a relia#le diagnostic sign. ;etter diagnostic screening tests include serum 9-dimer and ultrasound studies. (Option 1) ;lue c*anotic toes are seen with acute arterial occlusion such as em#olism or severe vasoconstriction (eg use o" multiple vasopressors). (Option 3) 9r* shin* hairless skin is associated with chronic peripheral atherosclerotic arterial disease. @air "ollicles would not grow with lack o" #lood suppl*. !ducational o"#ecti$e% :linical mani"estations characteristic o" a lower-etremit* 92T include unilateral edema cal" pain or tenderness to touch warmth and er*thema and low-grade temperature.
hich o" the "ollowing "indings re"lect concerning vital signs that re,uire "urther nursing assessment and intervention! Select all that apply. *fter al+uterol administration, 5-year-old client reports tremor and has pulse "2$!min ". *fter hydromorphone " m intra/enous push 014, decreases from "3$!)$ mm to ""$!#$ mm 2. (lient recei/in +lood transfusion7 pre-infusion: "2$!)$ mm and pulse )$!min7 now: $!#$ mm and "$$!min
3. 9etal heart rate monitored durin la+or chanes from "8$!min to "$$!min with decelerations
8. urse preparin to administer prescri+ed nifedipine7 +lood pressure is $!6$ mm
5.
:orrect Answered correctl*
86> Time3
= seconds
Updated3 '=%57%5'&8
!,planation%
cute hemolytic reaction during a #lood trans"usion usuall* develops within the 'irst 1 minutes . 1igns%s*mptoms include chills "ever lower #ack pain ("rom damaged cells in the kidne*s)
tach*cardia tach*pnea and h*potension. Acute hemol*tic reaction is an emergency that re,uires the nurse to stop the trans'usion and treat shock. Normal "etal heart tones are &&'-&?'%min. 9ecrease in heart rate with decelerations could indicate uteroplacental insu''iciency and must #e assessed. Ni"edipine (Procardia) is a potent calcium channel #locker antih*pertensive. +t should not #e administered when the clients ;P is on the lower end o" the accepta#le range as this ma* result in hypotension. (Option 1) Al#uterol (2entolin) is a #ronchodilator #eta-adrenergic agonist. 4pected side e""ects include tremor tach*cardia and palpitation. Normal pulse rate in a 8-*ear-old can #e C'-&5'%min and averages &''%min. This is the upper limit o" epected "indings. (Option 2) This is the upper normal dosing limit "or initial +2P administration o" h*dromorphone (9ilaudid) a potent narcotic. @*potension and #rad*cardia are epected adverse e""ects. /rthostatic h*potension occurs most o"ten with am#ulation or positioning in the semi-Bowlers position. :lients are not ordinaril* allowed to #e am#ulator* "or 5'-6' minutes a"ter +2P administration o" narcotics. This one-time reading is not signi"icant enough to re,uire emergenc* intervention. !ducational o"#ecti$e% ;eta-adrenergic agents have an epected side e""ect o" tremor or palpitations and narcotics can cause mild h*potension or #rad*cardia. +ntervention is not necessar* unless the values are signi"icant or the client #ecomes s*mptomatic.
A health care provider (@:P) prescri#es ce"uroime 6' mg%kg%da* P/ divided in e,ual doses ever* &5 hours "or a child with a urinar* tract in"ection. The child weighs 65 l#. ;ased on the ce"uroime la#el how man* milliliters would the nurse administer per dose! =ecord your anser using one decimal place . :lic> the e,hi"it "utton 'or additional in'ormation . Answer3
(mL)
2/2.2 B 1".$" ".2/day
A health care provider (@:P) prescri#es ce"uroime 6' mg%kg%da* P/ divided in e,ual doses ever* &5 hours "or a child with a urinar* tract in"ection. The child weighs 65 l#. ;ased on the ce"uroime la#el how man* milliliters would the nurse administer per dose! =ecord your anser using one decimal place . :lic> the e,hi"it "utton 'or additional in'ormation .
Answer3
(mL)
The steps #elow should #e used to calculate the amount o" ce"uroime that needs to #e administered per dose3
1. 'onvert pounds to kilograms 71 kg B 2.2 lb:
2 lb C 2.2 lb B 1".$"$"$" kg
2. 'alculate prescribed amount per day in milligrams
0 mg/kg = 1".$"$"$" kg B ".2 mg
. 'alculate prescribed amount per dose in milligrams
".2 mg C 2 daily doses B 218.1818 mg
". 'onvert prescribed dose rom milligrams to milliliters(
3esired = Duantity Available
2").")") m B 5 mL D 25$ m E 8.3636 mL 0round up to 8.8 mL4
64
4atio/proportion
25$ m D 5 mL E 2").")") m D F mL F E 8.3636 mL 0round up to 8.8 mL4
!ducational o"#ecti$e% To calculate pediatric doses that are prescri#ed in mg%kg%da* "ormat the nurse should convert pounds to kilograms calculate the prescri#ed amount per da* in m illigrams calculate the prescri#ed dose in milligrams and then convert the prescri#ed dose "rom milligrams to milliliters.
