NEWW!! NCLEX-RN EXAM-NGN WITH VERIFIED SOLUTIONS 100% 2024/2025, Exams of Nursing

Download NEWW!! NCLEX-RN EXAM-NGN WITH VERIFIED SOLUTIONS 100% 2024/2025 and more Exams Nursing in PDF only on Docsity! Neww!! Nclex-Rn Exam-Ngn With Verified Solutions 100% 2024/2025 The nurse witnesses the collapse of a child while outdoors. The child is not breathing and has a pulse of 50/min. The nurse calls emergency services and ini<ates rescue breathing. A>er 2 minutes of rescue breaths, the child is s<ll not breathing and is pale with a pulse of 30/min. What is the nurse's next ac<on? 1. Ini<ate chest compressions Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse remains <60/min and there are signs of poor perfusion (skin pallor), the nurse should ini<ate chest compressions and reassess the pulse every 2 minutes The charger nurse is responsible for making room assignments mul<ple clients. Which pari of client assignments to a shared room is appropriate? 3. Client who had a bowel resec<on 1 day ago and client with asthma exacerba<on. When making room assignments, it is important to remember that a client with an ac<ve or suspected infec<on should not be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma exacerba<on does not have an infec<on and is not at risk for spreading infec<on to a client who had a recent bowel resec<on surgery. Brainpower Read More The clinic nurse is assessing a client who is being treated for depression and suicidal idea<on. Which client statement best indicates that the client is not currently at risk for suicide? 2. "I plan to aSend my grandchild's gradua<on next month" Clients receiving treatment for depression and suicidal idea<on must be carefully monitored for indica<ons of increasing suicidal intent. During a client interview, the nurse should assess: - Access to psychiatric medica<ons - Availability of help during a crisis (counselor, family) - Future goals and plans - Home and environment risks - Overall affect and level of energy - Possible access to weapons Clients who ar<culate long-term personal goals and family milestones are less likely to aSempt death by suicide The nurse is caring for a client who had an anterior wall myocardial infarc<on 2 days ago. The telemetry technician no<fies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority interven<on? 1. Administer potassium supplement In ventricular trigeminy, premature ventricular contrac<ons (pvcs) occur every third heartbeat. Myocardial injury (eg, myocardial infarc<on) predisposes the client to ectopy (eg, pvcs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia). Pvcs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emo<onal stress, s<mulants, fever, and Stage 1: Intact skin with nonblanchable redness Stage 2: Par<al-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead <ssue) may be present; undermining and tunneling may be present Pressure injuries are described as "unstageable" if the base is covered by necro<c <ssue or eschar A client with type 1 diabetes mellitus has prescrip<ons for NPH insulin and regular insulin. At 0730, the client's blood glucose level is 322 mg/dl (17.9 mmol/L), and the breakfast tray has arrived. What ac<on should the nurse take? Click the exhibit buSon for addi<onal informa<on. 4. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first Intermediate-ac<ng insulins (NPH) can be safely mixed with short-ac<ng (regular) and rapid-ac<ng (eg, lispro, aspart) insulins in one syringe. Regular insulin should be drawn into the syringe before intermediate-ac<ng insulin to avoid cross-contamina<ng mul<dose vials (mnemonic - RN: Regular before NPH). To prepare the mixed dose: Inject 25 units of air into the NPH insulin vial without inver<ng the vial or passing the needle into the solu<on. Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles. Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the syringe will necessitate was<ng the en<re quan<ty. A client is receiving packed rbcs intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescrip<on to begin intravenous piggyback (IVPB) amphotericin B. What is the nurse's best ac<on? 4. Wait 1 hour a>er blood transfusion finishes administering amphotericin B Amphotericin B is an an<fungal medica<on used to treat systemic fungal infec<ons. It is commonly associated with severe adverse effects, including hypotension, fever, chills, and nephrotoxicity. Due to the similarity between the adverse effects of amphotericin B and the symptoms of a blood transfusion reac<on (eg, chills, fever, hypotension, kidney injury), the nurse's best ac<on is to complete the blood transfusion and allow one hour of observa<on before ini<a<ng amphotericin B (Op<on 4). This enables the nurse to dis<nguish between transfusion-related reac<ons and adverse effects from amphotericin B. Findings that require further inves<ga<on in a client with penetra<ng stab wounds to the neck, chest, and/or abdomen include: Unilateral chest wall expansion (one side of the chest expands more than the other) and diminished breath sounds, which indicate the presence of air (eg, open pneumothorax) or fluid in the pleural space (eg, hemothorax, pleural effusion) Vital sign instability (eg, tachycardia, hypotension, tachypnea, hypoxemia) and signs of poor perfusion (eg, skin pallor), which are concerning for hemorrhage and respiratory compromise For each finding below, click to specify if the finding is consistent with the disease process of hemothorax or tension pneumothorax. Each finding may support more than one disease process. Hemothorax: results from the accumula<on of blood loss in the pleural cavity -- > loss of intravascular blood vlolume: tachycardia, hypotension, unilateral diminished breath sounds Pneumothorax is characterized by air inside the pleural space, which disrupts the nega<ve pressure that maintains lung expansion, causing the lung to collapse either par<ally or completely. Tension pneumothorax develops if air enters but cannot escape the pleural space --> this trapping compresses the heart and great vessels and displaces the midline structures (trachea) to the opposite side. Tension pneumothorax: tachycardia, hypotension, subcutaneous emphysema/crepitus on palpita<on (air gets into the <ssue under the skin), unilateral diminished breath sounds (also tracheal devia<on, hyperresonance to percussion) Endoctracheal intuba<on would worsen the exis<ng pneumothorax by delivering posi<ve pressure ven<la<on, which would increase intrathoracic pressure ==> compress the heart and great vessels and lead to cardiac arrest. Which interven<on does the nurse an<cipate next? WRONG 4. Chest tube inser<on A tension pneumothorax is life-threatening and requires immediate chest tube placement to decompress the pleural space, promote reexpansion of the A>er listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory repor<ng? 4. 