The nurse is demonstrating the appropriate use of a car seat to a client. The nurse is demonstrating which level of prevention?
Rationale:
The nurse is demonstrating primary prevention. Primary prevention focuses on educating clients to prevent injury, which in this case involves the proper use of a car seat to ensure child safety.
B: Secondary This level involves early detection and intervention after a health issue has occurred, which is not relevant to the proactive education on car seat safety.
C: Tertiary This level aims at rehabilitation and management of existing health conditions, rather than preventing injuries, as demonstrated by the nurse's focus on car seat use.
D: Quaternary This level seeks to prevent unnecessary interventions and overmedicalization, which does not align with the educational demonstration of car seat safety that promotes injury prevention.
The nurse receives a prescription to administer dopamine at 5 mcg/kg/min. The nurse has a bag labeled with dopamine 200 mg in 250 mL of D5W on hand. The client weighs 81.81 kg (179.98 lbs). How many mL/hr will the nurse administer?
Rationale:
31 mL/hr
To calculate the infusion rate, first determine the required dose: 5 mcg/kg/min × 81.81 kg equals 409.05 mcg/min. Converting this to milligrams gives 0.40905 mg/min. With dopamine at 200 mg in 250 mL, the concentration is 0.8 mg/mL. Dividing the dose by the concentration shows an administration rate of 31 mL/hr.
A: 25 mL/hr This dosage does not meet the required 31 mL/hr, resulting in insufficient medication delivery to achieve the desired therapeutic effect for the client's weight.
B: 50 mL/hr This rate exceeds the necessary dosage, leading to potential overmedication, which could result in adverse effects and complications for the patient’s treatment plan.
C: 15 mL/hr This volume is drastically lower than the calculated requirement, indicating inadequate delivery of dopamine, which may compromise the client's treatment outcomes and therapeutic goals.
While preparing to change the dressing of a female patient with end-stage renal disease, the nurse notices that the patient's son is silently holding her hand and praying. Which of the following should be the nurse's initial action?
Rationale:
C: Leave the room quietly and come back after 15 minutes to change the client's dressing. This respects the emotional moment shared between the patient and her son, allowing them privacy during a significant time of need.
A: Continue preparing for the procedure in the room. This action would intrude on the vulnerable moment, potentially causing distress to both the patient and her son, disrupting their emotional connection.
B: Notify the chaplain. While this could provide support, it would delay immediate attention to the family's emotional needs, which are being addressed in the present moment.
D: Ask the son if he wants the nurse to join in prayer. This may disrupt their prayer, imposing on a private experience instead of honoring their need for solitude during this sensitive time.
Relaxin is a hormone that is released throughout a woman's pregnancy to help prepare her uterine ligaments for the growth of her fetus and uterus. A downside to relaxin is that it may:
Rationale:
Relaxin may lead to musculoskeletal injury due to loose ligaments. This hormone's role in softening and relaxing pelvic ligaments can increase the risk of injuries, as structural support becomes compromised during pregnancy.
A: Cause high blood pressure in some women. While hormonal changes can affect blood pressure, relaxin primarily influences ligament flexibility, not vascular function or blood pressure regulation.
C: Make urinating more difficult than normal. Relaxin does not have a direct impact on urinary function; its main effects are related to ligament laxity and joint stability during pregnancy.
D: Increase bowel motility. Although hormonal changes can affect digestion, relaxin specifically targets ligaments to facilitate fetal growth, and does not primarily influence gastrointestinal activity or motility.
The nurse is providing teaching to a client experiencing chronic constipation. Which of the following meals would be the best choice for this client in order to promote a bowel movement?
Rationale:
B: brussels sprouts and a whole grain roll. This meal is high in dietary fiber, which is essential for promoting regular bowel movements. The combination of vegetables and whole grains encourages intestinal health and digestive efficiency.
A: steak and a baked potato. While the potato provides some fiber, the high-fat content of steak may hinder digestion, making this choice less effective for addressing constipation.
C: white rice with chicken. White rice lacks fiber, which is crucial for alleviating constipation, and chicken does not contribute significantly to fiber intake, making this option unsuitable.
D: ham sandwich with tomato soup. The sandwich may contain processed ingredients, and tomato soup typically lacks adequate fiber, resulting in a meal that does not effectively support bowel regularity.
The nurse is planning a staff development conference about diabetic ketoacidosis (DKA). Which of the following information should the nurse include?
Rationale:
Elevating blood glucose levels by 50 to 75 mg/dL/hr is a targeted strategy in managing diabetic ketoacidosis. This rate ensures a controlled decrease while minimizing complications associated with rapid glucose fluctuations, aligning with established clinical guidelines.
B: Dextrose 5% in water (D5W) should be available to treat symptoms of hypoglycemia. This option doesn't pertain to DKA management, where hyperglycemia is the primary concern, not hypoglycemia.
C: Hypovolemia caused by DKA may be treated with 3% saline. While hypertonic saline can correct hyponatremia, it is not the standard treatment for the hypovolemic state in DKA.