The unit sta"" consists o" a registered nurse (RN) a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP). hich are the "est tasks "or the charge nurse to assign to the LPN! Select all that apply. *dminister a clientGs daily dose of su+cutaneous heparin
". *dminister a scheduled oral analesic to a 2 days postoperati/e client
2. (omplete an admission nursin inter/iew for a client admitted for electi/e h ysterectomy 3. 'einforce teachin on self-administration of daily insulin to a new client with dia+etes
8. Tally the shiftGs inta
Administering regular oral and in0ection medicationsM the scope o" practice related to narcotics and intravenous medications varies #*
!,planation% !,planation%
The LPN can per"orm higher-level skills in sta"le clients. These skills include3 •
Administering regular oral and in0ection medicationsM the scope o" practice related to narcotics and intravenous medications varies #* state
•
Per"orming sterile procedures (eg dressing changes)
•
1uctioning and tu#e "eedings
•
@igher-level assessments (eg #owel sounds apical pulse)
+t is prudent to assign clients epected to re,uire "re,uent scheduled medications to the LPN as that process can #e time consuming. RNs should provide initial client education to evaluate the clients comprehension and a#ilit*M LPNs can rein'orce teaching especiall* on #asic skills such as insulin administration. (Option 3) The RN should conduct the initial assessment%admission as this involves anal*sis and planning the clients care plan. The LPN could #e assigned speci"ic tasks within the process (eg o#taining a set o" vital signs). The responsi#ilit* o" the entire process however should remain under the RNs responsi#ilit*. (Option ) +t is important that the LPNs skill set not #e underutilied. +t is not cost-e""ective "or the LPN to #e assigned routine tasks that the UAP could per"orm.
!ducational o"#ecti$e% LPNs are assigned higher-level skills in sta"le clients. These include routine oral and in0ection medications per"orming sterile procedures and rein"orcing teaching initiall* per"ormed #* an RN. +t is not cost-e""ective to have the LPN assigned to routine tasks that the UAP could per"orm.
A client with a hip "racture is placed in ;ucks traction. hich nursing intervention is most important when caring "or this client! Heepin the eBtremity a+o/e the clientGs heart le/el ?"6%@ ". ain assessment and analesia use e/ery 2 hours ?8%@
2. S
3. Turnin the client, usin an a+duction pillow, e/ery 2 hours ?2"%@ 8.
;ucks skin traction is used to immo#ilie a "ractured hip and reduce pain and swelling until the client can #e sta#ilied "or surger* (eg hip replacement internal "iation). A traction #oot is applied directl* to the skin #elow the "racture on the a""ected lower etremit*. The weight (8-&' l# F5.5?-7.8 kgG) connected #* a rope that passes through a pulle* is attached to the #oot. The client is positioned supine in the center o' the "ed. ;od* alignment is maintained with the direction o" the pull keeping the eight hanging 'reely and not touching the "loor. These clients are at increased risk "or impaired skin integrit* and neurovascular status as traction eerts pressure on nerves #lood vessels and so"t tissue. 1kin #reakdown can occur ver* ,uickl* especiall* at pressure points. There"ore the nurse should per"orm neuro$ascular (eg pulse capillar* re"ill color temperature sensation movement) and s>in assessments (eg heel dorsum o" "oot) e$ery 2 hours (Option 3). (Option 1) The etremit* in traction should #e kept a"o$e the clientAs heart le$el "or e""ective countertraction (#etween #od* and weights). @owever skin and neurovascular status assessments are a priorit*. (Option 2) Bre,uent pain assessments are important. The nurse should check neurovascular status #e"ore giving pain medication as the increasing pain ma* #e due to underl*ing nerve or muscle ischemia. (Option 4) o not turn a client in uc>As traction 'rom side to side . An a#duction pillow is used to maintain proper thigh and hip alignment in postoperative hip arthroplast*. The nurse encourages the client to use the overhead trapee to li"t move the upper #od* and change position "re,uentl*. !ducational o"#ecti$e% :lients with ;ucks skin traction re,uire neurovascular and skin assessments ever* 5 hours. Position the client supine in the center o" the #ed and maintain #od* alignment with the direction o" the pull keeping the weight hanging "reel*. 9o not turn the client "rom side to side.
