Free NCLEX-RN practice questions
179 original questions in Next Generation NCLEX formats (select all that apply, matrix, drop-down, highlight, bow-tie and unfolding case studies) across the test plan categories.
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NCLEX-RN practice questions
- 179 questions
- Management of Care · Safety and Infection Control · Health Promotion · Psychosocial Integrity · Basic Care and Comfort · Pharmacology · Reduction of Risk · Physiological Adaptation
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An RN delegates a stable client's 1000 vital signs to an assistive personnel (AP). The AP accepts the task. Which statement about responsibility for this client is most accurate?
Correct answer: C
Delegation transfers a task, not accountability. The delegating nurse remains answerable for the client's overall care, while the delegatee who accepts the task is responsible for completing it correctly and reporting back on time.
- A Incorrect: the delegatee is responsible for the delegated task only, not for the client's overall outcome.
- B Incorrect: the nurse who delegates keeps accountability; it does not move up to the charge nurse.
- C Correct: the licensed nurse keeps overall accountability, and the delegatee is responsible for the accepted task.
- D Incorrect: accountability is not split equally; the roles carry different responsibilities, whatever paperwork is signed.
Learn this topic: Delegation and assignment: what the RN can hand off, and to whom 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 3.4 Delegation ·
An RN on a medical-surgical unit works with one assistive personnel (AP). For each task, indicate whether the RN can give it to the AP or must keep it.
Can give to the AP RN keeps the task Measure and record urine output for a stable client Teach a client newly prescribed insulin how to self-inject Take vital signs on a client whose blood pressure has dropped since the last check Help a stable client walk to the bathroom Complete the admission assessment of a client who just arrived Remind a client to use the incentive spirometer the RN taught them to use this morning Select one option in each row.
Correct answer: Measure and record urine output for a stable client: Can give to the AP; Teach a client newly prescribed insulin how to self-inject: RN keeps the task; Take vital signs on a client whose blood pressure has dropped since the last check: RN keeps the task; Help a stable client walk to the bathroom: Can give to the AP; Complete the admission assessment of a client who just arrived: RN keeps the task; Remind a client to use the incentive spirometer the RN taught them to use this morning: Can give to the AP
Assistive personnel can do routine tasks for stable clients that need no clinical judgment: intake and output, ambulation help, and reinforcing teaching the nurse already gave. Assessment, new client teaching, and any care for an unstable client stay with the RN, because they require nursing judgment and the right circumstance (a stable client) is missing.
- Measure and record urine output for a stable client Can give to the AP: measuring intake and output is routine data collection that needs no clinical judgment.
- Teach a client newly prescribed insulin how to self-inject RN keeps: new client teaching requires nursing knowledge; AP may only reinforce teaching already given.
- Take vital signs on a client whose blood pressure has dropped since the last check RN keeps: a falling blood pressure means the client may be unstable, so the right circumstance for delegation is missing.
- Help a stable client walk to the bathroom Can give to the AP: help with ambulation and toileting for a stable client is an AP activity of daily living task.
- Complete the admission assessment of a client who just arrived RN keeps: admission assessments require clinical judgment and cannot go to an AP or LPN/VN.
- Remind a client to use the incentive spirometer the RN taught them to use this morning Can give to the AP: reminding a client to use a device the RN already taught them to use reinforces existing teaching; it is not new teaching.
Learn this topic: Delegation and assignment: what the RN can hand off, and to whom 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 3.3 Assignment · Open RN Nursing Management and Professional Concepts 2e, 3.4 Delegation ·
An RN asks an assistive personnel (AP) to take vital signs on a stable client every 4 hours. Which instructions by the RN reflect the right directions and communication for this delegation? Select all that apply.
Select all that apply.
Correct answer: A, C, E
Right directions and communication means the RN states what data to collect, what to report, and the time frame, and invites questions in a two-way exchange. The delegatee may not change care on their own, cannot re-delegate, and cannot be given tasks that need assessment or judgment.
- A Correct: a specific reporting trigger tells the AP exactly what finding must come back to the RN.
- B Incorrect: a delegatee cannot delegate to another person; if unable to finish, the AP must tell the nurse.
- C Correct: two-way communication lets the delegatee ask clarifying questions before accepting.
- D Incorrect: changing treatment is a decision; the AP may not modify care without the nurse.
- E Correct: giving a time frame for completing and reporting the data is part of clear direction.
- F Incorrect: lung assessment requires clinical judgment and cannot be delegated to an AP.
Learn this topic: Delegation and assignment: what the RN can hand off, and to whom 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 3.4 Delegation · Open RN Nursing Management and Professional Concepts 2e, 3.3 Assignment ·
After handoff report, the nurse reviews four assigned clients. Which client should the nurse see first?
Correct answer: B
Use the ABCs and the CURE levels. New chest pain with faster breathing is a critical need that threatens breathing and circulation, so this client is seen first. The client who needs the bathroom is urgent (a safety risk) and can be helped by a teammate, while chronic pain and discharge teaching are routine.
- A Incorrect: chronic pain at a moderate level is a routine need; the body has adapted to this long-standing problem.
- B Correct: new chest pain with increased work of breathing is a critical need under the ABCs and must be assessed now.
- C Incorrect: this is an urgent safety need (fall risk), but it ranks below a critical breathing and circulation problem; the nurse can send a teammate to help.
- D Incorrect: discharge teaching for a stable client is routine care that can wait until critical needs are met.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing ·
The nurse uses the CURE levels to organize care on a medical-surgical unit. For each client need, indicate the level it belongs to.
Critical Urgent Routine Extra Client asks to have their hair washed this afternoon Client at high risk for falls says they must urinate right now Client reports sudden shortness of breath and chest pain Stable client is due for scheduled 0900 oral medications Client after surgery rates pain 7/10 when turning Select one option in each row.
Correct answer: Client asks to have their hair washed this afternoon: Extra; Client at high risk for falls says they must urinate right now: Urgent; Client reports sudden shortness of breath and chest pain: Critical; Stable client is due for scheduled 0900 oral medications: Routine; Client after surgery rates pain 7/10 when turning: Urgent
CURE ranks needs as Critical (act now to prevent decline, such as breathing or chest pain problems), Urgent (discomfort or a significant safety risk), Routine (typical scheduled care) and Extras (comfort that is not essential). Critical needs come first, and routine tasks never outrank critical or urgent ones.
- Client asks to have their hair washed this afternoon Extra: washing hair adds comfort and satisfaction but is not essential to the client's outcomes.
- Client at high risk for falls says they must urinate right now Urgent: a client at high risk for falls who must urinate now may try to get up alone, which is a significant safety risk.
- Client reports sudden shortness of breath and chest pain Critical: breathlessness with chest pain threatens breathing and circulation and needs immediate action.
- Stable client is due for scheduled 0900 oral medications Routine: scheduled medications for a stable client are typical daily nursing care.
- Client after surgery rates pain 7/10 when turning Urgent: significant pain causes discomfort and needs prompt attention, but it is not a threat to airway, breathing or circulation.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing ·
Two clients on a medical unit both have a temperature of 100.8°F (38.2°C) and a cough. Client A was admitted 2 days ago with community-acquired pneumonia and is receiving IV antibiotics; the temperature and cough are unchanged since admission. Client B was admitted yesterday for observation after a fall at home and has a history of osteoarthritis. The nurse's first action should be to because, for that client, the findings are .
Choose the best option from each list to complete the sentence.
Correct answer: assess Client B; unexpected for the client's condition
When two clients have the same findings, ask whether each finding is expected or unexpected for that client's condition. Fever and cough are expected with pneumonia, are unchanged, and are already addressed by the antibiotic plan, but they are unexpected in a client admitted after a fall and may signal a new problem, so that client is assessed first. Unexpected findings often need immediate nursing action.
- Assess Client B first: the same findings are new and unexplained in a client admitted after a fall. Client A's fever and cough fit the known pneumonia and are unchanged; rechecking temperatures delays the needed assessment, and requesting orders before assessing skips the assessment step.
- The findings are unexpected for Client B's condition; they are not expected with a fall or osteoarthritis, they are new rather than chronic, and they are actual rather than potential.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing · MedlinePlus: Community-acquired pneumonia in adults ·
The surgeon has explained a laparoscopic cholecystectomy to a client and asks the nurse to witness the consent form. Before signing, the client says, "I'm still not sure why they need to take my gallbladder out or what else I could do." What is the nurse's best action?
Correct answer: D
Consent is valid only when the client understands the reason for the procedure, its risks and benefits, and the alternatives. Explaining the procedure is the provider's responsibility. When a client voices questions or a lack of understanding, the nurse advocates by holding the signing and asking the provider to return.