D: The urine output would increase once regular insulin is initiated. Although insulin can influence urine output, this option lacks specificity as various factors affect renal function and fluid balance during DKA treatment.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 2 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child's sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
The nurse considers if the client may have an infection caused by a tick. Click to specify if the features are consistent with the disease process of Rocky Mountain spotted fever (RMSF) or Lyme Disease.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Fever
B
Petechial rash that becomes diffuse
C
Erythema migrans (bullseye rash)
D
Myalgia
E
Causative agent Rickettsia rickettsii
F
Causative agent Borrelia burgdorferi
Rationale:
C: Erythema migrans (bullseye rash) is a hallmark sign of Lyme Disease, which is characterized by a distinctive circular rash. This rash typically appears at the site of a tick bite, aligning with the child's recent camping trip.
A: Fever is common in various infections, but the child’s report of feeling 'warm' doesn’t strongly indicate Lyme Disease. Other symptoms play a more crucial role in diagnosis.
B: Petechial rash that becomes diffuse is indicative of Rocky Mountain spotted fever, not Lyme Disease. The vignette does not describe any such rash, which is essential for RMSF diagnosis.
D: Myalgia can occur in Lyme Disease but is not specific to it. The child's presenting symptoms focus more on the rash and lymphadenopathy, which signify Lyme Disease rather than general muscle pain.
E: Causative agent Rickettsia rickettsii refers to Rocky Mountain spotted fever. The nursing assessment highlights signs consistent with Lyme Disease, not RMSF, indicating a different infectious etiology.
F: Causative agent Borrelia burgdorferi is indeed associated with Lyme Disease, but the question centers on identifying symptoms rather than merely naming the pathogen responsible for the illness.
The nurse is caring for a 4-year-old client who suffered second and third-degree burns to the chest, abdomen, and legs. Vital signs: P 117, RR 44, BP 90/60, pulse oximetry reading 88% on room air. The nurse should initially
Rationale:
Obtain a prescription for intravenous fluid replacement. This is crucial for a child with significant burns, as they are at high risk for hypovolemic shock due to fluid loss and require immediate resuscitation.
B: Prepare the client for airway intubation. While airway protection is important, the priority in this situation is to address fluid resuscitation before considering intubation.
C: Perform wound care to the burned areas. Immediate wound care is necessary, but it cannot take precedence over stabilizing the patient’s hemodynamic status through fluid replacement first.
D: Review the client's laboratory data. Although laboratory data may provide important insights, immediate action regarding fluid resuscitation is essential for managing the child's critical condition effectively.
The nurse is discharging an adolescent with sickle cell disease. Which statement should the nurse include in the teaching?
Rationale:
Keep a water bottle with you at school so that you can stay hydrated. Staying well-hydrated is crucial for adolescents with sickle cell disease, as it helps prevent pain crises and maintains overall health. Ensuring constant access to fluids aids in the management of their condition and supports optimal physiological function.
B: Follow a high-calorie, high-protein diet. While nutrition is important, this statement alone does not address the specific hydration needs critical for managing sickle cell disease effectively.
C: Do not take the annual influenza vaccine. Vaccination is vital for sickle cell patients to prevent infections, which can lead to severe complications. This option contradicts essential health advice.
E: Daily aerobic exercise is recommended. Although exercise can be beneficial, it must be balanced with hydration needs; focusing solely on exercise overlooks the importance of proper fluid intake for these patients.
The nurse is collecting data on a client who is taking prescribed digoxin and furosemide. Which finding requires follow-up?
Rationale:
Vomiting and halos around lights indicate potential digoxin toxicity, which necessitates immediate follow-up. These symptoms are significant red flags that must be assessed to prevent serious complications arising from the medication.
A: Night sweats and headache do not directly correlate with digoxin or furosemide use, making them less urgent. They could stem from numerous unrelated causes requiring separate evaluation.
C: Fatigue and dry, flaky skin might suggest dehydration or other issues, but they are not specifically linked to the effects of digoxin or furosemide. Further investigation is warranted but not urgent.
D: Low blood pressure and dark urine could indicate dehydration or renal issues, yet they do not directly suggest digoxin toxicity. These findings require monitoring but are not as critical as option B.
The following scenario applies to the next 1 items
The nurse is caring for a 72-year-old client in the emergency department (ED)
Item 1 of 1
Nurses' Notes
1430: 72-year-old male was brought to the ED with reports of dyspnea, chest pain, diaphoresis, and restlessness. The client's daughter reports that he recently took a long drive across several states and that the symptoms started abruptly. The client's oxygen saturation was 80% on room air and improved to 86% on 100% FiO2 via a nonrebreather mask. The physician was immediately notified at this time of the client's condition and came to the bedside for evaluation.
1442: The physician ordered rapid sequence intubation medications for immediate endotracheal intubation (ETT). The physician intubated the client using a #8 ETT and connected the client to mechanical ventilation using assist-control at a tidal volume of 500 mL, rate of 12/minute, 100% FiO2, PEEP 5 cm H2O. Post-intubation vital signs: T 99° F (37° C), P110, RR 12, BP 90/62, pulse oximetry reading 98%.
The nurse has reviewed both of the Nurses' Note entries and is planning care for the client. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Request an order for a chest radiograph (x-ray)
B
Obtain an order for an arterial blood gas (ABG)
C
Collaborate with respiratory therapy to assist in the client's care
D
Place the client in low-Fowler's position
E
Request an order to administer an 0.45% saline intravenous fluid bolus
F
Turn the client every four hours
G
Suction the endotracheal tube (ETT) every two hours
Rationale:
Requesting an order for a chest radiograph (x-ray) is indicated. This imaging is essential to assess potential causes of dyspnea and chest pain, providing critical information for diagnosis and treatment planning, especially after intubation and mechanical ventilation initiation.