hen caring "or an adult client who is in so"t wrist restraints what is the appropriate nursing action to prevent inter"erence with medical treatment! *ssess raden scale e/ery 2 hours ?)%@ ". *ssess peripheral circulation and neuro/ascular status e/ery hour ?63%@
2. &ffer liquids, nutrition, and toiletin e/ery 8 hours ?%@
3. 'elease the restraints and perform rane of motion eBercises 0'&=4 e/ery 3$ minutes ?"6%@ 8.
+ncorrect :orrect answer
5
Answered correctl*
?7> Wrist restraints can cause skin #reakdown and circulator* and neurovascular de"icits. According to the guidelines the nurse assesses s>in integrity and neuro$ascular status (eg pulses color skin temperature sensation movement) e$ery hour . (Option 1) The ;raden scale is a risk assessment tool used in acute and long-term care settings to identi"* clients at increased risk "or pressure ulcers. +t is usuall* per"ormed dail*. (Option 3) Unless the client is receiving continual +2 "luids enteral "eedings or has an indwelling urinar* catheter "luids nutrition and toileting are o""ered ever* 5 hours or as needed. (Option 4) Restraints are released R/ eercises are per"ormed and skin integrit* is assessed ever* 5 hours or as needed. !ducational o"#ecti$e% :lients in medical-surgical restraints used to prevent inter"erence with medical treatment are monitored and assessed according to "ederal state and regulator* agenc* guidelines. Iuidelines include client o#servation and assessment o" skin integrit* and neurovascular status ever* hourM restraint release and R/ eercises ever* 5 hoursM and o""ering "luids nutrition and toileting ever* 5 hours.
A home health nurse visits a client 5 weeks a"ter discharge "rom the hospital. The client eperienced an acute m*ocardial in"arction and su#se,uent heart "ailure. @ome medications are listed in the ehi#it. hich s*mptom reported #* the client is most concerning to the nurse! :lic> on the e,hi"it "utton 'or additional in'ormation . ome medications
*spirin: )" m +y mouth, daily (lopidorel: #5 m +y mouth, daily =etoprolol FL: 5$ m +y mouth, daily 9urosemide: 8$ m +y mouth, twice daily Lisinopril: 5 m +y mouth, daily *tor/astatin: 8$ m +y mouth, daily
ruisin easily, especially on arms ?36%@
". 9atiue ?3%@ 2. 9eelin depressed ?2%@ 3. =uscle cramps in les ?55%@
8.
:orrect Answered correctl*
88> Time3
76 seconds
Updated3 &&%56%5'&8
!,planation% !,planation% !,planation% !,planation%
The nurse would #e most concerned with the clients report o" muscle cramps in the legs. This could #e a sign o" h*pokalemia caused #* use o" the diuretic "urosemide or possi#l* a reaction "rom the statin medication atorvastatin. 0ypo>alemia ma* mani"est as muscle cramps& ea>ness& or paralysis and t*picall* starts with the leg muscles . @*pokalemia could #e dangerous in this client due to possi#le arrh*thmias in the presence o" eisting cardiac d*s"unction. The client ma* need to #e started on supplemental potassium and a high-potassium diet i" the serum potassium level is low. +" the potassium level is normal atorvastatin ma* #e responsi#le "or muscle cramps. (Option 1) ;ruising especiall* on the upper etremities is common with the use o" antiplatelet agents such as aspirin and clopidogrel. The nurse should teach the client to monitor "or other more severe signs o" #leeding such as #lood in the stool. (Option 2) The m*ocardial in"arction and heart "ailure have most likel* reduced the clients "unctional capacit* and can cause "atigue. ;eta #lockers such as metoprolol can also cause "atigue. This will improve with time and the nurse should talk to the client a#out possi#le cardiac reha#ilitation.
(Option 3) Beeling depressed is common a"ter an acute health-related event such as a m*ocardial in"arction. The client needs to #e evaluated "urther and ma* need an antidepressant. @owever "eelings o" depression are not immediatel* li"e-threatening unless the client ehi#its suicidal ideation. !ducational o"#ecti$e% The nurse should recognie muscle cramps in the legs as a possi#le sign o" h*pokalemia in the client taking diuretics. uscle cramps should #e reported to the health care provider in anticipation o" checking a potassium level adding a potassium supplement and instructing the client to eat potassium-rich "oods.