- A Incorrect: explaining the procedure, its purpose and alternatives belongs to the provider, not the witnessing nurse.
- B Incorrect: a prior explanation does not make consent informed if the client still does not understand it.
- C Incorrect: this client is alert and able to decide; a family member signs only when the client lacks capacity or is a minor.
- D Correct: the client does not yet understand the procedure or alternatives, so the provider must clarify before consent is signed.
Learn this topic: Informed consent and advance directives: the nurse's role 5-minute lesson
Source: Open RN Nursing Fundamentals, 1.6 Legal Considerations and Ethics · Open RN Nursing Management and Professional Concepts 2e, 5.6 Other Legal Issues ·
A nurse is teaching a newly admitted client about advance directives. For each statement the client makes, indicate whether it is accurate or inaccurate.
Accurate Inaccurate "My health care agent will also handle my bank accounts." "My living will says which treatments I do or don't want." "I need to hire a lawyer to make this legal." "I can change my advance directive whenever I want." "A DNR order means no one will treat my pain." "My provider writes the DNR order in my chart." Select one option in each row.
Correct answer: "My health care agent will also handle my bank accounts.": Inaccurate; "My living will says which treatments I do or don't want.": Accurate; "I need to hire a lawyer to make this legal.": Inaccurate; "I can change my advance directive whenever I want.": Accurate; "A DNR order means no one will treat my pain.": Inaccurate; "My provider writes the DNR order in my chart.": Accurate
A living will states the treatments a client wants or refuses if they become unable to decide, and a health care power of attorney names an agent for health care decisions only. Advance directives do not require an attorney and can be changed at any time. A DNR is a provider's medical order about CPR only; it does not stop other treatment such as pain medicine.
- "My health care agent will also handle my bank accounts." Inaccurate: a health care power of attorney covers health care decisions, not finances; a financial power of attorney is a separate document.
- "My living will says which treatments I do or don't want." Accurate: a living will records the treatments the client wants or refuses if incapacitated.
- "I need to hire a lawyer to make this legal." Inaccurate: advance directives do not require an attorney; social workers or chaplains often help complete them.
- "I can change my advance directive whenever I want." Accurate: a client can change advance directive decisions at any time and should share the new documents.
- "A DNR order means no one will treat my pain." Inaccurate: a DNR order is specific to CPR and does not cover pain medicine, other medicines or nutrition.
- "My provider writes the DNR order in my chart." Accurate: a DNR is a medical order written by the health care provider after discussion with the client or proxy.
Learn this topic: Informed consent and advance directives: the nurse's role 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 5.6 Other Legal Issues · MedlinePlus: Advance care directives · MedlinePlus: Do-not-resuscitate order ·
The provider has just explained a colonoscopy to an 81-year-old client, and the nurse is about to witness the consent form. Click to highlight the findings that should lead the nurse to question the client's decision-making capacity and contact the provider.
1430: Client is wearing reading glasses and holding the consent form. When asked if they have questions, client says, , and . Client correctly states . Client points to the corner and says . Client's son . Per the assistive personnel, client this morning, which is new since admission.
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: "Whatever you want, just do it"; asks nothing about the procedure; "the bugs are back on the wall"; could not feed or dress themself
Formal capacity decisions belong to providers, but the nurse should raise concerns when cues appear. Blanket acceptance of care, no questions about the treatment, hallucinations, and a new inability to perform activities of daily living all suggest the client may not be able to give informed consent right now, so the nurse holds the signing and contacts the provider.
- "Whatever you want, just do it" Highlight: blanket acceptance of whatever is offered is a cue to question decision-making capacity.
- asks nothing about the procedure Highlight: an absence of questions about the treatment being offered is a capacity cue.
- full name and date of birth Do not highlight: correctly stating name and date of birth is an expected, reassuring finding.
- "the bugs are back on the wall" Highlight: describing things that are not there suggests hallucinations, a cue to question capacity.
- is sitting at the bedside Do not highlight: a family member at the bedside is not a sign of impaired capacity and does not change who consents.
- could not feed or dress themself Highlight: a new inability to perform activities of daily living is a cue that decision-making capacity may have changed.
Learn this topic: Informed consent and advance directives: the nurse's role 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 5.6 Other Legal Issues ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% The nurse reviews the 1000 note. Click to highlight the findings that require immediate follow-up.
1000: Assistive personnel reports that the client when helped to sit on the edge of the bed and was returned to bed. Client is . Skin . Hip dressing has . Urine output . Rates hip pain . Pedal pulses .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: got dizzy and sweaty; restless and asks, "What is happening to me?"; pale, cool and clammy; a new 12 cm (4.7 in) area of bright red drainage; 40 mL over the last 2 hours
Recognizing cues means picking out the findings that are new and point to a change in condition. Dizziness and sweating on sitting up, new restlessness, pale cool clammy skin, fresh bright red drainage and a drop in urine output are all new since 0730 and fit fluid loss. Stable pain and present pedal pulses are not new problems.
- got dizzy and sweaty Highlight: dizziness when sitting up suggests low blood pressure, and sweating is a sign of shock.
- restless and asks, "What is happening to me?" Highlight: new restlessness and anxiety are signs of poor perfusion from blood loss.
- pale, cool and clammy Highlight: pale, cool, clammy skin is a sign of hypovolemic shock.
- a new 12 cm (4.7 in) area of bright red drainage Highlight: new bright red drainage on a dressing that was dry at 0730 suggests active bleeding.
- 40 mL over the last 2 hours Highlight: 40 mL in 2 hours is far below the 60 mL/hr seen overnight; decreased urine output is a sign of fluid loss.
- 4/10, unchanged from 0730 Do not highlight: pain is unchanged and at the same level as at handoff.
- present bilaterally Do not highlight: pedal pulses are present, which is not a new or worsening finding.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: MedlinePlus: Hypovolemic shock · Open RN Nursing Fundamentals, 15.2 Basic Fluid and Electrolyte Concepts · Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% For each finding, indicate whether it supports or does not support hypovolemia from blood loss.
Supports hypovolemia Does not support hypovolemia Heart rate trend 84 → 98 → 122/min Temperature 98.6°F (37.0°C) Blood pressure 90/54 mm Hg at 1000 Hip pain 4/10, unchanged from 0730 Hemoglobin 11.0 → 7.6 g/dL (13.8–17.2 g/dL for males) Urine output 40 mL over 2 hours Select one option in each row.
Correct answer: Heart rate trend 84 → 98 → 122/min: Supports hypovolemia; Temperature 98.6°F (37.0°C): Does not support hypovolemia; Blood pressure 90/54 mm Hg at 1000: Supports hypovolemia; Hip pain 4/10, unchanged from 0730: Does not support hypovolemia; Hemoglobin 11.0 → 7.6 g/dL (13.8–17.2 g/dL for males): Supports hypovolemia; Urine output 40 mL over 2 hours: Supports hypovolemia
Blood loss lowers the circulating volume, so the heart speeds up, blood pressure falls, the kidneys make less urine, and hemoglobin and hematocrit drop. A normal temperature and unchanged pain do not point toward or away from bleeding, so they do not support the hypothesis.
- Heart rate trend 84 → 98 → 122/min Supports: a rapid pulse is a sign of hypovolemic shock as the heart tries to keep up output.
- Temperature 98.6°F (37.0°C) Does not support: the temperature is normal and unchanged from 0400; shock can lower body temperature, but this value gives no evidence of it.
- Blood pressure 90/54 mm Hg at 1000 Supports: low blood pressure is a sign of shock from severe blood or fluid loss.
- Hip pain 4/10, unchanged from 0730 Does not support: unchanged pain at the surgical site is not a sign of fluid loss.
- Hemoglobin 11.0 → 7.6 g/dL (13.8–17.2 g/dL for males) Supports: hemoglobin fell from 11.0 to 7.6 g/dL, far below the male normal range of 13.8–17.2 g/dL; bleeding is a cause of low hemoglobin.
- Urine output 40 mL over 2 hours Supports: decreased urine output is a sign of fluid loss and hypovolemic shock.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: MedlinePlus: Hypovolemic shock · MedlinePlus: Hemoglobin test · Open RN Nursing Fundamentals, 15.2 Basic Fluid and Electrolyte Concepts ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% The client is most likely experiencing . The nurse's priority concern is , as shown by .
Choose the best option from each list to complete the sentence.
Correct answer: bleeding that is causing hypovolemia; inadequate tissue perfusion; falling blood pressure and rising heart rate
Fresh bright red drainage and a hemoglobin drop from 11.0 to 7.6 g/dL point to bleeding. Falling blood pressure, a rising heart rate, low urine output and cool clammy skin show the blood loss is starting to affect circulation, so poor tissue perfusion (risk of shock) outranks pain, infection and skin concerns under the ABCs.