D: Place the client in low-Fowler's position. This position may hinder respiratory effort and is less effective for a client requiring mechanical ventilation and optimal oxygenation.
E: Request an order to administer a 0.45% saline intravenous fluid bolus. Administering hypotonic fluid could exacerbate potential fluid overload and impair respiratory function in this critically ill client.
G: Suction the endotracheal tube (ETT) every two hours. Routine suctioning can lead to complications such as airway trauma and should only be performed as clinically indicated, not on a fixed schedule.
The charge nurse has received a change-of-shift report on the following clients in the maternity unit. The nurse should first assess the client who
Rationale:
C: The client who is 32 weeks pregnant and admitted 2 hours ago with placenta previa, experiencing increased lower back pain, should be prioritized for assessment due to potential complications associated with this condition. Increased pain may indicate bleeding or placental issues requiring immediate attention to ensure both maternal and fetal safety.
A: Delivered a term newborn 2 days ago, reporting sweating and increased urinary frequency, indicates typical postpartum changes rather than immediate concerns, allowing for a lower priority in assessment.
B: At 15 weeks pregnant with hyperemesis gravidarum and increased nausea following a meal, this client is experiencing manageable symptoms that don’t suggest an urgent need for assessment compared to others.
D: In the first stage of labor with early decelerations, while monitoring is essential, this pattern typically does not indicate immediate distress, thus not necessitating the highest priority for assessment at this time.
The nurse is caring for a client who is edentulous. Which of the following diet orders should the nurse request from the healthcare provider?
Rationale:
B: a mechanical soft diet. This diet is appropriate for an edentulous client as it consists of foods that are easier to chew and swallow, ensuring adequate nutrition without causing discomfort or difficulty during eating.
A: a low sodium diet. This option does not address the specific needs of an edentulous client, focusing instead on sodium intake rather than food consistency and texture.
C: a renal diet. Primarily designed for individuals with kidney issues, this diet is irrelevant for someone who requires modifications for chewing and swallowing due to lack of teeth.
D: a high-fiber diet. While fiber is important, this diet may include hard-to-chew foods that could pose challenges for someone without teeth, potentially leading to difficulties in consumption.
The nurse is educating a group of students on the measles, mumps, and rubella (MMR) vaccine. Which statement, if made by the student, would indicate effective teaching?
Rationale:
C: It is safe for breastfeeding women to receive the MMR vaccine. This statement reflects accurate knowledge, as research supports that administering the MMR vaccine does not pose risks to breastfeeding infants, making it appropriate for nursing mothers.
A: Egg allergy is a contraindication to giving this vaccine. This assertion is misleading, as current guidelines indicate that individuals with egg allergies can safely receive the MMR vaccine.
B: This is a three-series vaccine that should be started at birth. The MMR vaccine is not given in a three-series format and is typically first administered at 12-15 months of age.
D: This vaccine is safe if the client is pregnant. Pregnant individuals should avoid the MMR vaccine due to potential risks to the fetus, as it contains live attenuated viruses.
The nurse is providing dietary education to a client with renal failure who is receiving hemodialysis. The nurse determines that the teaching has been effective when the client selects which items from the menu?
Rationale:
Blueberries, cream of wheat, coffee. This combination provides essential nutrients while being low in potassium and phosphorus, making it suitable for a client with renal failure undergoing hemodialysis.
B: Bacon, banana, orange juice. High in potassium and phosphorus, this selection poses a risk for clients with renal failure, potentially leading to complications during treatment.
C: Sausage, eggs, tomato juice. The sodium and phosphorus content in sausage and tomato juice can exacerbate renal issues, thus making this choice inappropriate for someone with renal failure.
D: Cured pork, grits, kiwi. Cured pork contains high sodium levels, while grits and kiwi are rich in potassium, which is contraindicated for clients on hemodialysis.
The nurse is preparing to administer prescribed intravenous phenytoin to a client with epilepsy. Prior to starting the infusion, the nurse should
Rationale:
Establish continuous cardiac monitoring. Continuous cardiac monitoring is essential prior to administering phenytoin intravenously due to the potential for cardiovascular side effects, including arrhythmias, especially in individuals with a history of seizures.
B: Obtain the serum peak level prior to infusion. Serum peak levels are measured post-infusion to evaluate drug efficacy and safety, not before starting the infusion process.
C: Initiate continuous electroencephalography (EEG) monitoring. EEG monitoring is generally used to assess brain activity but is not a prerequisite for administering intravenous phenytoin.
D: Insert an indwelling urinary catheter. Urinary catheterization is not necessary for phenytoin administration and does not address the immediate concerns related to cardiovascular stability during the infusion.
The med-surge nurse receives a report on a client who is legally blind. Which action by the nurse would be most likely to reduce this client's anxiety?
Rationale:
B: Orient the client to their room.
Providing orientation to the room alleviates anxiety by familiarizing the client with their surroundings. This proactive approach enhances their sense of safety and autonomy, mitigating feelings of vulnerability associated with their visual impairment.
A: Assign the client to a private room.
While privacy may offer comfort, it does not address the anxiety stemming from unfamiliarity and disorientation, which are significant factors for a legally blind individual in a hospital setting.