5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures a>er falling from a tree Signs of abuse may include: Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures) Burns in the shape of household items (eg, iron, spatula), from cigareSes, or from immersion in scalding liquid Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Op;on 4) Injuries to genitalia Lapsed <me between the injury and the <me when care is sought Inconsistency between the injury and the caregiver's explana<on of the injury (eg, client's developmental age, mechanism of injury) The nurses on a medical-surgical unit maintain a public social media page. Which of the following social media posts wriSen by a nurse breaches client confiden<ality? Select all that apply. 1. "I private-messaged everyone a cute story about our sweet client with demen<a." 2. "It breaks my heart that our paraplegic client was so neglected by her husband." 4. "The client in room 5 is posi<ve for influenza, so please remember your flu vaccines!" 5. "Wash your hands well if you had room 4 this week! Cultures are posi<ve for Clostridioides difficile." The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks unlicensed assis<ve personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inser<ng the urinary catheter. All op;ons must be used. 1. Perform hand hygiene and open sterile urinary catheteriza<on kit 2. Apply sterile gloves and place fenestrated drape with shiny side down 3. Use nondominant hand to grasp penis below glans 4. Use dominant hand to cleanse meatus with coSon balls or swab s<cks 5. Use dominant hand to insert catheter un<l urine return is observed 6. Advance catheter to tubing bifurca<on and inflate balloon The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 meq/L (5.2 mmol/L) to plan menu choices. Which items would be best to include in the meal plan? WRONG 2. Grilled chicken sandwich on white bread, applesauce Clients with end-stage renal disease are unable to excrete potassium; therefore, the nurse should teach them to choose foods low in potassium to maintain normal serum potassium levels (3.5-5.0 meq/L [3.5-5.0 mmol/L]). Grilled chicken sandwich on white bread and applesauce are low in potassium These clients should avoid foods high in potassium (eg, green leafy and cruciferous vegetables; legumes; melons; bananas; strawberries; milk and milk products; most beef, fish, and shellfish; and whole grains) to maintain normal serum potassium levels When caring for a client with ulcera<ve coli<s, which of the following nursing ac<vi<es are appropriate for the registered nurse to delegate to the licensed prac<cal nurse? Select all that apply. WRONG 1. Administer a prescribed suppository 2. Monitor for a change in bowel sounds 3. Remind the client to track daily weights Ulcera;ve coli;s (UC) is a chronic disease characterized by inflamma;on and ulcera;ons in the large intes;nes, resul;ng in urgent, frequent, bloody diarrhea; abdominal pain; fever; and fa;gue. Frequent diarrhea may cause weight loss and electrolyte imbalances; therefore, the client should be taught to measure daily weights. the nurse ques;on? Select all that apply. Click on the exhibit buUon for addi;onal informa;on. 2. Con<nue home dose of valsartan -Chronic kidney disease impairs the excre<on of excess potassium and can poten<ate hyperkalemia, which can lead to life-threatening arrhythmias (eg, ventricular fibrilla<on). ACE inhibitors (eg, lisinopril, ramipril) or angiotensin II receptor blockers (eg, valsartan, losartan, irbesartan) can be used to manage hypertension secondary to renal disease; however, these drugs can worsen hyperkalemia 3. Obtain CT scan of abdomen with contrast - Clients with chronic kidney disease and elevated crea<nine are unable to excrete the iodinated contrast administered for CT scans. Toxic effects from the contrast can occur; therefore, this prescrip<on should be clarified before the scan. Urosepsis is a type of bloodstream infec;on that originates from the urinary tract. The ini<al treatment of sepsis focuses on the management or preven<on of sep<c shock, mainly by administering boluses of isotonic IV fluids (fluid resuscita<on) and IV broad-spectrum an;bio;cs (Op;on 1). Blood and urine cultures are obtained, ideally before the first dose of an<bio<cs (Op;on 4). Con<nuous vital sign and cardiac telemetry monitoring are ini<ated as hyperkalemia (high potassium of 6.5) and sepsis cause cardiovascular disturbances (eg, dysrhythmias and hypotension, respec<vely) While the nurse and unlicensed assis<ve personnel are turning an intubated and heavily sedated client during a bath, the client coughs and expels the endotracheal tube. What is the priority nursing ac<on? 2. Deliver rescue breathing with a bag-valve-mask aSached to 100% oxygen If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-<lt chin-li> or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve- mask with 100% oxygen un<l reintuba<on is achieved (Op;on 2). Code blue should only be ini<ated if cardiac arrest occurs A client is at 28 weeks gesta<on with suspected preeclampsia. Which of the following signs/symptoms indicate that the client has developed this syndrome? Select all that apply. 2. Epigastric pain 4. Headaches and blurry vision 5. Proteinuria Preeclampsia is a mul<system disorder that can occur during pregnancy and is defined as new-onset hypertension and proteinuria or signs of end-organ damage. Cerebral symptoms (eg, headache, visual changes) from severe hypertension and/or epigastric pain secondary to decreased liver perfusion and hepa<c damage can occur. Pregnancy causes an intravascular volume expansion larger than the rise in the number of red blood cells, resul<ng in hemodilu<on. The nurse is performing a medica<on reconcilia<on during a clinic visit with a client recently prescribed lithium. Which of the client's home medica<ons is the priority to clarify with the health care provider? 2. Hydrochlorothiazide Lithium is a mood stabilizer most o>en used to treat bipolar affec<ve disorders. Lithium has a very narrow therapeu;c index (0.8-1.2 meq/L [0.8-1.2 mmol/L]) that should be closely monitored; it also has the poten<al for many drug interac;ons. Several medica<ons can cause increased lithium levels, including thiazide diure<cs (eg, hydrochlorothiazide), nonsteroidal an<-inflammatory drugs, and an<depressants. Thiazide diure;cs have demonstrated the greatest poten;al to increase lithium concentra;ons, with a possible 25%-40% increase in concentra<ons (Op;on 2). The nurse should assess the client for signs and symptoms of lithium toxicity and report the findings to the health care provider. We have an expert-wriUen solu;on to this problem! Four pediatric clients are brought to the emergency department at the same <me. Which client should be seen first? 