The nurse in the emergenc* department is assessing a &5-month-old diagnosed with intussusception. hich "indings should the nurse epect! Select all that apply. alpa+le oli/e-shaped mass in epiastrium ". alpa+le sausae-shaped mass in upper riht quadrant
2. roIectile /omitin containin +lood 3. Screamin and drawin the
8. Stool miBed with +lood and mucus
5.
:orrect
Answered correctl*
6=> Time3
76 seconds
Updated3 &5%&7%5'&8
!,planation% !,planation% !,planation% !,planation%
ntussusception is a common o#structive disorder in in"anc* that occurs when one segment o" the #owel telescopes into another. The classic clinical triad is intermittent& se$ere& crampy a"dominal painM a palpa#le @sausage
#elly@ stools. /ther mani"estations include inconsola#le cr*ing drawing the knees up to the chest during episodes o" pain and vomiting. The child ma* appear normal and com"orta#le #etween episodes. (Option 1) +n"ants with in"antile h*pertrophic p*loric stenosis o"ten present with ecessive hunger ("re,uent "eeder) a palpa#le olive-shaped mass in the epigastrium to the right o" the um#ilicus and pro0ectile vomiting (can #e up to 6 "eet). (Option 3) Pro0ectile vomiting (without #lood) is seen with p*loric stenosis and elevated intracranial pressure. ;lood* vomiting is seen with gastric ulcers and variceal #leed. +ntussusception causes non-pro0ectile vomiting that is usuall* non-#lood* #ut stools mied with mucus and #lood are seen. !ducational o"#ecti$e% The classic clinical triad o" intussusception is intermittent severe cramp* a#dominal painM a palpa#le sausage-shaped mass on the right side o" the a#domenM and currant 0ell* stools.
The nurse assesses a client diagnosed with acute pericarditis. hich assessment would re,uire immediate "ollow-up! 'lient reports chest pain that is worse with deep inspiration E11-F
1. 3istant heart tones and Gugular venous distension E-F
2. 'H showing *)5segment elevations in all leads E+-F . #ericardial riction rub auscultated at the let sternal border E1-F ".
:orrect Answered correctl*
6?>
Time3 5' seconds Updated3 '=%'7%5'&8
!,planation%
!,planation%
!,planation%
!,planation%
cute pericarditis is an in"lammation o" the pericardium the dou#le-walled mem#ranous sac that surrounds the heart. The in"lammation can cause pericardial e''usion a #uildup o" "luid #etween the pericardial la*ers. A serious sometimes "atal complication o" acute pericarditis is cardiac tamponade in which large amounts o" pericardial "luid cause the heart to #e s,ueeed and una#le to contract e""ectivel*. 0eart tones #ecome mu''led cardiac output and #lood pressure drop pulse increases and the client develops #ugular $enous distension pulsus paradous and narrowed pulse pressure. This li"e-threatening condition re,uires emergenc* pericardiocentesis (insertion o" a needle into the pericardial sac to remove the "luid). (Option 1) +n acute pericarditis the in"lamed la*ers o" the pericardium ru# against the heart and cause pain. This pain is o"ten worse with deep #reathing or in the supine position and is relieved #* sitting upright and leaning "orward. The client should #e placed in Bowlers or high Bowlers position "or com"ort.
(Option 3) +n acute pericarditis 1T-segment elevation is seen in almost all leads (as the entire pericardium is in"lamed). This is in contrast to acute m*ocardial in"arction in which 1T-segment elevation is seen in localied leads (depending on which vessel is occluded). (Option 4) Pericardial "riction ru# is an epected "inding with acute pericarditis. The ru##ing together o" the in"lamed pericardial la*ers causes the characteristic high-pitched leather* and scratch* sound. !ducational o"#ecti$e% A potentiall* lethal complication o" acute pericarditis is cardiac tamponade. 1igns o" tamponade include 0ugular venous distension distant heart sounds and decreased #lood pressure
The nurse prepares to instill dial*sate "or a client receiving peritoneal dial*sis. hich nursing action is priority! Ansurin that the drainae collection +a is +elow the le/el of the a+domen ?2"%@ ". lacin the client in semi-9owlerGs position ?)%@ 2. 'ecordin the characteristics 0e, color4 of output dialysate ?"2%@ 3. sin sterile technique when spi
8.