C: Request for a sitter to be assigned.
Having a sitter may provide companionship, but it does not actively engage the client in understanding their environment, leaving them potentially feeling isolated and still anxious about their surroundings.
D: Instruct the UAP to check on the client frequently.
Frequent checks can ensure safety but fail to empower the client through orientation, leaving them reliant on others instead of fostering their independence and confidence in navigating the space.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 2 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.†Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
The nurse is most concerned about the client developing ___ due to ___ and ___
Rationale:
The client is most concerned about developing ischemic stroke due to anticoagulant use and atrial fibrillation.
Atrial fibrillation increases the risk of thrombus formation, especially when combined with anticoagulants like warfarin. The client's irregular pulse and history of hypertension further heighten the likelihood of embolic events, making ischemic stroke a critical concern in his current condition.
B: intra-abdominal hemorrhage Significant assessment findings do not indicate abdominal trauma or bleeding; the client shows no signs of distention or pain, suggesting this is not a primary concern.
C: neurological assessment While ongoing neurological assessment is crucial, it is not the primary concern; the focus is on potential complications stemming from his underlying conditions and medication use.
E: pulse The pulse irregularity observed may indicate atrial fibrillation but does not directly pose a critical risk compared to the potential for stroke associated with anticoagulants.
F: anticoagulant use Although relevant, the mention of anticoagulant use alone does not encompass the broader risk context; it’s the combination with atrial fibrillation that raises immediate concern for ischemic stroke.
The following scenario applies to the next 1 items
The nurse is caring for a 23-year-old male in the psychiatry clinic
Item 1 of 1
History and Physical
Chief Complaint - 23-year-old male presents with his mother, who insists, 'he needs some help; all he does is work and play video games and doesn't socialize with anyone.'
History of Present Illness - 23-year-old Caucasian male presents with his mother with reports of his asociality starting to impact his life. He reports that while in high school, he had a degree of anxiety about socializing with his peers. He thought that as the years passed, it would get better.
He states his anxiety has declined, but he gets paranoid around individuals because they may want to 'do him wrong.' He cannot point to an example of maleficence caused by his friends. He states he doesn't have a problem with his self-esteem, but sometimes social situations are avoided because 'I can see ahead into the future, and I want to avoid people who can bring me harm through their negative energy.' The client reports that he spends his time playing video games, stating he likes games that are fantasy related because 'they take me a while.' He states he has a strong interest in tarot card readings, and for his close friends, he does provide readings. He did offer the examiner a tarot card reading. His interest in tarot cards came from his self-described ability to interpret the spirits of individuals and their auras.
He states that occasionally, he will browse social media and identify a quote or lyric that he feels 'was directed towards me.' The client is employed as an overnight hotel clerk, and his highest level of education is a high school diploma. The client has never been married and has no children. His last relationship was seven years ago, which was brief. He identifies himself as heterosexual. He has a distant criminal history of petty theft and identity theft. No history of violent crimes. He has never been incarcerated. He denies drinking alcohol. However, he does smoke marijuana 2-3x a week. He lives in the basement with his Mother and declines to move out because he has no plans.
Medical History - No past medical history, no past psychiatric history. The client has never been hospitalized—no family history of psychiatric illness.
Mental Status Examination - Alert and fully oriented; Fair concentration; No psychomotor retardation or agitation; Cooperative behavior; Adequately groomed; unkept hair that is bright green in color. He has multiple facial piercings (nose, eyebrow, lip). Speech is at a normal rate with a slightly increased volume Affect is bright, and he describes his mood as 'okay.' Denies suicidal or homicidal ideations. Intact insight and judgment
Complete the sentence below by choosing from the list of options. The client is at highest risk of developing ___ as evidenced by the client's ___
Rationale:
The client is at highest risk of developing schizotypal personality disorder as evidenced by the client's illogical thought content.
The client's experiences of paranoia, belief in negative energies, and his unusual interest in tarot readings reflect traits associated with schizotypal personality disorder, indicating a tendency towards social anxiety and eccentricity that heightens his risk for developing this condition.
A: antisocial personality disorder. The client's distant criminal history does not indicate a consistent pattern of behavior typical of antisocial personality disorder, which involves disregard for others’ rights and societal norms.
B: bipolar disorder. No signs of mood swings or manic episodes are present in the client's report, which focuses on anxiety and social avoidance rather than the mood instability characteristic of bipolar disorder.
D: dependent personality disorder. The client's living situation and lack of plans do not demonstrate the submissive behavior and reliance on others typical of dependent personality disorder, as he exhibits some independence.
F: criminal history. The client's petty theft and identity theft are not sufficient to suggest a heightened risk for developing a personality disorder without additional patterns of behavior indicating antisocial traits.
G: self-esteem. The client explicitly states that he does not have a problem with his self-esteem, which diminishes the likelihood of developing issues related to self-worth often seen in various personality disorders.
The nurse is reviewing a client's list of medications who has cystic fibrosis. The nurse anticipates a prescription for which medication?
Rationale:
A: Multivitamin A multivitamin is essential for clients with cystic fibrosis due to their malabsorption of nutrients. It helps to ensure they receive adequate fat-soluble vitamins and supports overall health management in this condition.
B: Aspirin This medication does not address the specific nutritional needs or respiratory complications associated with cystic fibrosis, making it unsuitable for the client's treatment plan.