3. Child with bruising behind the ears a>er a football injury Bruising behind the ear (eg, BaSle sign) following head trauma may indicate a basilar skull fracture (Op;on 3). Because of their close proximity to the brainstem, basilar skull fractures pose a risk of serious intracranial injury, which is the most common cause of trauma;c death in children. Other signs include blood behind the tympanic membrane, periorbital hematomas (ie, raccoon eyes), and cerebrospinal fluid leakage from the nose or ears. This client The ostomy bag is emp<ed when one-third full. The client with a colostomy is encouraged to drink plenty of fluids to prevent dehydra<on (the semiliquid consistency of stool from an ascending colostomy results in increased fluid loss) and decrease intake of gas-forming foods (beans, onions, broccoli). The nurse in an ambulatory surgery center triages telephone messages from clients. Which client should the nurse call back first? 4. Client who underwent placement of an arteriovenous gra> who reports a temperature of 100.9 F (38.3 C) - Arteriovenous (AV) gra` placement involves surgical connec<on of an artery and a vein using a synthe<c material to gra> a hemodialysis access site. Postopera;ve infec;on of an AV gra> may cause thrombosis, gra` failure, or systemic infec;on. Fever in a postopera<ve client may indicate infec<on of the gra> site, which warrants immediate no<fica<on of the health care provider (HCP); this client may require an<bio<cs and surgical removal of the gra` (Op;on 4). The nurse is planning care for a client with bipolar disorder and acute mania who is being admiSed involuntarily a>er aSemp<ng to run across a five- lane highway. Which interven<on is the priority to include in the care plan? 3. Offer high-calorie snacks the client can eat while on the move and during tasks When caring for a client with mania, the nurse should priori;ze physiological needs over psychological or self-fulfillment needs. The nurse can address imbalanced nutri<on in a manic client by providing high- calorie snacks and finger foods that the client can carry and eat without having to sit down. Bipolar disorder is characterized by alterna<ng episodes of depression and mania. Manic clients demonstrate hyperac<vity and distrac<bility and may refuse to sit s<ll long enough to drink or eat, placing them at risk for inadequate nutri<onal intake. Click to highlight below the 2 findings that are a safety concern. 1. Clients may forget to take medica;ons due to cogni<ve decline, limited hand mobility, and sensory altera<ons. This can be problema<c because older adults o>en have various health condi<ons and take mul<ple medica<ons. Clients can have difficulty remembering familiar faces and the surrounding environment; they will o>en become disoriented (eg, wandering and lost in the neighborhood). This becomes a safety risk because they are unable to find their way back home and can become lost for long periods of <me. Becoming more withdrawn indicates the client may be feeling depressed. The nurse should assess for other symptoms of depression (eg, hopelessness, loss of pleasure); however, this finding does not pose an immediate safety concern. For each characteris<c below, click to specify if the characteris<c is consistent with the disease process of Alzheimer disease or delirium. Alzheimer Disease: irreversible, hallucina<ons, speech changes (word-finding difficul<es_ Delirium: acute onset, hallucina<ons, speech changes Alzheimer disease is an irreversible, progressive form of demen<a. Speech changes, and memory and social skills slowly decline as the disease progresses, while hallucina<ons tend to appear later in the course of the disease. Delirium is an acute, reversible, altera<on in mental state involving a reduced or fluctua<ng level of consciousness, speech changes, and hallucina<ons. Complete the following sentence by choosing from the list of op<ons. The nurse suspects the client's condi<on is caused by Neurodegenera<ve changes in the brain Alzheimer disease (AD) is caused by neurodegenera;ve changes in the brain. As individuals age, some develop insoluble amyloid plaques in the brain <ssue. Amyloid plaques cause an inflammatory response that leads to cell damage and neuron death in surrounding areas. In clients with AD, more plaques are apparent, especially in areas of the brain that are essen<al for memory and cogni<ve func<on (eg, hippocampus). Ul<mately, plaques will involve other areas of the brain, including the parts responsible for language and reasoning (eg, cerebral cortex). In addi<on to excess amyloid plaques, clients with AD also have abnormal accumula<ons of twisted protein (tau) that collect inside nerve cells and cause neuronal death. The brain will eventually shrink by the final stage of the disease. The client is aSemp<ng to remove a newly inserted peripheral IV. Which of the following interven<ons are appropriate at this <me? Select all that apply. 2.Ask the unlicensed assis<ve personnel to stay with the client un<l a siSer is available 3.Play the client's favorite music and look at family photos together therefore be able to draw simple shapes (eg, circle, square) and perform more self-care ac<vi<es (eg, ea<ng with a spoon and fork) (Op;ons 1 and 4). The gross motor skills and balance of a child age 4 improve, allowing for more independent, complex movements (eg, walking up and down stairs) (Op;on 5). It is normal for preschool-age children to be unable to sit quietly for longer than 15 minutes at a <me. Jump rope: age 5 The nurse in the public health clinic is caring for a client with pubic lice. Which of the following statements should the nurse include in the educa<on? Select all that apply. 2. Remove nits from pubic hair with a fine-toothed nit comb." 3."Sexual partners should also receive treatment." 4."Wash clothes and linens with hot water." 5."Wash pubic hair with lice treatment shampoo." Pediculosis pubis (ie, "crabs") is an infesta<on of pubic lice. Clients with pubic lice should be given the following instruc<ons: Use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair to kill lice (Op;on 5) A>er treatment, remove nits with a fine-toothed nit comb, fingernails, or tweezers (Op;on 2) Wash and dry clothes, towels, and bedding with hot water and highest- heat dryer setng (Op;on 4) Sexual partners should also receive pubic lice treatment (Op;on 3) A client with a history of a seizure disorder has a seizure while sitng in a chair. Which nursing interven<ons are appropriate for a client experiencing a seizure? 1. Administer oxygen as needed if client becomes cyano<c - Administer oxygen as needed in response to signs of hypoxia (eg, cyanosis, pallor) (Op;on 1). 3.Move the client from the chair to the floor to prevent a fall - Assist seated or standing clients to lie down (le> lateral) while protec<ng the head, and posi<on the client on the side to maintain a patent airway and prevent aspira<on 4.Record the dura<on of seizure ac<vity for documenta<on - Record and document the <me and dura;on of the seizure Loosen restric;ve clothing and clear the area near the client (eg, furniture corners, sharp or hard objects) to prevent injury. The nurse auscultates the lung sounds of a client with shortness of breath. Then, the nurse no<fies the health care provider about the adven<<ous sounds heard. Which medica<on prescrip<on should the nurse an<cipate? Listen to the audio clip. (Headphones are required for best audio quality.) 