:orrect Answered correctl*
88> Time3
5$ seconds
Updated3 &&%'=%5'&8
!,planation% !,planation% !,planation% !,planation%
Peritoneal dialysis (P9) is a process that uses the a#dominal lining (peritoneum) as a semipermea#le mem#rane to dial*e a client whose kidne*s are not "unctioning properl*. A catheter is placed in the peritoneal cavit* "or in"using dial*sate (dial*sis "luid). 9ial*sate is in"used into the cavit* and then the tu#ing is clamped to allow the "luid to dwell "or a speci"ied period. A"ter the speci"ied dwell time the catheter is unclamped and the "luid (e""luent) drains out via gravit*. aste products and electrol*tes cross the mem#rane into the dial*sate during the dwell time with the aid o" added osmotic agents. Peritonitis an in"ection o" the peritoneal cavit* is a ma0or concern with P9. There is also a risk "or in"ection at the catheter eit site which can lead to peritonitis i" untreated. Using sterile techni?ue when spiking and attaching #ags o" dial*sate "luid to the clients catheter is a priorit* to prevent contamination and decrease the incidence o" in"ection. An* signs o" developing complications (eg cloud* e""luent low-grade "ever redness or tenderness o" the eit site) should #e reported to the health care provider. (Option 1) The catheter drainage #ag is placed #elow the level o" the a#domen to aid gravit* in "luid out"low (e""luent). The placement is important #ut not the highest priorit*.
(Option 2) The client is t*picall* placed in Bowlers or semi-Bowlers position to utilie gravit*. +" the out"low #ecomes sluggish the client can #e turned "rom side to side to increase "low. The positioning is important #ut not a priorit*. (Option 3) :loud* e""luent indicates in"ection #lood* e""luent indicates possi#le per"oration and #rown e""luent indicates suspected #owel per"oration. There"ore documenting the e""luent characteristics is important #ut not a priorit* over sterile techni,ue (prevention). !ducational o"#ecti$e% +n"ection (peritonitis) is a ma0or complication o" peritoneal dial*sis. Using sterile techni,ue when spiking and changing #ags o" dial*sate is a priorit* to avoid contamination and reduce the risk o" peritonitis.
The nurse is assigned to care "or 8 clients using assistance "rom eperienced unlicensed assistive personnel (UAP). hich tasks should the nurse assign to UAP! Select all that apply. Amptyin a urinary drainae +a and recordin output
". Amptyin and recharin a emo/ac drain 2. Ascortin a disruntled /isitor off the unit
3. ro/idin perineal care around the 9oley catheter with soap and water
8.
'eapplyin sequential compression de/ices
5.
+ncorrect :orrect answer
&78 Answered correctl*
7&> Time3
7& seconds
Updated3 &5%'=%5'&8
!,planation% !,planation% !,planation% !,planation%
+n order to delegate appropriatel* the nurse must o#serve the "ive rights o" delegation to ensure that UAP have the skills and eperience re,uired to per"orm the task. UAP are a#le to do #asic tasks that re,uire little assessment and are sa"e "or them to per"orm. /#taining a clean catch urine specimen empt*ing a urinar* drainage #ag (Option 1) and providing perineal care around the Bole* catheter with soap and water (Option 4) are all #asic tasks that can #e sa"el* per"ormed #* UAP. @owever specimen collection "rom a Bole* catheter is considered a sterile procedure and should not #e assigned to UAP. Reappl*ing se,uential compression devices can also #e delegated to UAP (Option ). (Option 2) A @emovac or ackson-Pratt wound drain needs to #e assessed to ensure it is working properl*. Although UAP can measure the drainage assessing the "unctioning o" the drain and the drainage as well as recharging the drain should #e per"ormed #* a nurse. (Option 3) ith a disgruntled visitor there ma* #e a need "or skilled communication to keep the situation "rom escalating. The visitor should #e escorted o"" the unit #* either a nurse or a securit* o""icer. !ducational o"#ecti$e% /#taining a clean catch urine specimen empt*ing a urinar* drainage #ag and providing perineal care around the Bole* catheter with soap and water are #asic tasks that can #e per"ormed sa"el* #* UAP.
The long-term care nurse is caring "or a client newl* diagnosed with macular degeneration. hich client statement would support this diagnosis! J1 ha/e +een seein small flashes of liht.J ?"3%@ ". J1 ha/e trou+le threadin my sewin needle7 1 ha/e to hold it at armGs lenth.J ?"2%@ 2. J1 notice that my peripheral /ision is +ecomin worse.J ?28%@ 3. J1 see a +lurry spot in the middle of the pae when 1 read.J ?8)%@
8.
:orrect Answered correctl*
7$> Time3
&$ seconds
Updated3 &5%&8%5'&8
!,planation% !,planation% !,planation% !,planation%