C: Warfarin The use of warfarin, an anticoagulant, is unrelated to the management of cystic fibrosis and does not provide any therapeutic benefit for this client's condition.
D: Simvastatin This cholesterol-lowering medication is not indicated for cystic fibrosis patients, as their primary concerns revolve around nutrient absorption and respiratory function rather than cholesterol management.
E: Salmeterol While salmeterol may assist with respiratory function, it is less critical than a multivitamin for addressing the specific nutritional deficiencies in cystic fibrosis management.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 3 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child's sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
The client is demonstrating manifestations consistent with
Rationale:
The client is demonstrating manifestations consistent with Lyme disease. The raised, nonpainful lesion on the leg, along with a history of a camping trip, suggests a tick-borne illness like Lyme disease, particularly given the enlarged lymph node and the child's recent exposure to the outdoors.
A: influenza Symptoms do not align with influenza, which typically includes systemic signs like high fever and significant malaise, contrary to the client’s mild symptoms and localized skin lesion.
B: Rocky Mountain spotted fever The absence of fever, rash characteristics, and the specific history do not support this diagnosis, which is usually associated with a distinct rash and systemic illness.
D: None of the above Choosing this option disregards the clear indications of Lyme disease, particularly the skin lesion and lymphadenopathy following outdoor activity, which are characteristic of tick exposure.
The nurse is teaching a client with hypertension about dietary modifications. Which of the following statements by the client would require follow-up?
Rationale:
I'm glad I can still eat beef and pork daily. This statement indicates a misunderstanding of dietary recommendations for hypertension, as frequent consumption of red meats like beef and pork can contribute to elevated blood pressure levels.
B: I will need to get used to eating fruits and vegetables. This shows a willingness to adapt to healthier eating habits, which is essential for managing hypertension effectively.
C: I should avoid eating canned foods. This reflects an understanding of the need to limit sodium intake, as many canned foods contain high levels of salt that can raise blood pressure.
D: I already told my spouse to buy me some yogurt when I get home. This demonstrates a positive approach to incorporating healthier snacks, particularly if choosing low-fat or unsweetened options beneficial for hypertension management.
The nurse is caring for a client who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions?
Rationale:
Sertraline is prescribed for Major Depressive Disorder. This selective serotonin reuptake inhibitor effectively alleviates depressive symptoms, enhancing mood and overall emotional stability, making it a first-line treatment for this condition.
B: Attention Deficit Hyperactivity Disorder Sertraline does not target the core symptoms of ADHD, which typically require stimulants or non-stimulant medications, rendering it unsuitable for managing this disorder.
E: Bipolar Disorder While sertraline may be used cautiously in bipolar patients, it is not a primary treatment due to the risk of triggering manic episodes, necessitating mood stabilizers instead.
The nurse is caring for a client who is prescribed IV heparin. The client is prescribed 12 units/kg/hr. The client weighs 92 kgs (202.4 lbs). The heparin is labeled with 25,000 units in 250 mL of D5W. How many mL/hr should the client receive?
Rationale:
11 mL/hr.
To determine the infusion rate, first calculate the total units needed: 12 units/kg/hr × 92 kg = 1,104 units/hr. The concentration of heparin is 25,000 units in 250 mL, equating to 100 units/mL. Therefore, dividing 1,104 units by 100 units/mL results in 11 mL/hr for the client’s prescribed dosage.
A: 10 mL/hr This calculation would provide only 1,000 units/hr, which is insufficient for the client's required dose of 1,104 units/hr.
B: 12 mL/hr This choice exceeds the necessary dosage, resulting in an administration of 1,200 units/hr, which could lead to potential complications or overdose.
C: 13 mL/hr This option delivers an excessive 1,300 units/hr, significantly above the required 1,104 units/hr, risking adverse effects from an overdose of heparin.
The nurse is teaching a class on substance use disorders. It would be correct for the nurse to characterize physical dependence as
Rationale:
Physical dependence is a need for a drug to avoid physical withdrawal symptoms. This definition highlights the physiological aspect of dependence, where the body adapts to substances and experiences uncomfortable symptoms without them.
A: obsessive desire for the euphoric effects of a drug. This describes psychological dependence rather than physical dependence, which focuses on the body's adaptation and withdrawal symptoms rather than cravings for euphoria.
C: severe effects that may be life-threatening. While physical dependence can lead to serious health issues, this definition does not specifically address the necessity of the drug to prevent withdrawal symptoms.
D: unpleasant symptoms related to the absence of a drug. Although this hints at withdrawal, it lacks the critical component of the need for the drug to prevent those symptoms, missing the concept of dependence.
The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress?
Rationale:
Tachycardia indicates that the infant's body is responding to cold stress by increasing heart rate to maintain body temperature, suggesting inadequate thermoregulation and potential hypothermia in the 2-hour-old infant.
A: Shivering Infants typically do not shiver at this age; they rely on other mechanisms to generate heat, making shivering an unlikely early indicator of cold stress in neonates.
B: Hyperglycemia Elevated blood sugar levels do not directly signal cold stress; this condition might occur due to metabolic responses but is not a primary assessment finding for cold stress.
D: Bradypnea A decreased respiratory rate is not associated with cold stress, as infants typically exhibit increased respiratory rates to help regulate body temperature in response to cold exposure.