- Bleeding with hypovolemia fits the falling hemoglobin and new bloody drainage; the temperature is normal (against infection), respirations are 24/min (against respiratory depression), and the catheter is draining (against retention).
- Inadequate tissue perfusion is a circulation problem and ranks above pain, infection risk and skin integrity.
- Falling blood pressure with a rising heart rate shows circulation is failing to keep up; pain, temperature and the catheter do not show perfusion.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: MedlinePlus: Hypovolemic shock · Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing · MedlinePlus: Hemoglobin test ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% The nurse plans care for the next hour. Which actions should the nurse include in the plan? Select all that apply.
Select all that apply.
Correct answer: A, C, F
An unstable client needs frequent RN assessment, a prompt structured report to the surgeon, and protection from falls caused by low blood pressure. Vital signs on an unstable client are not delegated, a blood pressure medication is held when the pressure is already low, and walking a dizzy, bleeding client is unsafe.
- A Correct: a structured SBAR report with the trend and new hemoglobin gives the surgeon what is needed to act.
- B Incorrect: vital signs on an unstable client should not be delegated; the right circumstance (a stable client) is missing.
- C Correct: dizziness from low blood pressure creates a fall risk, a safety need that comes right after the circulation problem.
- D Incorrect: the blood pressure is already 90/54 mm Hg; a medication that lowers blood pressure is held and the provider notified when readings fall below expected parameters.
- E Incorrect: getting up already caused dizziness; walking a client with low blood pressure risks a fall.
- F Correct: a high-acuity client with unstable vital signs needs frequent nursing assessment.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 3.4 Delegation · MedlinePlus: Hypovolemic shock · Open RN Nursing Fundamentals, 2.4 Communicating With Health Care Team Members · Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing · Open RN Nursing Pharmacology 2e, 6.4 Nursing Process Related to Cardiovascular and Renal Medications ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% The surgeon examines the client, orders 2 units of packed red blood cells, and explains the transfusion. After the surgeon leaves the room, the client, who is alert and oriented, tells the nurse, "I didn't really follow what the doctor said about the risks." The surgeon is still on the unit, and the blood bank says the first unit will be ready in 20 minutes. Which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: B, E, F
The provider explains the transfusion and obtains written consent; when the client does not understand, the nurse asks the provider to return. Before starting, the RN confirms the signed consent is on the chart, starts the transfusion slowly, and stays with the client for the first 15 minutes to watch for a reaction. Starting blood is an RN task.
- A Incorrect: explaining risks is the provider's role; the nurse should not fill gaps in the consent discussion.
- B Correct: the client does not understand the risks, so the provider must clarify before consent is valid.
- C Incorrect: initiating a blood transfusion is an RN task and cannot be given to assistive personnel.
- D Incorrect: a transfusion starts at a slow rate, then increases only if there is no sign of a reaction.
- E Correct: unless it is an emergency, written informed consent must be in the record before a transfusion starts.
- F Correct: the nurse remains with the client during the first 15 minutes to monitor for a transfusion reaction.
Learn this topic: Informed consent and advance directives: the nurse's role 5-minute lesson
Source: Open RN Nursing Advanced Skills, 3.4 Checklist for Administration of Blood Products · Open RN Nursing Fundamentals, 1.6 Legal Considerations and Ethics · Open RN Nursing Management and Professional Concepts 2e, 3.3 Assignment ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% By 1600, both units of packed red blood cells have been transfused. At 1030 the nurse outlined the drainage on the dressing. Compare each current finding with the client's data at 1000–1015. Indicate whether each finding shows that care has been effective (improved since 1000–1015) or ineffective (unchanged or worse).
Effective Ineffective Heart rate 88/min Drainage has spread past the 1030 outline Blood pressure 116/70 mm Hg Hemoglobin 9.4 g/dL (13.8–17.2 g/dL for males) Urine output 25 mL over the last 2 hours Alert, oriented ×4, and no longer restless Select one option in each row.
Correct answer: Heart rate 88/min: Effective; Drainage has spread past the 1030 outline: Ineffective; Blood pressure 116/70 mm Hg: Effective; Hemoglobin 9.4 g/dL (13.8–17.2 g/dL for males): Effective; Urine output 25 mL over the last 2 hours: Ineffective; Alert, oriented ×4, and no longer restless: Effective
Evaluating outcomes means comparing each new finding with the client's earlier data. Heart rate, blood pressure, hemoglobin and mental status have all improved since 1000–1015, even though hemoglobin is not yet normal. Spreading drainage means bleeding continues, and urine output has fallen further (below 30 mL/hr), so both need prompt follow-up with the surgeon.
- Heart rate 88/min Effective: heart rate fell from 122/min toward the client's earlier baseline.
- Drainage has spread past the 1030 outline Ineffective: drainage spreading beyond the outline shows the site is still bleeding.
- Blood pressure 116/70 mm Hg Effective: blood pressure rose from 90/54 mm Hg back near the earlier readings.
- Hemoglobin 9.4 g/dL (13.8–17.2 g/dL for males) Effective: hemoglobin rose from 7.6 g/dL after the transfusion; it is still below the male normal range, but it has improved since 1015.
- Urine output 25 mL over the last 2 hours Ineffective: 25 mL in 2 hours is even lower than the 40 mL seen at 1000, so kidney perfusion has not improved.
- Alert, oriented ×4, and no longer restless Effective: the restlessness seen at 1000 has resolved, suggesting better perfusion to the brain.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: MedlinePlus: Hypovolemic shock · MedlinePlus: Hemoglobin test · Open RN Nursing Fundamentals, 15.2 Basic Fluid and Electrolyte Concepts ·
The adult daughter of a client calls the medical unit and asks why her mother was moved to the telemetry unit overnight. The client is alert and oriented and has not told the nurse whether she wants health information shared with her family. Which response by the nurse is best?
Correct answer: C
When an alert client is available to decide, HIPAA lets the nurse share health information with a family member only after the client agrees or, given the chance, does not object, and Open RN advises checking first whether the client has granted permission (agency policy may require it in writing). Until then the nurse does not release, hint at, or summarize the information. The nurse can ask the client and then follow her wishes.
- A Incorrect: a date of birth confirms who the caller knows, not that the client agreed to share her information.
- B Incorrect: even a brief summary of her condition discloses health information the client has not agreed to share.
- C Correct: the alert client decides whether her daughter receives her health information, so the nurse asks the client first.
- D Incorrect: the provider is under the same rule; transferring the call does not replace the client's permission.
Source: Open RN Nursing Fundamentals 2e, 1.6 Legal Considerations and Ethics · 45 CFR 164.510 Uses and disclosures requiring an opportunity for the individual to agree or to object (Cornell LII) ·
A client's family files a malpractice lawsuit against a nurse. Which elements must be proven for the claim to succeed? Select all that apply.
Select all that apply.
Correct answer: A, B, C, D
Malpractice is negligence by a licensed professional, and it is an unintentional tort, so intent to harm is not part of the claim. The plaintiff must prove four elements: duty, breach of the standard of care, causation and harm with damages. Civil cases are decided by a preponderance of the evidence, not the criminal standard of beyond a reasonable doubt.
- A Correct: duty exists once the nurse accepts responsibility for the client, such as after a handoff report.
- B Correct: breach means the nurse did not act as a reasonably prudent nurse would in the same situation.
- C Correct: causation links the nurse's breach to the client's injury.
- D Correct: harm means the injury caused damages, such as added medical costs or lost function.
- E Incorrect: malpractice is an unintentional tort; intent belongs to torts such as battery.
- F Incorrect: beyond a reasonable doubt is the criminal standard; civil malpractice uses a preponderance of the evidence.
Learn this topic: What are a nurse's legal duties, and how does charting protect clients? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 5.2 Understanding the Legal System · Open RN Nursing Fundamentals 2e, 1.6 Legal Considerations and Ethics ·
A provider prescribes a medication dose that is 10 times the maximum dose listed in the drug reference. When the nurse calls, the provider says, "It's correct. Just give it." What should the nurse do next?
Correct answer: C
Safety first: a nurse who carries out an order that the nurse knew or should have known could harm a client can be disciplined, so "the provider ordered it" is not a defense. Changing the dose on one's own is practicing beyond the nurse's scope. The nurse holds the dose, follows the chain of command until the concern is resolved, and documents exactly who was notified and when.
- A Incorrect: executing an order the nurse knows could harm the client is grounds for discipline.
- B Incorrect: changing a prescribed dose without an order is practicing beyond the nurse's scope.