2. Bumetanide Coarse crackles = presence of fluid or mucus in lower respiratory tract -< pulmonary edema/fibrosis --> loop diure<c Coarse crackles (loud, low-pitched bubbling) are heard primarily during inspira<on and are not cleared by coughing. The sound is similar to that of Velcro being pulled apart. Coarse crackles may be confused with fine crackles (eg, atelectasis), which have a high-pitched, popping sound. Coarse crackles are present when fluid or mucus collects in the lower respiratory tract (eg, pulmonary edema, pulmonary fibrosis). During heart failure, the le> ventricle fails to eject enough blood, causing increased pressure in the pulmonary vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Loop diure;cs (eg, bumetanide, furosemide) treat pulmonary edema by reducing intravascular fluid volume through significant increase of fluid excre;on by the kidneys Clients with asthma or chronic obstruc<ve pulmonary disease (eg, emphysema) develop wheezing due to bronchospasm. Bronchodilators (eg, albuterol, ipratropium) and systemic cor<costeroids (eg, methylprednisolone) may be prescribed to these clients Upper respiratory infec<ons or chronic bronchi<s ==> guaifensin to loosen and improve the expectora<on of mucus We have an expert-wriUen solu;on to this problem! Math: The nurse is preparing to administer a con<nuous dopamine infusion at 5 mcg/kg/min. The client weighs 187 lb and the available medica<on contains 400 mg of dopamine in 250 ml of D5W. At what rate in milliliters per hour (ml/hr) should the nurse program the infusion pump? Answer: 16 Dopamine is an inotrope and vasopressor used to treat distribu<ve shock and maintain cardiac output. To calculate the dopamine infusion rate in milliliters per hour, the nurse should first iden<fy the prescribed dose (eg, 5 mcg/kg/min) 4."Since I am sexually ac<ve, I should receive the HPV vaccine series. Treatment for genital warts (eg, topical podophyllin, cryotherapy) is usually effec<ve but does not prevent warts from recurring (Op;on 1). High-risk HPV strains (eg, types 16 and 18) increase the risk of oral, genital, and cervical cancers (Op;on 3).The HPV vaccine helps prevent several HPV strains and is most effec<ve if received before ini<a<on of sexual ac<vity. Clients who are already sexually ac;ve may s;ll benefit from HPV vaccina;on (Op;on 4). (Op;on 2) Because HPV infec<on in females age <21 rarely progresses to malignancy, most clinical organiza<ons recommend ini<a<on of cervical cancer screening (eg, Pap tes<ng) at age 21, regardless of sexual history. Subsequently, overdiagnosis and treatment (eg, cervical excision procedures) leading to nega<ve future reproduc<ve outcomes (eg, preterm birth) are minimized. The charge nurse is making client assignments for the oncoming shi>. Which client assignment is most appropriate for a nurse who is 10 weeks pregnant? 3. Client with a methicillin-resistant Staphylococcus aureus wound infec<on Health care workers (hcws) who are pregnant do not carry a high risk for contrac<ng methicillin-resistant Staphylococcus aureus (MRSA) as long as appropriate infec<on precau<ons (ie, contact precau<ons) are in place (Op;on 3). Even if the HCW who is pregnant were to contract MRSA, there are few known harmful effects to the fetus. Because TORCH infec<ons (Toxoplasmosis, Other [eg, syphilis], Rubella, Cytomegalovirus, Herpes simplex virus) can cause fetal abnormali;es, hcws who are pregnant should not be assigned clients with these infec<ons. Clients receiving brachytherapy have radioac<ve implants placed in a body cavity. To safely care for these clients, hcws limit/cluster client <me and keep a distance of at least 6 > (1.8 m) unless wearing lead shielding for direct care. If possible, hcws who are pregnant should not care for these clients because fetal radia<on exposure is teratogenic. A nurse is caring for a client admiSed with unstable angina. A>er 5 minutes on an IV nitroglycerin infusion, the client reports improving chest pain but a new dull, throbbing headache. What is the appropriate nursing ac<on? 2. Document the finding and administer prescribed acetaminophen Nitroglycerin is an an;anginal medica;on that causes potent vasodila;on (both coronary and systemic) and is used in the treatment of acute coronary syndrome (eg, unstable angina, myocardial infarc;on). Vasodila<on relieves chest pain by decreasing venous return to the heart, resul<ng in decreased preload (ie, decreased oxygen demand). IV nitroglycerin administra<on requires con<nuous cardiac monitoring and frequent blood pressure assessment (ie, every 15 minutes for the first hour). Headache is an expected adverse effect from vasodila<on of cranial vessels and should decrease with con<nuing nitroglycerin therapy. As long as the client does not have severe hypotension (eg, systolic blood pressure <90 mm Hg), the finding can be documented and the headache treated with aspirin or acetaminophen (Op;on 2). If the headache becomes severe or persistent despite acetaminophen, the health care provider (HCP) may temporarily decrease the dosage. The nurse should not arbitrarily stop the infusion or decrease the rate. Which of the following situa<ons would be classified as an adverse event, requiring the nurse to complete an incident report? 1. Cerebrospinal fluid sample is sent to the laboratory labeled as a urine sample 3. Nurse fails to report a potassium of 6.5 meq/L (6.5 mmol/L) to the health care provider 4. Postpartum client a>er epidural anesthesia falls while ambula<ng to the bathroom 5.Provider prescribes 5000 units of heparin; nurse gives 1 ml (10,000 units/ml) of heparin An incident/adverse event is an unforeseen or unintended outcome that results in harm, or has the poten;al to cause harm, which may or may not have been preventable. Examples of client incidents include falls, mislabeled laboratory specimens, and medica;on administra;on errors (Op;ons 1, 4, and 5). Communica;on errors may also be classified as adverse events because the omission or miscommunica<on of cri<cal informa<on may result in harm, incomplete treatment, or inadequate follow-up (Op;on 3). Other incident types involving health care staff may include needles<ck injuries or confiden<ality breaches of protected health informa<on. A nurse is caring for a client at 37 weeks gesta<on who is undergoing a contrac<on stress test. Which fetal strip should the nurse associate with a nega<ve contrac<on stress test? A contrac;on stress test (CST) evaluates fetal well-being under stress by iden<fying uteroplacental insufficiency. Uterine blood flow is decreased during uterine contrac<ons, which stresses the fetus during labor. Contrac<ons are s<mulated using either oxytocin administra;on or nipple s;mula;on. A fetal tracing is evaluated un<l 3 uterine contrac<ons, each las<ng 40-60 seconds, are captured within 10 minutes. A nega<ve test has no late or variable decelera<ons and is associated with good fetal outcomes (Op;on 2). A posi<ve A client arrives in the emergency department with right-sided paralysis and slurred speech. The nurse understands that the client cannot receive thromboly<c therapy due to which reason? 