The nurse is triaging a child with suspected impetigo. Which action should the nurse take?
Rationale:
Initiate contact precautions. This action is essential for preventing the spread of impetigo, which is highly contagious and transmitted through direct contact with the infected skin or contaminated items.
A: Initiate droplet precautions. Droplet precautions are not necessary for impetigo, as the infection primarily spreads through direct skin contact rather than respiratory droplets.
B: Set up a decontamination room. A decontamination room is not warranted in this situation, as impetigo does not require such extensive measures for a localized skin infection.
C: Use a disposable blood pressure cuff. Using a disposable blood pressure cuff does not address the primary concern of preventing contact transmission, which is critical in managing impetigo.
E: Apply sterile gloves while examining the client. While applying sterile gloves is important for maintaining hygiene, it does not specifically address the requirement for contact precautions in this highly contagious condition.
The nurse is caring for a four-year-old child. While developing a plan of care, the nurse recognizes the child is in which stage of Erikson's stages of psychosocial development?
Rationale:
Initiative vs. Guilt. At four years old, children are typically exploring their abilities and initiating activities, which aligns with Erikson's stage of Initiative vs. Guilt, fostering creativity and leadership skills.
B: Autonomy vs. Shame and Doubt. This stage occurs during ages one to three, focusing on developing independence and self-control, which is not applicable to a four-year-old child.
C: Industry vs. Inferiority. This stage is relevant for children aged six to twelve, emphasizing competence and achievement in school and social settings, thus not fitting a four-year-old's developmental stage.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 5 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child's sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
Progress Notes
1401: The client was evaluated. The rash is localized, raised, and appears like a bullseye. The client has inguinal lymphadenopathy. The client's recent camping trip supports the probability of a vector-borne illness—specifically, Lyme disease.
Orders
• laboratory tests: IgM and IgG antibodies
• doxycycline 100 mg capsule p.o. twice daily for fourteen days
• discharge client home
• follow-up with a primary care physician in two weeks
The nurse reviews and executes the physician's orders. Which of the following actions should the nurse take when performing venipuncture on a 10-year-old client?
Rationale:
C: Demonstrate the procedure using a stuffed animal. This action helps familiarize the child with the process, alleviating anxiety and fostering cooperation during the venipuncture, which is essential for a successful outcome.
A: Identify the child by only checking their identification armband. This action does not engage the child or address their anxiety, which is critical for ensuring cooperation during a procedure.
B: Apply a cold compress to the area to promote vasodilation. Cold compresses constrict blood vessels rather than dilate them, potentially making venipuncture more difficult rather than easier for the child.
D: Allow the child to decide which arm they would like for the venipuncture. While this choice may empower the child, it does not specifically address anxiety or involve them in the learning process.
E: Ask the child if they want to help set up some equipment. While this could encourage involvement, it may not sufficiently prepare the child for the procedure itself, reducing overall effectiveness.
F: Offer the child a sedative to help them relax before the procedure. Sedatives can pose risks and may not be necessary if the child is adequately prepared through education and engagement.
The nurse is caring for a pregnant client at 28 weeks' gestation who presents to the emergency department with signs of preeclampsia. The primary healthcare provider (PHCP) orders magnesium sulfate. What potential complication should the nurse closely monitor for during magnesium sulfate administration?
Rationale:
Hyporeflexia. During magnesium sulfate administration, monitoring for hyporeflexia is crucial as it indicates potential toxicity or excessive magnesium levels, which can compromise neuromuscular function and necessitate prompt intervention.
A: Pulmonary edema. While magnesium sulfate can lead to fluid retention, pulmonary edema is not a direct complication of its administration and is more commonly associated with fluid overload or other conditions.
B: Hyperglycemia. Magnesium sulfate does not typically induce hyperglycemia; rather, it may affect glucose metabolism in other circumstances, making this option irrelevant in the context of its administration.
D: Increased fetal movement. Magnesium sulfate may actually lead to decreased fetal movement rather than increased, as it can cause sedation in both the mother and potentially the fetus, altering movement patterns.
The following scenario applies to the next 1 items
The nurse is caring for a client in active labor
Item 1 of 1
Nurses' Note
23-year-old primipara at 39 gestational weeks was admitted for induction via oxytocin. Currently, she is 100% effaced and 10 cm dilated. An internal fetal spiral electrode and intrauterine pressure catheter were placed. Uterine contractions are now 2 to 2.5 minutes apart, 70 to 90 seconds in duration. The fetal heart tracing showed decreased fetal heart rate following uterine contraction. This pattern was present in more than 50% of the uterine contractions.
Medications
Oxytocin via continuous infusion
Complete the following sentence from the list of options. Based on the fetal heart rate tracing, the client is experiencing ___ that is caused by ___
Rationale:
Late decelerations that are caused by reduced blood flow to the placenta. This situation indicates that the fetal heart rate decreases after contractions, suggesting an inadequate blood supply due to uteroplacental insufficiency, which is characteristic of late decelerations.
B: early decelerations Early decelerations occur simultaneously with contractions and are typically related to fetal head compression, not a decrease in blood flow like late decelerations.
C: variable decelerations Variable decelerations are abrupt changes in fetal heart rate due to umbilical cord compression, which differs from the prolonged decrease seen in late decelerations.