- C Correct: the nurse holds the dose and pursues the concern through the chain of command to resolution.
- D Incorrect: handing the unsafe dose to a coworker still exposes the client to harm and avoids the nurse's duty.
Learn this topic: What are a nurse's legal duties, and how does charting protect clients? 5-minute lesson
Source: Open RN Nursing Pharmacology 2e, 2.3 Legal Foundations and National Guidelines for Safe Medication Administration · Open RN Nursing Management and Professional Concepts 2e, 5.2 Understanding the Legal System · Open RN Nursing Management and Professional Concepts 2e, 5.4 Frequent Allegations and SBON Investigations · Open RN Nursing Management and Professional Concepts 2e, 5.5 Protecting Your Nursing License ·
A nurse manager audits a nurse's electronic notes for one client. Click to highlight the entries that break legal documentation rules.
. . . . . .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: 0800: Client is lazy and will not cooperate with care; 0900: Dressing change scheduled for 1200 charted as done, entered early to save time; 1100: Client found on bathroom floor; incident report filed
Documentation must be objective, factual and professional, so labels such as "lazy" do not belong in the record. Care is never charted before it is done; missed charting is entered as a late entry showing when it was written and when the care happened. The fall, the provider notification and the orders belong in the record, but the incident report is not part of the medical record and is not mentioned there.
- 0800: Client is lazy and will not cooperate with care Highlighted: "lazy" is a judgment, not an objective, factual and professional description.
- 0815: Lungs clear in all fields; respirations 18/min and unlabored Not highlighted: this is an objective assessment the nurse performed.
- 0900: Dressing change scheduled for 1200 charted as done, entered early to save time Highlighted: documenting a task before it is done is falsification.
- 1030: Late entry for a 0930 pain reassessment; pain 2/10 Not highlighted: a late entry that shows both times is the correct way to add missed charting.
- 1100: Client found on bathroom floor; incident report filed Highlighted: the fall belongs in the record, but the incident report should not be mentioned in it.
- 1115: Dr. Patel notified at 1105 of the fall; X-ray of left hip ordered Not highlighted: provider notification is documented with the name, the time and the response.
Learn this topic: What are a nurse's legal duties, and how does charting protect clients? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 2.5 Documentation · Open RN Nursing Management and Professional Concepts 2e, 5.5 Protecting Your Nursing License ·
Before discharge, a nurse explains a new twice-daily inhaler schedule to a client. Which question by the nurse best uses the teach-back method?
Correct answer: B
Teach-back checks understanding by asking the client to state in their own words what they need to know or do. Yes-or-no questions such as "Do you understand?" or "Does that make sense?" are not teach-back, because clients tend to say yes whether or not they understand. If teach-back shows a gap, the nurse explains it a different way and asks again.
- A Incorrect: a yes-or-no question usually gets a "yes" whether or not the client understands.
- B Correct: asking the client to explain in their own words is the teach-back method.
- C Incorrect: "Does this make sense?" is a yes-or-no question, not teach-back.
- D Incorrect: offering to repeat the teaching does not show what the client actually understood.
Learn this topic: How do nurses hand off care safely between shifts, units and home? 5-minute lesson
Source: AHRQ Health Literacy Universal Precautions Toolkit, Use the Teach-Back Method: Tool 5 ·
A nurse is giving bedside shift report for a client in a semiprivate room. The roommate has two visitors in the room. For each action, indicate whether it is good practice or should be avoided.
Good practice Avoid Introducing the oncoming nurse and inviting the client to take part Looking at the IV site and the incision together with the oncoming nurse Asking the client what she wants to happen during the next shift Stating the client's new cancer diagnosis aloud while the roommate's visitors are present Using medical shorthand so the report goes faster Scanning the room for safety hazards, such as clutter on the floor Select one option in each row.
Correct answer: Introducing the oncoming nurse and inviting the client to take part: Good practice; Looking at the IV site and the incision together with the oncoming nurse: Good practice; Asking the client what she wants to happen during the next shift: Good practice; Stating the client's new cancer diagnosis aloud while the roommate's visitors are present: Avoid; Using medical shorthand so the report goes faster: Avoid; Scanning the room for safety hazards, such as clutter on the floor: Good practice
Bedside shift report involves the client and family: introduce the oncoming nurse, invite them to take part, give the report in words they understand, look at lines, wounds and drains together, sweep the room for safety hazards, and ask what the client wants to happen during the next shift. HIPAA still applies, so sensitive information is not said aloud where visitors can overhear.
- Introducing the oncoming nurse and inviting the client to take part Good practice: the report starts by introducing staff and inviting the client and family to take part.
- Looking at the IV site and the incision together with the oncoming nurse Good practice: both nurses visually inspect IV sites, incisions and drains during the report.
- Asking the client what she wants to happen during the next shift Good practice: the report asks for the client's own goal for the next shift.
- Stating the client's new cancer diagnosis aloud while the roommate's visitors are present Avoid: HIPAA rules must be kept in mind when visitors are present or the room is shared.
- Using medical shorthand so the report goes faster Avoid: the report should use words that the client and family can understand.
- Scanning the room for safety hazards, such as clutter on the floor Good practice: a visual sweep of the room for physical safety concerns is part of the report.
Learn this topic: How do nurses hand off care safely between shifts, units and home? 5-minute lesson
Source: AHRQ, Bedside Shift Report Checklist (Guide to Patient and Family Engagement) · AHRQ, Strategy 3: Nurse Bedside Shift Report · Open RN Nursing Fundamentals 2e, 2.4 Communicating With Health Care Team Members ·
At discharge, a nurse compares the client's home medication list with the discharge orders. The client took furosemide daily at home, but furosemide is not mentioned anywhere in the discharge orders. The nurse should , because .
Choose the best option from each list to complete the sentence.
Correct answer: clarify the discrepancy with the provider first; medication errors often happen at transitions of care
Medication reconciliation compares the best possible medication history with current orders, resolves every difference and communicates the changes to the client and the next providers. Discrepancies are common at transitions such as discharge, so a home drug that is neither continued nor stopped in the orders is clarified with the provider before the client leaves. The discharge instructions should list every medicine, with new, changed and stopped drugs marked.
- The unexplained difference is clarified with the provider before discharge; telling the client to take everything or stop everything guesses at the provider's intent, and leaving it to the community pharmacist sends an unresolved discrepancy home.
- Medication errors often happen during transitions of care, which is why reconciliation is done at each one; the other reasons are false generalizations.
Learn this topic: How do nurses hand off care safely between shifts, units and home? 5-minute lesson
Source: Open RN Nursing Pharmacology 2e, 2.5 Preventing Medication Errors · MedlinePlus, Leaving the hospital - your discharge plan ·
A client with a productive cough is admitted, and the provider documents suspected pulmonary tuberculosis. Which room placement and staff protection should the nurse arrange?
Correct answer: C
Suspected or confirmed pulmonary tuberculosis requires airborne precautions plus standard precautions. The client goes into an airborne infection isolation room with the door closed, and staff wear a fit-tested N95 or higher respirator. Precautions start on suspicion; the nurse does not wait for sputum results.
- A A surgical mask is droplet-level protection and does not protect staff from airborne tuberculosis particles; the door should also stay closed.
- B Gown and gloves are contact precautions, and a curtain does not stop airborne particles from reaching a roommate.
- C Correct: tuberculosis spreads by small airborne particles, so the client needs an airborne infection isolation room and staff need a fit-tested N95 respirator.
- D A face shield with gown and gloves does not filter airborne particles; a fit-tested respirator is required.
Learn this topic: Which isolation precautions does each infection need? 5-minute lesson
Source: CDC Isolation Precautions Guideline, Appendix A: Type and Duration of Precautions · CDC: Transmission-Based Precautions ·
The nurse is reviewing new admissions on a medical unit. For each client's condition, select the transmission-based precaution the nurse should implement in addition to standard precautions.
Contact Droplet Airborne Clostridioides difficile diarrhea Pertussis Measles (rubeola) Meningococcal meningitis Scabies Suspected pulmonary tuberculosis Select one option in each row.
Correct answer: Clostridioides difficile diarrhea: Contact; Pertussis: Droplet; Measles (rubeola): Airborne; Meningococcal meningitis: Droplet; Scabies: Contact; Suspected pulmonary tuberculosis: Airborne
Match the precaution to how the organism travels. Organisms spread by touch or contaminated surfaces (C. difficile, scabies) need contact precautions; organisms spread in large respiratory droplets (pertussis, meningococcal disease) need droplet precautions; organisms carried on tiny airborne particles (measles, tuberculosis) need airborne precautions with an airborne infection isolation room and an N95 respirator.