4. Client's symptoms started 12 hours earlier Thromboly;c therapy (ie, t-PA) is used to dissolve blood clots and restore perfusion in clients with ischemic stroke. The nurse should assess for contraindica;ons to t-PA due to the risk for hemorrhage. Clients have a 3- to 4.5-hour window from onset of symptoms to receive t-PA to achieve full effec<veness of thromboly<c therapy Recent major surgery within the past 14 days is a contraindica;on because t- PA dissolves all clots in the body and may therefore disrupt the surgical site. -To receive t-PA, clients must have a systolic blood pressure (BP) ≤185 mm Hg and diastolic BP ≤110 mm Hg. In addi<on, BP should be maintained at ≤180/105 mm Hg throughout the administra<on of thromboly<c therapy and 24 hours therea>er - Loss of the gag reflex and other major func;ons would most likely make the client a candidate for thromboly;cs due to proof of deficits from stroke. Other contraindica/ons include hemorrhagic stroke and stroke or head trauma within the past 3 months. A nurse is teaching an inservice regarding preven<on of venous thromboembolism. Which nursing interven<ons should be included in the teaching? 1. Administer scheduled an<coagulants 2. Apply sequen<al compression devices 4. Have clients ambulate regularly as tolerated 5. Instruct clients to point and flex the feet in bed Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein thrombosis) forms and embolizes into the bloodstream (eg, pulmonary embolism). VTE prophylaxis should be implemented in all hospitalized clients. Measures include: Administra<on of an;coagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, ac<ve bleeding) (Op;on 1) Applica<on of compression devices or an<embolism stockings to limit venous stasis (Op;on 2) Frequent ambula;on, 4-6 <mes daily as tolerated, to improve circula<on and promote venous return (Op;on 4) Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by ac<va<ng calf muscles (Op;on 5) Eleva<ng the legs while in bed promotes venous return by gravity. However, the nurse should ensure that any pillows used to elevate the legs do not place pressure directly behind the knees, as pressure on the posterior knees compresses leg veins. Clients should also avoid crossing the legs to prevent pressure on the back of the knees. A student nurse is accompanying the charge nurse when conduc<ng daily rounds. Which personal protec<ve measure by the charge nurse does the student nurse ques<on? 3. Wears 2 pairs of gloves when emptying the urinary catheter collec<on bag of a client who is HIV posi<ve The best way for health care workers to protect themselves against possible HIV transmission is to consistently follow standard (universal) precau;ons with all clients, regardless of HIV status. HIV is transmiSed through contact with blood, breast milk, semen, and vaginal secre<ons. No extra precau;ons are needed for rou<ne care of clients that are HIV posi<ve because the virus is not spread through casual contact, droplets, or aerosolized par<cles. Some nurses have the common misconcep;on that double-gloving reduces the risk of contrac<ng HIV. Appropriate use of a single pair of clean gloves provides a barrier between the nurse's hands and the client's blood and body fluids (Op;on 3). In compliance with standard precau<ons, situa<ons in which blood or body fluids may splash or be sprayed (eg, suc<oning, irriga<on) require addi<onal personal protec<ve equipment (eg, face shield, gown) as necessary. A client comes to the emergency department with crushing substernal chest pain. Which of the following interven<ons should the nurse an<cipate? Select all that apply. 1. Administer IV pain medica<on 2. Check blood pressure and heart rate 3.Obtain a 12-lead ECG 4.Obtain blood specimens The nurse needs to quickly iden<fy the signs and symptoms of myocardial infarc;on and ini<ate interven<ons to preserve cardiac muscle. The nurse should also recognize that female and older clients may have nonspecific symptoms (eg, fa<gue, indiges<on, shortness of breath). Ini<al interven<ons in the emergency management of chest pain include: Frequent monitoring of the IV inser<on site for extravasa<on to prevent <ssue necrosis because Potassium is a vesicant (Op;on 2). Frequent monitoring of renal func<on laboratory results (eg, blood urea nitrogen, crea<nine) and urine output as clients with impaired renal func;on are unable to excrete potassium and other electrolytes effec<vely, poten<ally leading to toxicity (Op;on 3). Cardiac monitoring during therapy because changes in potassium levels can cause cardiac rhythm disturbances, and rapid infusion can cause cardiac arrest (Op;on 4). Maintaining a kcl maximum infusion rate of 10 meq/hr (10 mmol/hr) and the maximum concentra<on of 40 meq/L (40 mmol/L). Higher rates and concentra<ons require a central venous catheter (Op;on 5) Kcl is never administered by IV push or as a fluid bolus. Kcl is always diluted and given via infusion pump. A 2-month-old infant is admiSed with respiratory syncy<al virus and bronchioli<s. Which of the following interven<ons should the nurse an<cipate? 1. Administer an<pyre<cs 2.Ini<ate IV fluids 4.Maintain isola<on precau<ons 5.Suc<on as needed Administering an;pyre;cs to reduce fever and provide comfort (Op;on 1). Ini<a<ng IV fluids to correct dehydra<on due to fever, tachypnea, or poor oral intake (Op;on 2). Maintaining contact isola;on; droplet precau;ons are added if within 3 > (0.91 m) of the client, depending on the facility policy (Op;on 4). Providing supplemental oxygen and suc;oning to support oxygen exchange and clear the airway (Op;on 5). The nurse is preparing to don sterile gloves before suc<oning a client's tracheostomy. Place the steps of donning sterile gloves in the correct order The nondominant hand is used to apply the glove of the dominant hand first. Using the dominant hand to apply the second glove improves dexterity and decreases the risk of contamina<on of the gloved dominant hand. 1. Perform hand hygiene and remove the outer glove package (Place the inner glove package on a clean, dry surface) 2. Open the inner glove package by folding back the edges 3. Use the nondominant fingers to grasp the edge of the cuff of the dominant glove (touch only the inside surface of the glove) 4. Pull the glove over the dominant hand 5. Use the dominant fingers to grasp the cuff of the nondominant glove 4. Pull the glove over the nondominant hand Which 3 findings are most important for the nurse to report to the health care provider? 