E: umbilical cord compression While umbilical cord compression can cause variable decelerations, it does not explain the consistent pattern of decreased heart rate following contractions, indicating a different issue.
F: fetal head compression Fetal head compression leads to early decelerations, which do not align with the observed late decelerations following contractions, indicating reduced placental blood flow instead.
The nurse is teaching a group of nursing students about the five rights of delegation. The nurse is correct to include that this involves the right
Rationale:
The right task is a critical component of the five rights of delegation. It ensures that nurses delegate appropriate responsibilities to the right individuals, maintaining patient safety and effective care delivery while adhering to legal and ethical standards.
A: intention Delegation does not focus on intention; rather, it emphasizes the specific tasks assigned to ensure clarity and accountability in nursing responsibilities.
B: alternative The concept of alternatives does not pertain to delegation rights; it is more about options in care rather than the delegation process itself.
C: assessment Assessment refers to evaluating patient needs and outcomes, which is distinct from the delegation rights that focus on assigning tasks to others effectively.
The nurse is caring for a client three hours postpartum after delivering a term newborn infant. Which assessment finding would indicate an early sign of postpartum hemorrhage?
Rationale:
A: Heart rate change from 80 to 125 bpm. An elevated heart rate, particularly postpartum, often signifies compensatory mechanisms in response to blood volume loss, indicating a risk for postpartum hemorrhage.
B: Blood pressure change from 125/90 to 119/82 mmHg. This slight drop in blood pressure does not typically indicate hemorrhage; rather, it could suggest normal postpartum adjustments or stable hemodynamics.
C: A decrease in respiratory rate from 22 to 16 breaths per minute. A reduced respiratory rate can reflect sedation or relaxation, not a direct indicator of postpartum hemorrhage or related complications.
D: Saturation of one peri-pad since delivery. This minimal saturation level suggests normal lochia flow; significant blood loss would typically result in quicker saturation and warrant further concern for hemorrhage.
The emergency department nurse is caring for a client with sudden onset of edema of the lips and acute shortness of breath following a bee sting. The nurse knows that the first-line medication for this presentation is:
Rationale:
D: Parenteral epinephrine is the first-line medication for acute allergic reactions, such as anaphylaxis from a bee sting. It rapidly reverses airway swelling and improves breathing by constricting blood vessels and dilating airways.
A: Oral diphenhydramine does not provide immediate relief for severe allergic reactions and is not suitable for acute airway compromise, as its onset of action is slower.
B: Nebulized albuterol primarily addresses bronchospasm and does not effectively manage the systemic effects of anaphylaxis, such as significant edema and cardiovascular instability that occur after a bee sting.
C: Oral prednisone takes hours to days to exert its anti-inflammatory effects and is not appropriate for immediate treatment in acute scenarios like anaphylaxis, where rapid intervention is crucial.
The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?
Rationale:
Hydrochlorothiazide for a client with hyperparathyroidism should be questioned. This medication can exacerbate hypercalcemia by promoting calcium reabsorption in the kidneys, potentially worsening the client’s condition related to parathyroid hormone imbalances.
A: Levothyroxine for a client with a myxedema coma is appropriate, as it addresses the severe hypothyroidism associated with this life-threatening condition, aiding in the restoration of metabolic function.
C: Hydrocortisone for a client with adrenal insufficiency is suitable since it replaces cortisol levels, crucial for managing the condition and preventing adrenal crisis, ensuring proper physiological function.
D: Regular insulin for a client with diabetic ketoacidosis is necessary, as it helps lower blood glucose levels and corrects metabolic acidosis effectively, supporting the management of the acute complication.
The nurse is teaching a group of students about incident reports. Which of the following statements made by the student would require further teaching?
Rationale:
Reporting can only be completed if it is within one hour after the event. Accurate incident reporting is crucial for proper documentation and follow-up; timing restrictions are not universally mandated, making this statement misleading and requiring clarification.
B: Witnesses to an incident should be mentioned in the report. Including witnesses is essential for accountability and can provide additional context and verification of the incident.
C: A client eloping does not require an incident report. Client elopement is a significant safety concern, necessitating documentation to ensure proper response measures and to prevent future occurrences.
D: A slip and fall by a client should be reported. Any incident involving a client’s safety, such as a slip and fall, requires documentation to address potential hazards and liability issues.
E: Incidents involving visitors do not have to be reported. All incidents, regardless of the individual involved, must be documented to maintain safety standards and address any liability concerns effectively.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 5 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.†Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Orders
• insert peripheral vascular access device
• serum type and screen
• transfuse two units of fresh frozen plasma
• perform a bedside swallow evaluation
• apply sequential compression devices
• obtain a complete metabolic panel (CMP)
The nurse has received orders from the physician. Select three (3) orders that the nurse should consider a priority.
Rationale:
Insert peripheral vascular access device, serum type and screen, and transfuse two units of fresh frozen plasma are the priority orders for the nurse.
Establishing vascular access and preparing for potential blood transfusions is crucial, especially with the client's elevated INR indicating a bleeding risk. The serum type and screen are essential for safe transfusion, ensuring compatibility and minimizing complications related to the subarachnoid hemorrhage.
D: Perform a bedside swallow evaluation. This order does not address the immediate risks associated with the client's hemorrhage and anticoagulation status, which requires urgent intervention.
E: Apply sequential compression devices. While important for preventing deep vein thrombosis, this order does not directly address the critical need for managing the client's bleeding and transfusion needs.