- Clostridioides difficile diarrhea Contact: C. difficile spreads through stool on hands and surfaces, so gloves and a gown are worn for contact with the client and the room.
- Pertussis Droplet: pertussis spreads in respiratory droplets; precautions continue until 5 days after effective antibiotics start.
- Measles (rubeola) Airborne: measles particles stay suspended in air, so the client needs an airborne infection isolation room.
- Meningococcal meningitis Droplet: meningococcal meningitis needs droplet precautions until 24 hours after effective therapy starts.
- Scabies Contact: scabies spreads by skin contact; precautions continue until 24 hours after effective treatment starts.
- Suspected pulmonary tuberculosis Airborne: suspected pulmonary tuberculosis needs airborne precautions from the moment it is suspected.
Learn this topic: Which isolation precautions does each infection need? 5-minute lesson
Source: CDC Isolation Precautions Guideline, Appendix A: Type and Duration of Precautions · Open RN Nursing Fundamentals 2e, 9.6 Preventing Infection · CDC: Clinical Safety: Hand Hygiene for Healthcare Workers ·
A nursing home resident is colonized with methicillin-resistant Staphylococcus aureus (MRSA) and has an indwelling urinary catheter. The resident has no diarrhea and no draining wounds, and is on enhanced barrier precautions. When should staff wear a gown and gloves? Select all that apply.
Select all that apply.
Correct answer: A, C, E
Enhanced barrier precautions target gown and glove use to high-contact care: dressing, bathing, transferring, hygiene, changing linens or briefs, toileting help, device care and wound care. Low-contact tasks need only standard precautions. Residents on enhanced barrier precautions are not confined to their rooms and may join group activities.
- A Correct: changing linens is listed as a high-contact care activity.
- B Delivering a tray is not high-contact care, so standard precautions are enough.
- C Correct: care of an indwelling device such as a urinary catheter is high-contact care.
- D Talking with the resident involves no high-contact care and needs no gown or gloves.
- E Correct: bathing or showering is a high-contact care activity.
- F Residents on enhanced barrier precautions may attend group activities, and walking alongside is not high-contact care.
Learn this topic: Which isolation precautions does each infection need? 5-minute lesson
Source: CDC: Implementing Enhanced Barrier Precautions in Nursing Homes ·
An 80-year-old client admitted with pneumonia becomes confused during the night and twice tries to climb out of bed alone. There is no restraint order. Which action should the nurse take first?
Correct answer: B
Restraints are a last resort and may be used only after less restrictive measures fail. The nurse starts with fall precautions and alternatives to restraint, such as a low, locked bed and a bed exit alarm, plus closer supervision and an assessment for delirium. Side rails used to keep a client from leaving the bed count as a restraint.
- A Side rails raised to stop a client from leaving the bed meet the definition of a restraint, and a confused client may climb over them.
- B Correct: a low, locked bed and a bed exit alarm are less restrictive measures that should be tried before any restraint.
- C Restraint orders may never be written as PRN (as-needed) orders.
- D A vest restraint skips the required trial of less restrictive alternatives and can cause entanglement or strangulation.
Learn this topic: How do nurses prevent falls and use restraints safely? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 5.7 Restraints · Open RN Nursing Fundamentals 2e, 5.6 Preventing Falls · 42 CFR 482.13 Condition of participation: Patient's rights (restraint or seclusion) ·
A 42-year-old client in the emergency department was placed in bilateral soft wrist restraints at 0820 after striking a staff member. Click to highlight the findings in the 0915 nursing note that require follow-up by the nurse.
0915: The restraint order reads . The provider . Right hand ; left hand warm with brisk capillary refill. Client . Client was and .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: wrist restraints as needed for agitation; is cool and pale; has been calm and following directions for 40 minutes
Restraint orders can never be PRN, so an as-needed order must be clarified with the provider. A cool, pale hand signals poor circulation in a restrained limb and needs immediate attention. Restraints must be removed at the earliest possible time, so a client who has been calm and following directions should be evaluated for release.
- wrist restraints as needed for agitation Requires follow-up: restraint orders may never be written as PRN or standing orders.
- evaluated the client face to face at 0850 No follow-up needed: for violent behavior the client must be seen face to face within 1 hour, and 0850 is within 1 hour of 0820.
- is cool and pale Requires follow-up: a cool, pale hand suggests impaired circulation in the restrained limb.
- has been calm and following directions for 40 minutes Requires follow-up: restraints must be discontinued at the earliest possible time, so the nurse evaluates the client for release.
- offered fluids at 0900 No follow-up needed: offering fluids meets the restrained client's basic needs.
- repositioned at 0900 No follow-up needed: regular position changes help prevent complications of immobility.
Learn this topic: How do nurses prevent falls and use restraints safely? 5-minute lesson
Source: 42 CFR 482.13 Condition of participation: Patient's rights (restraint or seclusion) · Open RN Nursing Fundamentals 2e, 5.7 Restraints · OpenStax Clinical Nursing Skills, 9.5 Limited Movement Devices ·
Complete the statements about restraint safety. An order to restrain a 30-year-old client for violent behavior is valid for up to before it must be renewed. The client must be seen face to face by a physician, other licensed practitioner or specially trained registered nurse within of starting the restraint. Raising all four side rails so a client who wants to get up cannot leave the bed is considered .
Choose the best option from each list to complete the sentence.
Correct answer: 4 hours; 1 hour; a restraint
For violent or self-destructive behavior, each restraint order lasts up to 4 hours for adults, 2 hours for ages 9 to 17 and 1 hour for children under 9, renewable up to 24 hours in total, and the client must be seen face to face within 1 hour. Whether side rails are a restraint depends on purpose: used to keep a client from leaving the bed, they restrict freedom of movement and are a restraint.
- 4 hours is the adult limit; 2 hours applies to ages 9 to 17, 1 hour to children under 9, and 24 hours is the total renewal cap, not a single order.
- The face-to-face evaluation must happen within 1 hour of starting a restraint for violent or self-destructive behavior.
- Side rails used to prevent a client from voluntarily leaving the bed meet the definition of a restraint; rails raised to help with repositioning do not.
Learn this topic: How do nurses prevent falls and use restraints safely? 5-minute lesson
Source: 42 CFR 482.13 Condition of participation: Patient's rights (restraint or seclusion) · Open RN Nursing Fundamentals 2e, 5.7 Restraints ·
A nurse is helping triage adults at the scene of a bus crash using START triage. Which victim should the nurse tag red (immediate)?
Correct answer: D
START checks walking, breathing, perfusion and mental status in order. A victim who is breathing faster than 30 per minute is tagged red because breathing is compromised, even if the victim is quiet and follows commands. Walking victims are green, stable non-walking victims who pass every check are yellow, and a victim who does not breathe after the airway is opened is black.
- A No breathing after the airway is opened places the victim in the black (expectant) category.
- B A victim who can walk to the designated area is tagged green, no matter how loud the distress.
- C Normal breathing rate, a radial pulse and following commands make this serious injury yellow (delayed).
- D Correct: a respiratory rate over 30 per minute is a breathing compromise and is tagged red.
Learn this topic: How do nurses triage victims in a disaster? 5-minute lesson
Source: HHS REMM: START Adult Triage Algorithm · HHS REMM: START Adult Triage Algorithm, Text Version · Open RN Nursing: Mental Health and Community Concepts 2e, 18.3 Emergency Preparedness, Response, and Recovery ·
After a warehouse explosion, the nurse uses START triage on adult victims. For each victim, select the triage tag the nurse should assign.
Green (minor) Yellow (delayed) Red (immediate) Black (expectant) Walks to the designated area holding a swollen wrist Cannot walk; respirations 22/min, capillary refill 1 second, follows commands, open lower leg fracture Cannot walk; respirations 20/min, capillary refill 4 seconds, follows commands Not breathing; no breathing after the airway is opened Cannot walk; respirations 24/min, radial pulse present, does not follow simple commands Select one option in each row.
Correct answer: Walks to the designated area holding a swollen wrist: Green (minor); Cannot walk; respirations 22/min, capillary refill 1 second, follows commands, open lower leg fracture: Yellow (delayed); Cannot walk; respirations 20/min, capillary refill 4 seconds, follows commands: Red (immediate); Not breathing; no breathing after the airway is opened: Black (expectant); Cannot walk; respirations 24/min, radial pulse present, does not follow simple commands: Red (immediate)
START moves through walking, breathing, perfusion and mental status. Walking victims are green. A victim who fails breathing (rate over 30), perfusion (capillary refill over 2 seconds or no radial pulse) or mental status (cannot follow simple commands) is red. A victim who passes all three is yellow, and a victim who does not breathe after the airway is opened is black.