3. Heart Sounds - Heart sounds: A gra;ng, squeaky sound heard over the le> chest wall during S1 or S2 can indicate pericardial fric<on rub, which occurs when inflamed surfaces of the heart rub against each other. The nurse should have the client lean forward and auscultate at the end of expira<on to differen<ate between pericardial fric<on rub and pleural fric/on rub (caused by inflamed lung /ssue) 4. Pain Assessment -New-onset chest pain that worsens with deep breathing may indicate reinfarc<on or pulmonary embolism 5. Temperature -An elevated temperature (ie, ≥100.4 F [38 C]) within the first 3 postopera<ve days is a sign of an inflammatory process. Follow-up is required to determine whether it is related to nosocomial infec<on, post-MI complica<ons (eg, pericardi<s), or a noninfec<ous e<ology (eg, pulmonary embolism) ( Acute-onset pain s/mulates the sympathe/c nervous system and can cause a subsequent eleva/on in blood pressure. The client's blood pressure is only mildly elevated and is not most concerning at this /me. For each finding below, click to specify if the finding is consistent with the disease process of an acute myocardial infarc<on, pericardi<s, or pulmonary embolism. Each finding may support more than one disease proces Acute Myocardial Infarc<on: ST-segment eleva<on on ECG - Acute myocardial infarc<on (MI) occurs when at least one of the coronary arteries becomes occluded. An MI can cause ECG changes such as ST-segment eleva<on (STEMI), depending on the extent of coronary artery occlusion and myocardial wall infarc<on. Manifesta<ons include ischemic chest pain (ie, angina) that radiates to the back, le> arm, or jaw; nausea; and diaphoresis. The chest pain, however, is not relieved by leaning forward or worsened with deep breathing. A pericardial fric<on rub (ie, gra<ng, squeaky sound auscultated over the chest wall) does not occur with MI. Pericardi<s (swelling and irrita<on/inflamma<on of the thin, saclike <ssue surrounding the heart (pericardium) caused by viral infec<ons but occur following recent MI and surgery. ST-segment eleva<on on ECG, pain that worsens with deep breathing, chest pain relieved by leaning forward, gra<ng The nurse suspects the client is experiencing cardiac tamponade and measures the client's blood pressure. Which finding does the nurse expect? 1. Decrease in systolic blood pressure during inspira<on Signs of cardiac tamponade include tachycardia, muffled heart tones, jugular vein distension, and an abnormal decrease in systolic blood pressure (>10 mm Hg) with inspira;on (ie, pulsus paradoxus) A significant difference in blood pressure between the upper and lower extremi/es is caused by coarcta/on of the aorta. A widened pulse pressure (ie, significant difference between systolic and diastolic blood pressure) is seen when there is a large volume of blood to pump from the ventricles (eg, aor/c regurgita/on, hyperthyroidism). Cardiac tamponade wrap up Acute compression of the heart caused by fluid accumula<on in the pericardial cavity An emergency pericardiocentesis is performed to treat cardiac tamponade. The nurse understands that _________ indicates that the procedure was effec<ve. Answer: An increase in blood pressure A pericardiocentesis is the emergency treatment for cardiac tamponade. Pericardiocentesis involves percutaneous needle aspira<on to drain the fluid accumula<ng in the pericardium, which relieves elevated intrapericardial pressures and restores hemodynamic stability. An increase in blood pressure indicates that the procedure was effec<ve at relieving compression on the heart and restoring cardiac func<on. A nurse reviews the plan of care for a client who has increased intracranial pressure. Which of the following nursing ac<ons should be included? Select all that apply. 1. Administer a stool so>ener - Administering stool so>eners to prevent straining when defeca<ng (Op;on 1). Straining and coughing increase intrathoracic and intraabdominal pressure, which increases ICP. 2. Dim the lights when not providing care -Keeping the client in a calm environment with minimal noise and disturbances (eg, dimmed lights, limited visitors) (Op;on 2). 4. Maintain the body in the midline posi<on at 30 degrees - Keeping the head and body midline and avoiding extreme hip or neck flexion because it impedes venous drainage (Op;on 4). 5. Perform oral suc<oning only when necessary - Suc;oning only when needed to maintain the airway and for no more than 2 passes las<ng ≤10 seconds per pass (Op;on 5) Trea;ng fever aggressively (eg, acetaminophen) but keeping the client from shivering to reduce metabolic demands. Frequently monitoring arterial blood gases to prevent hypercapnia, which can increase ICP by causing cerebral vasodila<on For clients with increased ICP, eleva;ng the head of the bed is preferred over using pillows, which may flex the neck, decrease venous drainage, and increase ICP. The nurse is caring for an adult client who is in so> wrist restraints. Which of the following nursing ac<ons should be included in the plan of care? SATA 1. Offer fluids, nutri<on, and toile<ng every 2 hours and as needed 2.Perform neurovascular assessment every hour 4.Release restraints to perform range of mo<on exercises every 2 hours Clients in physical restraints must be regularly assessed to prevent skin breakdown, neurovascular deficits, and other safety concerns. Facili<es may determine the frequency of client monitoring; however, general guidelines include: - Offering fluids, nutri;on, and toile;ng every 2 hours and as needed (Op;on 1) - Performing hourly neurovascular checks (eg, pulses, color, skin temperature, sensa<on, movement) (Op;on 2) - Briefly releasing restraints for skin integrity assessment and range of mo<on exercises every 2 hours (Op;on 4) Restraints should be a last resort and discon<nued as soon as possible. The nurse should regularly reassess (eg, every hour) the client's con<nued need for restraints. The nurse administers an intermiSent bolus enteral feeding to a client via nasogastric tube. Which of the following ac<ons by the nurse are appropriate? Select all that apply. 2. Assess the tube placement marking at the naris inser<on site - Check the tube placement marking at the naris inser<on site. Displacement of the marking indicates that the tube may have been par<ally withdrawn (Op;on 2). 