F: Obtain a complete metabolic panel. Although useful for overall assessment, this order is lower priority compared to immediate interventions required for the client's bleeding risk and anticoagulation management.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a pregnant client.
Item 1 of 1
Nurses' Notes
Emergency Department
0735: Client reports sudden onset of nausea and vomiting, heavy vaginal bleeding with dark red blood, frequent low-intensity contractions, lower abdominal pain rated 9/10 on the Numerical Rating Scale for past two hours, and dull lower back pain rated 2/10 on the Numerical Rating Scale for the past 24 hours. Client is 30 weeks gestation (G=4 T=3 P=0 A=0 L=3) and is Rh-positive. Vital signs: T 99.8 â° F (37.7 â° C), P 99, RR 16, BP 112/76, pulse oximetry reading 94% on room air. Uterine tenderness present with gentle palpation. Client states they are a one-pack per day cigarette smoker and denies any alcohol or illicit drug use.
The nurse reviews the client's admission data to begin the plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
initiate electronic fetal monitoring (EFM), administer Rh immune globulin, assess for signs of hyperemesis gravidarum, start peripheral access device, perform an ultrasound examination
B
placenta previa, preterm labor, placental abruption, preeclampsia
C
continuous electronic fetal monitoring (EFM), 24-hour urine specimen, strict intake & output, vital signs, serum creatinine levels
Rationale:
Placental abruption. This condition is characterized by the premature separation of the placenta from the uterine wall, leading to symptoms such as heavy vaginal bleeding, abdominal pain, and uterine tenderness, as observed in the client.
A: Initiate electronic fetal monitoring (EFM), administer Rh immune globulin, assess for signs of hyperemesis gravidarum, start peripheral access device, perform an ultrasound examination. EFM is essential for monitoring fetal well-being, but Rh immune globulin is not indicated in this situation.
C: Continuous electronic fetal monitoring (EFM), 24-hour urine specimen, strict intake & output, vital signs, serum creatinine levels. While monitoring vital signs is critical, the other parameters do not align with assessing placental abruption.
The nurse is planning care for a client with bipolar I disorder who is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care?
Rationale:
C: Provide structured solitary activities. This intervention is beneficial as it offers the client a calming environment, reduces overwhelming stimuli, and helps manage their energy levels during a manic episode.
A: Attend group therapy while hospitalized. Group therapy can be overstimulating for clients in a manic state, potentially escalating their symptoms and impairing their ability to engage meaningfully.
B: Confront aggressive behavior. Confrontation may provoke further aggression or agitation, escalating the situation rather than promoting de-escalation or providing support to the client in distress.
D: Provide small, frequent low-calorie foods. While nutrition is important, focusing solely on low-calorie foods may neglect the client's energy needs and fail to address their overall health during manic episodes.
The nurse is caring for a client with hypernatremia. Which prescribed intravenous fluid (IVF) would be appropriate?
Rationale:
A: Dextrose 5% in water (D5W)
D5W is appropriate for hypernatremia as it provides free water to help dilute serum sodium levels. This isotonic solution aids in rehydrating cells and restoring normal osmotic balance.
B: 3% saline
This option contains a hypertonic solution, which would exacerbate hypernatremia by increasing sodium concentrations rather than addressing the elevated levels effectively.
C: Lactated Ringer's 5% Dextrose in Water (D5LR)
Although it contains dextrose, this combination also includes electrolytes that may not sufficiently address hypernatremia, potentially complicating the client's sodium imbalance.
D: 0.9% saline
This isotonic saline does not provide the necessary free water to correct hypernatremia; it maintains sodium levels instead of diluting them, failing to resolve the condition adequately.
A nurse is working on discharging a client when the client expresses interest in becoming an organ donor. Which action by the nurse best facilitates the organ donation process?
Rationale:
Providing the client with information about how to register as an organ donor. This action directly supports the client’s desire to become an organ donor by offering essential guidance and resources necessary for the registration process, thereby ensuring their wishes can be honored in the future.
B: Advising the client to sign an organ donor card and carry it with them at all times. While helpful, this action focuses on a physical document rather than the registration process itself, which is foundational for organ donation.
C: Scheduling the client for immediate organ donation surgery upon expressing interest. This option misinterprets the organ donation process; immediate surgery is not feasible without proper consent and medical considerations being thoroughly addressed.
D: Assisting the client in completing advance directives specifying their wish for organ donation. Although related, advance directives encompass a broader scope of healthcare decisions and do not specifically facilitate the immediate registration for organ donation.
The nurse is conducting a community health course. The nurse recognizes which of the following would be an example of secondary prevention?
Rationale:
Sexually transmitted disease (STD) partner notification exemplifies secondary prevention as it aims to identify and treat individuals who have been exposed to an STD, thereby preventing further transmission and complications.
B: Human immunodeficiency virus (HIV) PrEP pre-exposure prophylaxis focuses on prevention before exposure, categorizing it as primary prevention rather than addressing existing health issues through intervention.
C: Reviewing safe food-handling practices in the home promotes health and prevents illness, falling under primary prevention as it seeks to avert health issues before they occur.
D: Cardiac rehabilitation following a heart attack serves as tertiary prevention aimed at managing and improving health after a disease event, rather than preventing the occurrence of future heart issues.