- Walks to the designated area holding a swollen wrist Green: a victim who can walk to the designated area is in the minor (walking wounded) category.
- Cannot walk; respirations 22/min, capillary refill 1 second, follows commands, open lower leg fracture Yellow: breathing under 30, normal capillary refill and following commands mean the serious fracture can wait for transport.
- Cannot walk; respirations 20/min, capillary refill 4 seconds, follows commands Red: capillary refill longer than 2 seconds shows poor perfusion.
- Not breathing; no breathing after the airway is opened Black: no spontaneous breathing after the airway is opened places the victim in the expectant category.
- Cannot walk; respirations 24/min, radial pulse present, does not follow simple commands Red: inability to follow simple commands fails the mental status check even though breathing and pulse are adequate.
Learn this topic: How do nurses triage victims in a disaster? 5-minute lesson
Source: HHS REMM: START Adult Triage Algorithm · HHS REMM: START Adult Triage Algorithm, Text Version · Open RN Nursing: Mental Health and Community Concepts 2e, 18.3 Emergency Preparedness, Response, and Recovery ·
A nurse enters a client's room and finds a small fire burning in the wastebasket next to the bed. The nurse's first action is to . Next, the nurse . When using the fire extinguisher, the nurse aims the nozzle at .
Choose the best option from each list to complete the sentence.
Correct answer: move the client away from the fire; activates the fire alarm; the base of the fire
Fire response follows RACE: rescue anyone in immediate danger, activate the alarm, confine the fire by closing doors and windows, then extinguish a small fire or evacuate. Extinguishers follow PASS: pull the pin, aim low at the base of the fire, squeeze the handle and sweep side to side, because the base is where the fire is smothered.
- Rescue comes first in RACE: the client next to the fire is in immediate danger; alarm, confine and extinguish follow.
- Activating the alarm is the second RACE step so others can start safety measures; calling family and documenting can wait.
- Aim at the base of the fire; spraying the top of the flames or the smoke does not smother the fire.
Learn this topic: How do nurses triage victims in a disaster? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 5.9 Environmental Safety ·
Nurses' Notes
Day 3, 0700: 82-year-old client admitted 2 days ago with community-acquired pneumonia, receiving IV ceftriaxone. Walks with a walker at home; fell at home 2 months ago. Home medications include furosemide daily. Received lorazepam 0.5 mg by mouth at 2200 for sleep. Shares a semiprivate room with another client.
Overnight the client had 5 loose, watery stools since 0100, one of them incontinent in bed, and reports cramping lower abdominal pain. At 0530 the client was found sitting on the edge of the bed, trying to stand without the walker, saying, "I have to get to my bathroom at home." Call light found on the floor. Client is oriented to person only (oriented to person, place and time on admission) and is picking at the IV site on the left forearm. Lungs: crackles in the right lower lobe, fewer than on admission. Drank 240 mL of water at 0600. Stool sample for C. difficile toxin sent to the lab at 0630.
Vital Signs
Time Temp HR RR BP SpO2 Day 1, admission 101.8°F (38.8°C) 96/min 24/min 128/74 mm Hg 92% room air Day 3, 0700, lying 100.6°F (38.1°C) 108/min 20/min 108/62 mm Hg 95% room air Day 3, 0705, standing — 122/min — 86/50 mm Hg — Laboratory Results
Test Day 1 Day 3 Normal range WBC 14,200/microL 16,900/microL 4,500–11,000/microL Potassium 4.1 mEq/L 3.2 mEq/L 3.7–5.2 mEq/L Stool C. difficile toxin — Pending No toxin detected The nurse reviews the client's record at 0700. Click to highlight the findings that require immediate follow-up.
Since 0100 the client . At 0530 the client was . Client is . Call light . Lungs: . Client . SpO2 .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: had 5 loose, watery stools; trying to stand without the walker; oriented to person only; found on the floor
New, frequent watery stools in a hospitalized older adult on antibiotics point to a possible C. difficile infection, and a client with three or more stools in 24 hours is isolated on suspicion, before the test result. New confusion, trying to stand without the walker and a call light out of reach are cues of a high, immediate fall risk. Fewer crackles and a better oxygen saturation show the pneumonia is improving, and drinking water is not a concern.
- had 5 loose, watery stools Requires follow-up: frequent watery stools during antibiotic therapy suggest C. difficile infection, which calls for isolation on suspicion, and they also cause fluid loss.
- trying to stand without the walker Requires follow-up: getting up alone without the assistive device the client needs is a direct fall risk.
- oriented to person only Requires follow-up: the client was fully oriented on admission, so new confusion needs assessment for delirium and raises fall risk.
- found on the floor Requires follow-up: the call light must be within reach so the client can ask for help instead of getting up alone.
- crackles in the right lower lobe, fewer than on admission No immediate follow-up: fewer crackles than on admission show the pneumonia is improving.
- drank 240 mL of water at 0600 No immediate follow-up: oral fluid intake is appropriate for a client losing fluid in stool.
- 95% on room air No immediate follow-up: SpO2 is better than the 92% recorded on admission.
Learn this topic: Which isolation precautions does each infection need? 5-minute lesson
Source: MedlinePlus: C. diff Infections · CDC: Clinical Overview of C. diff Infection · Open RN Nursing Fundamentals 2e, 5.6 Preventing Falls ·
Nurses' Notes
Day 3, 0700: 82-year-old client admitted 2 days ago with community-acquired pneumonia, receiving IV ceftriaxone. Walks with a walker at home; fell at home 2 months ago. Home medications include furosemide daily. Received lorazepam 0.5 mg by mouth at 2200 for sleep. Shares a semiprivate room with another client.
Overnight the client had 5 loose, watery stools since 0100, one of them incontinent in bed, and reports cramping lower abdominal pain. At 0530 the client was found sitting on the edge of the bed, trying to stand without the walker, saying, "I have to get to my bathroom at home." Call light found on the floor. Client is oriented to person only (oriented to person, place and time on admission) and is picking at the IV site on the left forearm. Lungs: crackles in the right lower lobe, fewer than on admission. Drank 240 mL of water at 0600. Stool sample for C. difficile toxin sent to the lab at 0630.
Vital Signs
Time Temp HR RR BP SpO2 Day 1, admission 101.8°F (38.8°C) 96/min 24/min 128/74 mm Hg 92% room air Day 3, 0700, lying 100.6°F (38.1°C) 108/min 20/min 108/62 mm Hg 95% room air Day 3, 0705, standing — 122/min — 86/50 mm Hg — Laboratory Results
Test Day 1 Day 3 Normal range WBC 14,200/microL 16,900/microL 4,500–11,000/microL Potassium 4.1 mEq/L 3.2 mEq/L 3.7–5.2 mEq/L Stool C. difficile toxin — Pending No toxin detected For each client finding, specify whether it increases the client's risk for a fall, the risk of spreading infection to others, or both. Each finding may support more than one risk.
Fall risk Infection spread risk Walks with a walker at home Lorazepam 0.5 mg at 2200 BP 108/62 mm Hg lying, 86/50 mm Hg standing Watery stools with incontinence in bed Shares a semiprivate room Fell at home 2 months ago Select all that apply in each row.
Correct answer: Walks with a walker at home: Fall risk; Lorazepam 0.5 mg at 2200: Fall risk; BP 108/62 mm Hg lying, 86/50 mm Hg standing: Fall risk; Watery stools with incontinence in bed: Fall risk; Watery stools with incontinence in bed: Infection spread risk; Shares a semiprivate room: Infection spread risk; Fell at home 2 months ago: Fall risk
Fall risk factors include gait problems needing an assistive device, benzodiazepines, orthostatic blood pressure drops, frequent or urgent toileting and a recent fall. Diarrhea that may be C. difficile can contaminate hands, linens and surfaces, and a shared room exposes another client. Urgent, incontinent stools fit both problems, which is why this client needs fall and infection measures together.
- Walks with a walker at home Fall: needing an assistive device such as a walker signals gait or balance problems.
- Lorazepam 0.5 mg at 2200 Fall: lorazepam is a benzodiazepine, one of the highest-risk medication classes for falls because of sedation, dizziness and impaired balance.
- BP 108/62 mm Hg lying, 86/50 mm Hg standing Fall: the blood pressure drop on standing (orthostatic hypotension) can cause dizziness and falls.
- Watery stools with incontinence in bed Both: urgent toileting drives the client to get up alone, and infectious stool can spread to hands, linens and surfaces.
- Shares a semiprivate room Infection spread: a roommate can be exposed; clients needing contact precautions should have a single room when possible.
- Fell at home 2 months ago Fall: a fall within the past 3 months marks the client as higher risk for falling again.