3. Auscultate the client's bowel sounds prior to feeding that increases the risk for aor<c rupture. Clients with mechanical valve replacement via sternotomy require educa<on on lifestyle changes and preven<on of complica<ons, including: 2. "I will have to have my spouse li` and carry heavy objects for me for several months." - Avoiding heavy li`ing (ie, objects over 10 lb [4.5 kg]) for 3-6 months a`er surgery to prevent disrup<on of the sternotomy sutures/wires and allow the breastbone to heal 3."I will need to take prescribed warfarin for the rest of my life." - Maintaining lifelong an;coagulant therapy (eg, warfarin, apixaban) a>er a mechanical valve replacement to prevent thromboembolic events (eg, stroke) and valve thrombosis 4."If I gain more than 5 lb (2.3 kg) in 1 week, I will need to tell my health care provider." - Repor<ng signs and symptoms of heart failure (eg, weight gain >5 lb [2.3 kg] in 1 week) immediately which may indicate valve failure 5."My usual razor blades will need to be replaced with an electric shaver." - Ini;a;ng bleeding precau;ons (eg, using an electric shaver) because an<coagulant therapy increases the risk of uncontrolled bleeding The nurse is teaching about cons<pa<on preven<on to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply. 2. "Having a rou<ne for bowel movements is important, but I should not wait if I feel the urge." 4. I should try to eat more fruits and vegetables every day." 5."Increasing my daily exercise level may help keep my bowel movements regular." Cons<pa<on is a symptom of many disease processes, procedures, and medica<ons. To prevent cons<pa<on, educate the client to increase daily fiber intake, drink 2-3 L of NONCAFFEINATED fluids daily, increase daily ac<vity levels, and ini<ate a bowel regimen (avoiding delay of defeca<on, defeca<ng at the same <me each day). Clients should avoid caffeinated beverages, which promote diuresis and dehydra/on and may lead to cons/pa/on. The nurse is reinforcing educa<on about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. Which of the following statements by the client indicate a correct understanding? Select all that apply. 1. "I have switched from coffee to decaffeinated herbal tea in the mornings." 2."I plan to join a smoking-cessa<on program. "4."I prop myself up on a couple of pillows when I go to sleep." 5."I will switch to low-fat dairy products and avoid high-fat foods." Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflamma<on of the esophageal mucosa. The lower esophageal sphincter normally prevents stomach contents from entering the esophagus. Factors that decrease the tone of the lower esophageal sphincter (eg, caffeine, alcohol), delay gastric emptying (eg, faSy foods), or increase gastric pressure (eg, large meals) can precipitate GERD. The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of depression. Which statement by the student indicates a need for further teaching? 2. "Because this client has a mental illness, the agent with medical power of aSorney should sign the informed consent document." Informed consent is required for ECT. Clients who have mental illness can give or withhold consent unless they have been deemed incompetent through legal proceedings (Op;on 2). The client is also deemed incompetent if inebriated, psycho<c, delirious, or under the influence of mind-altering medica<on. Guidelines for determining competency to give consent apply to all clients, with or without mental illness. ECT FOR MOOD DISORDERS (DEPRESSION, BIPOLAR) OR SCHIZO Prior to ECT, clients should be NPO for 6-8 hours and receive both a short- ac<ng anesthesia and a muscle relaxant as well as a bite block. The nurse is preparing to administer insulin at 1700 to a client with type 1 diabetes mellitus whose blood glucose level was 245 mg/dl (13.6 mmol/L) at 1645. During what <me frame is the client at highest risk for hypoglycemia? Click the exhibit buUon for addi;onal informa;on. 1. 1730-2000 Rapid-ac;ng insulins (eg, aspart, lispro) peak quickly, o>en within 30 minutes to 3 hours of administra<on. Therefore, the client who receives insulin lispro at 1700 is at highest risk for hypoglycemia from 1730-2000 (Op;on 1). Insulin glargine is a long-ac<ng insulin that does not have a peak effect. thrombosis or stent occlusion; necessary prescrip<ons (eg, nitroglycerin, second PCI) should be obtained and promptly ini<ated (Op;on 3). Increased blood glucose must be treated but is not a priority over stent occlusion.. This client's 1+ pulses are not a concern because they are bilateral, not unilateral. Most clients with diabetes mellitus and coronary artery disease may also have baseline peripheral artery disease. The nurse is planning care for a client with a fractured femur who was placed in balanced suspension skeletal trac<on 2 hours ago. Which of the following interven<ons should the nurse include? Select all that apply 1. Encourage intake of at least 2 L of fluid per day to prevent cons<pa<on 2. Ensure that the weights hang freely and do not touch the ground 3. Monitor skin integrity and signs of infec<on at the pin inser<on sites 4.Perform frequent neurovascular checks on the affected extremity (especially in the first 24 hours) Inspec0ng the rope for fraying and ensuring its correct posi/on in the pulley track Ensuring proper alignment of the client and the pulley system to facilitate union of the fractured bone During the discharge process, the nurse observes a new parent placing a newborn into a car seat in the vehicle. Which ac<on by the parent requires the nurse to intervene? 2. Dresses the newborn in a sleep sack before securing the harness - The car seat's harness should be secured snugly at or below the shoulders, at the hips, and between the legs. The harness fits securely when the newborn is dressed in lightweight clothing. Tucking blankets between the newborn and the harness or dressing the newborn in bulky coats or a sleep sack reduces the car seat's effec;veness (Op;on 2). (Op;on 1) The car seat should be placed in the back seat and in the center (away from the doors), if possible. This protects the child from airbag deployment as well as collisions to the vehicle's sides. The nurse is preparing to administer acetaminophen to a 4-year-old client weighing 43 lb. Based on the prescrip<on, what is the volume of medica<on in milliliters (ml) that the child should receive with each dose? Click on the exhibit buUon for more informa;on. Record your answer using a whole number. 9 ml The nurse assists with medica<on reconcilia<on for a client visi<ng the clinic for a follow-up appointment. Which medica<on reported by the client requires further inves<ga<on? Click the exhibit buUon for addi;onal informa;on. 4. 200 mg of celecoxib PO once daily Nsaids (eg, naproxen, ibuprofen, celecoxib) are used for their analgesic, an<pyre<c, and an<-inflammatory proper<es. However, they increase the risk of thrombo;c events (eg, myocardial infarc<on [MI], stroke), especially in clients with cardiovascular disease (eg, coronary artery disease). The nurse should inves<gate why a client with a history of cardiovascular disease is taking an NSAID and alert the health care provider of its use (Op;on 4). The nurse accidentally administers orally dissolving mirtazapine (an atypical an/depressant and is used primarily for the treatment of a major depressive disorder. Mirtazapine is in a group of tetracyclic an/depressants (teca).) Through a client's percutaneous endoscopic gastrostomy tube instead of the prescribed sublingual route. A>er assessing the client for adverse reac<ons, what is the nurse's priority ac<on? 4. No<fy the prescribing health care provider Orally dissolving mirtazapine is an an<depressant specifically formulated for mucous membrane absorp<on, allowing quick entry into the bloodstream. Crushing and administering this medica<on through a percutaneous endoscopic gastrostomy tube is a wrong-route medica<on error. If medica;on errors occur, the priority is client safety. The nurse should first assess for adverse effects and stabilize the client's condi;on, if needed. The nurse should then immediately no;fy the health care provider (HCP) of the error and assessment findings (Op;on 4). The HCP may prescribe new interven<ons to prevent or reduce harm to the client. - Using printed materials with visuals, such as pictures and illustra<ons, or ac<ng out demonstra<ons to supplement verbal instruc<ons The nurse is caring for a client with a central venous catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC inser<on site is red and inflamed and that the client has a temperature of 102 F (38.8 C). Which new prescrip<on from the health care provider should the nurse implement first? 4. Obtain blood cultures and discon<nue the central venous catheter In response to a possible CRBSI (central-line related bloodstream infec<on), the CVC should be removed as soon as possible to prevent con<nued exposure to the infec<on source. Blood cultures should be obtained before ini<a<ng an;bio;c therapy, as an<bio<cs may contaminate the sample and prevent iden<fica<on of the infec<ous organism (Op;on 4). The nurse reinforces teaching to a client recently diagnosed with urge incon<nence. Which of the following client statements about self-management strategies indicate that teaching has been effec<ve? Select all that apply. Urge incon;nence (UI), also known as overac;ve bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate followed by urine leakage. UI may occur without cause or may result from neurological system dysfunc<on (eg, Parkinson disease, stroke) or spinal cord injury. Interven<ons for clients with UI include: 2. "I have an appointment with a nutri<onist to help me manage my diet so that I can lose my excess weight." - Losing excess weight to reduce pressure on the pelvic floor (Op;on 2) 3. "I joined a smoking cessa<on support group at the community center." - Avoiding dietary bladder irritants (eg, caffeine, nico<ne, ar<ficial sweeteners, citrus juices, alcohol, carbonated drinks) (Op;on 3) 4."I plan to do my daily Kegel exercises when I am riding the train to and from work." - Performing pelvic floor exercises (eg, Kegel) to strengthen the pelvic muscles and help prevent urinary leakage (Op;on 4) 5."I will make sure to urinate every 2 hours to reduce urgency and have fewer accidents." - Using bladder training, such as voiding every 2 hours while awake and gradually lengthening the intervals between voiding (Op;on 5) Taking an;cholinergic medica;ons (eg, tolterodine, oxybutynin), which reduce bladder spasms The nurse suspects that the client is withdrawing from ________ and should an<cipate _______ 1. Opioids (downer so in withdrawal everything goes UP!) 2. Administering buprenorphrine Opioid withdrawal occurs 4-48 hours a>er a client with a physiologic dependence to opioids (eg, heroin, oxycodone) suddenly discon<nues or dras<cally reduces opioid intake. When opioids are stopped a>er chronic use, the loss of their usual inhibitory effect leads to a sudden increase in norepinephrine. This results in withdrawal symptoms, which commonly include sleep disturbances, gastrointes<nal disturbances (eg, nausea, vomi<ng, diarrhea), abdominal pain, dilated pupils, lacrima<on (ie, watery eyes), and piloerec<on (ie, goosebumps). Treatment includes opioid agonist medica<ons (eg, buprenorphine, low-dose methadone) that provide steady ac<va<on of opioid receptors to maintain physiologic dependence. These medica<ons prevent withdrawal symptoms, diminish cravings, and reduce the euphoric effects of opioid misuse. Replacement of recrea<onal opioids with these agents is associated with decreased incidence of relapse, drug overdose, and death. The nurse is reviewing new laboratory results for a client with an exacerba<on of chronic obstruc<ve pulmonary disease. The client's serum ph is 7.39. Which result is a priority for the nurse to report to the health care provider? 4. Pao2 of 52 mm Hg (6.92 kpa) Chronic obstruc<ve pulmonary disease (COPD) is a progressive respiratory disease caused by alveolar destruc<on and loss of lung elas<city, resul<ng in impaired gas exchange. Because clients with COPD usually maintain a state of compensated respiratory acidosis, the urge to breathe becomes unresponsive to increasing levels of carbon dioxide gas (CO2). Instead, low oxygen levels promote respiratory efforts (ie, hypoxic drive) in clients with COPD Manifesta<ons of COPD exacerba<on (eg, tachypnea, wheezing) may progress to respiratory failure without treatment. Whereas a slight decrease in pao2 (normal: 80-100 mm Hg [10.6-13.3 kpa]) may be an expected finding for a client with COPD, pao2 <60 mm Hg (7.98 kpa) indicates severe hypoxia requiring immediate repor;ng to the health care provider (Op;on 4). Compensated respiratory acidosis occurs when renal resorp<on of HCO3− increases, causing elevated serum HCO3− (normal: 21-28 meq/L [21-28 mmol/L]) secondary to chronic CO2 reten/on (ie, paco2 >45 mm Hg [5.99 kpa]), which helps normalize serum ph (ie, normal arterial ph: 7.35-7.45). Complete the diagram by dragging from the choices below to specify what condi<on the client is most likely experiencing, 2 ac<ons the nurse should take to address the condi<on, and 2 parameters the nurse should monitor to assess the client's progress. Poten;al condi;on: Pancrea<<s Ac;ons to take: Administer opioid analgesics, Administer 0.9% sodium chloride Parameters to monitor: pain level, blood glucose level Pancrea;;s (ie, inflamma<on of the pancreas) is characterized by severe pain a>er ea<ng due to the release of pancrea<c enzymes (eg, lipase) in and around the pancreas, causing inflamma<on and autodiges<on of pancrea<c <ssue. Pain is usually located in the epigastric area and/or le` upper abdomen and may be par;ally relieved by leaning forward, which decreases abdominal tension. Serum lipase levels can rise to >3 ;mes the normal upper limit. Alcohol use, gallstones, and markedly elevated serum triglycerides are the common causes. Management includes: - Administering IV pain medica<ons (eg, opioid analgesics) and monitoring the client's pain level - Administering IV fluids (eg, 0.9% sodium chloride) to prevent hypovolemia due to dehydra<on and third spacing - Monitoring blood glucose levels because pancrea;c damage and inflamma;on can impair insulin release, leading to hyperglycemia