Learn this topic: Which isolation precautions does each infection need? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 5.6 Preventing Falls · MedlinePlus: Lorazepam · MedlinePlus: Low blood pressure · Open RN Nursing Fundamentals 2e, 9.6 Preventing Infection · CDC Isolation Precautions Guideline, Appendix A: Type and Duration of Precautions ·
Nurses' Notes
Day 3, 0700: 82-year-old client admitted 2 days ago with community-acquired pneumonia, receiving IV ceftriaxone. Walks with a walker at home; fell at home 2 months ago. Home medications include furosemide daily. Received lorazepam 0.5 mg by mouth at 2200 for sleep. Shares a semiprivate room with another client.
Overnight the client had 5 loose, watery stools since 0100, one of them incontinent in bed, and reports cramping lower abdominal pain. At 0530 the client was found sitting on the edge of the bed, trying to stand without the walker, saying, "I have to get to my bathroom at home." Call light found on the floor. Client is oriented to person only (oriented to person, place and time on admission) and is picking at the IV site on the left forearm. Lungs: crackles in the right lower lobe, fewer than on admission. Drank 240 mL of water at 0600. Stool sample for C. difficile toxin sent to the lab at 0630.
Vital Signs
Time Temp HR RR BP SpO2 Day 1, admission 101.8°F (38.8°C) 96/min 24/min 128/74 mm Hg 92% room air Day 3, 0700, lying 100.6°F (38.1°C) 108/min 20/min 108/62 mm Hg 95% room air Day 3, 0705, standing — 122/min — 86/50 mm Hg — Laboratory Results
Test Day 1 Day 3 Normal range WBC 14,200/microL 16,900/microL 4,500–11,000/microL Potassium 4.1 mEq/L 3.2 mEq/L 3.7–5.2 mEq/L Stool C. difficile toxin — Pending No toxin detected The client's new diarrhea is most likely caused by . At this moment, the client is at highest risk for as evidenced by .
Choose the best option from each list to complete the sentence.
Correct answer: Clostridioides difficile infection; a fall with injury; new confusion, urgent stools and an orthostatic BP drop
C. difficile infection usually follows antibiotic use and is more likely in adults 65 and older and in hospitalized clients; it causes watery diarrhea, fever and abdominal pain. Right now the most pressing threat is a fall with injury: the client is newly confused, has urgent stools, received a benzodiazepine (lorazepam) and drops blood pressure on standing, and has already tried to get up alone.
- C. difficile fits watery diarrhea, cramping, fever and a rising WBC count during antibiotic therapy in an older hospitalized adult; potassium is low, not high, and the pneumonia findings are improving.
- Multiple fall risk factors are present and the client has already tried to stand alone; nothing in the record shows swallowing problems, skin breakdown or worsening breathing.
- Confusion, urgent toileting and orthostatic hypotension are fall risk factors; the crackles, SpO2 and WBC count describe the infections, not the fall risk.
Learn this topic: How do nurses prevent medication errors? 5-minute lesson
Source: MedlinePlus: C. diff Infections · CDC: Clinical Overview of C. diff Infection · MedlinePlus: Lorazepam · Open RN Nursing Fundamentals 2e, 5.6 Preventing Falls · MedlinePlus: Low blood pressure · MedlinePlus: Potassium blood test · MedlinePlus: WBC count ·
Nurses' Notes
Day 3, 0700: 82-year-old client admitted 2 days ago with community-acquired pneumonia, receiving IV ceftriaxone. Walks with a walker at home; fell at home 2 months ago. Home medications include furosemide daily. Received lorazepam 0.5 mg by mouth at 2200 for sleep. Shares a semiprivate room with another client.
Overnight the client had 5 loose, watery stools since 0100, one of them incontinent in bed, and reports cramping lower abdominal pain. At 0530 the client was found sitting on the edge of the bed, trying to stand without the walker, saying, "I have to get to my bathroom at home." Call light found on the floor. Client is oriented to person only (oriented to person, place and time on admission) and is picking at the IV site on the left forearm. Lungs: crackles in the right lower lobe, fewer than on admission. Drank 240 mL of water at 0600. Stool sample for C. difficile toxin sent to the lab at 0630.
Vital Signs
Time Temp HR RR BP SpO2 Day 1, admission 101.8°F (38.8°C) 96/min 24/min 128/74 mm Hg 92% room air Day 3, 0700, lying 100.6°F (38.1°C) 108/min 20/min 108/62 mm Hg 95% room air Day 3, 0705, standing — 122/min — 86/50 mm Hg — Laboratory Results
Test Day 1 Day 3 Normal range WBC 14,200/microL 16,900/microL 4,500–11,000/microL Potassium 4.1 mEq/L 3.2 mEq/L 3.7–5.2 mEq/L Stool C. difficile toxin — Pending No toxin detected At 0900 the stool test is positive for C. difficile toxin. The provider prescribes contact precautions and fall precautions. For each nursing action, indicate whether it is indicated or not indicated for the plan of care.
Indicated Not indicated Move the client to a private room Put on a gown and gloves on every entry into the room Skip hand hygiene after care because gloves were worn Apply bilateral soft wrist restraints to keep the client in bed Offer toileting on a set schedule during hourly rounds Wear a fit-tested N95 respirator for all care Select one option in each row.
Correct answer: Move the client to a private room: Indicated; Put on a gown and gloves on every entry into the room: Indicated; Skip hand hygiene after care because gloves were worn: Not indicated; Apply bilateral soft wrist restraints to keep the client in bed: Not indicated; Offer toileting on a set schedule during hourly rounds: Indicated; Wear a fit-tested N95 respirator for all care: Not indicated
C. difficile needs contact precautions: a single room when possible, and a gown and gloves put on at room entry. Gloves are the priority because no hand-hygiene method removes every spore, but they never replace hand hygiene after removal. Falls are prevented with universal precautions plus scheduled toileting, not restraints, which are a last resort after alternatives fail. An N95 respirator is for airborne infections.
- Move the client to a private room Indicated: clients on contact precautions should be placed in a single room when possible, protecting the roommate.
- Put on a gown and gloves on every entry into the room Indicated: contact precautions call for a gown and gloves, put on at room entry.
- Skip hand hygiene after care because gloves were worn Not indicated: gloves are not a substitute for hand hygiene, which is done every time gloves come off.
- Apply bilateral soft wrist restraints to keep the client in bed Not indicated: restraints are used only after less restrictive measures fail, and they can cause falls and injury.
- Offer toileting on a set schedule during hourly rounds Indicated: scheduled toileting addresses the urgent stools that drive the client to get up alone.
- Wear a fit-tested N95 respirator for all care Not indicated: C. difficile is not airborne; an N95 respirator is for airborne precautions.
Learn this topic: Which isolation precautions does each infection need? 5-minute lesson
Source: CDC: Clinical Overview of C. diff Infection · CDC Isolation Precautions Guideline, Appendix A: Type and Duration of Precautions · CDC: Transmission-Based Precautions · Open RN Nursing Fundamentals 2e, 9.6 Preventing Infection · Open RN Nursing Fundamentals 2e, 5.6 Preventing Falls · Open RN Nursing Fundamentals 2e, 5.7 Restraints · CDC: Clinical Safety: Hand Hygiene for Healthcare Workers ·
Nurses' Notes
Day 3, 0700: 82-year-old client admitted 2 days ago with community-acquired pneumonia, receiving IV ceftriaxone. Walks with a walker at home; fell at home 2 months ago. Home medications include furosemide daily. Received lorazepam 0.5 mg by mouth at 2200 for sleep. Shares a semiprivate room with another client.
Overnight the client had 5 loose, watery stools since 0100, one of them incontinent in bed, and reports cramping lower abdominal pain. At 0530 the client was found sitting on the edge of the bed, trying to stand without the walker, saying, "I have to get to my bathroom at home." Call light found on the floor. Client is oriented to person only (oriented to person, place and time on admission) and is picking at the IV site on the left forearm. Lungs: crackles in the right lower lobe, fewer than on admission. Drank 240 mL of water at 0600. Stool sample for C. difficile toxin sent to the lab at 0630.
Vital Signs
Time Temp HR RR BP SpO2 Day 1, admission 101.8°F (38.8°C) 96/min 24/min 128/74 mm Hg 92% room air Day 3, 0700, lying 100.6°F (38.1°C) 108/min 20/min 108/62 mm Hg 95% room air Day 3, 0705, standing — 122/min — 86/50 mm Hg — Laboratory Results
Test Day 1 Day 3 Normal range WBC 14,200/microL 16,900/microL 4,500–11,000/microL Potassium 4.1 mEq/L 3.2 mEq/L 3.7–5.2 mEq/L Stool C. difficile toxin — Pending No toxin detected The client has been moved to a private room on contact precautions. The nurse is about to give care and then leave the room. Which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: A, C, D
Contact precautions use dedicated equipment that stays in the room, and PPE comes off gloves first, then gown, followed by hand hygiene. For C. difficile, gloves and a gown are the main barrier because no hand-hygiene method removes every spore. Fall prevention uses alternatives such as a bed exit alarm and a call light in reach; side rails used to keep a client in bed are a restraint.
- A Correct: dedicated equipment such as a stethoscope and blood pressure cuff stays in the room of a client on transmission-based precautions.
- B The PPE removal sequence takes off the gloves first, then the gown, followed by hand hygiene.
- C Correct: hand hygiene follows PPE removal every time; CDC prefers alcohol-based hand rub unless hands are visibly soiled, even for C. difficile, and calls for soap and water during outbreaks.
- D Correct: a bed exit alarm is an alternative to restraints, and a reachable call light is a universal fall precaution.
- E Side rails raised to stop a client from leaving the bed are a restraint, and a confused client may climb over them.
- F A mask on the client is a droplet or airborne source-control measure; C. difficile spreads by contact.
Learn this topic: Which isolation precautions does each infection need? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 9.6 Preventing Infection · Open RN Nursing Skills 2e, 4.7 Checklist for Personal Protective Equipment (PPE) · CDC Isolation Precautions Guideline, Appendix A: Type and Duration of Precautions · Open RN Nursing Fundamentals 2e, 5.6 Preventing Falls · Open RN Nursing Fundamentals 2e, 5.7 Restraints · CDC: Clinical Safety: Hand Hygiene for Healthcare Workers ·
Nurses' Notes
Day 3, 0700: 82-year-old client admitted 2 days ago with community-acquired pneumonia, receiving IV ceftriaxone. Walks with a walker at home; fell at home 2 months ago. Home medications include furosemide daily. Received lorazepam 0.5 mg by mouth at 2200 for sleep. Shares a semiprivate room with another client.
Overnight the client had 5 loose, watery stools since 0100, one of them incontinent in bed, and reports cramping lower abdominal pain. At 0530 the client was found sitting on the edge of the bed, trying to stand without the walker, saying, "I have to get to my bathroom at home." Call light found on the floor. Client is oriented to person only (oriented to person, place and time on admission) and is picking at the IV site on the left forearm. Lungs: crackles in the right lower lobe, fewer than on admission. Drank 240 mL of water at 0600. Stool sample for C. difficile toxin sent to the lab at 0630.
Vital Signs
Time Temp HR RR BP SpO2 Day 1, admission 101.8°F (38.8°C) 96/min 24/min 128/74 mm Hg 92% room air Day 3, 0700, lying 100.6°F (38.1°C) 108/min 20/min 108/62 mm Hg 95% room air Day 3, 0705, standing — 122/min — 86/50 mm Hg — Laboratory Results
Test Day 1 Day 3 Normal range WBC 14,200/microL 16,900/microL 4,500–11,000/microL Potassium 4.1 mEq/L 3.2 mEq/L 3.7–5.2 mEq/L Stool C. difficile toxin — Pending No toxin detected On day 4, the nurse evaluates the client's care. For each finding, indicate whether the plan has been effective or not effective.
Effective Not effective Client is oriented to person, place and time Client used the call light and waited for help to walk to the bathroom BP 84/50 mm Hg on standing, and the client reports dizziness A nursing assistant emptied the client's bedpan without wearing gloves No falls during the past 24 hours Two loose stools in 12 hours, down from 5 overnight Select one option in each row.
Correct answer: Client is oriented to person, place and time: Effective; Client used the call light and waited for help to walk to the bathroom: Effective; BP 84/50 mm Hg on standing, and the client reports dizziness: Not effective; A nursing assistant emptied the client's bedpan without wearing gloves: Not effective; No falls during the past 24 hours: Effective; Two loose stools in 12 hours, down from 5 overnight: Effective
Restored orientation, calling for help before getting up, no falls and fewer stools show progress. A continued blood pressure drop with dizziness on standing means fall risk from orthostatic hypotension persists and needs follow-up. Handling C. difficile stool without gloves is an infection-control failure, because gloves are the key barrier against spores on the hands.
- Client is oriented to person, place and time Effective: the client has returned to the orientation recorded on admission.
- Client used the call light and waited for help to walk to the bathroom Effective: calling for help before getting up shows the fall plan is working.
- BP 84/50 mm Hg on standing, and the client reports dizziness Not effective: an ongoing blood pressure drop with dizziness on standing keeps the client at high fall risk.
- A nursing assistant emptied the client's bedpan without wearing gloves Not effective: contact precautions require gloves for contact with C. difficile stool, and gloves are the priority because hand hygiene cannot remove every spore.
- No falls during the past 24 hours Effective: no falls shows the fall prevention measures are working so far.
- Two loose stools in 12 hours, down from 5 overnight Effective: fewer stools show the diarrhea is improving.
Learn this topic: How do nurses prevent medication errors? 5-minute lesson
Source: CDC: Clinical Overview of C. diff Infection · CDC Isolation Precautions Guideline, Appendix A: Type and Duration of Precautions · Open RN Nursing Fundamentals 2e, 9.6 Preventing Infection · Open RN Nursing Fundamentals 2e, 5.6 Preventing Falls · MedlinePlus: Low blood pressure · CDC: Clinical Safety: Hand Hygiene for Healthcare Workers ·
At 1400, a nurse discovers that a client's 1000 dose of an IV antibiotic was not given. The nurse notifies the provider and gives the dose as prescribed. Complete the statements. The incident report is completed by . The incident report . In the client's medical record, the nurse documents .
Choose the best option from each list to complete the sentence.
Correct answer: the staff member involved in the event; is not part of the medical record; the event, provider notification and care given
An incident (variance) report is completed by the staff member involved whenever an error, injury, fall or near miss occurs. It is a quality and safety tool for finding system problems, not a disciplinary record, and it is not part of the medical record. The chart describes the event itself, provider notification and the care given, but it does not mention the incident report.
- The staff member involved in the occurrence completes the report, because that person knows what happened and what was done in response.
- Incident reports are kept out of the medical record and are used to improve systems, not to punish staff.
- The medical record documents the event, provider notification and interventions, but never refers to the incident report itself.
Source: Open RN Nursing Fundamentals 2e, 2.5 Documentation · Open RN Nursing Fundamentals 2e, 5.2 Basic Safety Concepts ·
Fifteen minutes after a medication pass, a nurse realizes that a client received amlodipine 10 mg by mouth instead of the prescribed 5 mg. Which action should the nurse take first?
Correct answer: D
Client safety comes first: when a medication error occurs, the nurse's first response is to assess and monitor the client for effects of the medication. Next, the nurse notifies the nurse manager and the provider, who may order treatment or extra monitoring. The incident report comes after that, and it is never mentioned in the medical record.
- A The incident report is completed, but only after the client is assessed and the right people are notified.
- B The nurse manager and provider are notified, but assessing the client comes first.
- C Incident reports are not part of the medical record and are not mentioned in it.
- D Correct: the first response to a medication error is to monitor the client's condition.
Learn this topic: How do nurses prevent medication errors? 5-minute lesson
Source: Open RN Nursing Skills 2e, 15.2 Basic Concepts of Administering Medications · Open RN Nursing Fundamentals 2e, 2.5 Documentation ·
A nurse educator observes nurses during a medication pass. Which actions help prevent medication errors? Select all that apply.
Select all that apply.
Correct answer: A, C, E
Safe medication practice combines two identifiers, the rights checked three times, immediate documentation and clarification of unclear orders. The room number is never an identifier because clients change rooms. Nurses give only medications they checked themselves, and a barcode alert is a signal to stop and investigate, not to work around it.
- A Correct: at least two identifiers are confirmed against the wristband and the MAR before giving a medication.
- B Incorrect: a room number is never used as an identifier, because clients change rooms.
- C Correct: documenting immediately after giving a dose prevents another nurse from repeating it.
- D Incorrect: a nurse never gives a medication that the nurse did not personally check.
- E Correct: an order with an error-prone abbreviation is clarified with the provider and rewritten.
- F Incorrect: overriding an alert is a workaround; the nurse stops and investigates.
Learn this topic: How do nurses prevent medication errors? 5-minute lesson
Source: Open RN Nursing Skills 2e, 15.2 Basic Concepts of Administering Medications · Open RN Nursing Pharmacology 2e, 2.5 Preventing Medication Errors · Open RN Nursing Management and Professional Concepts 2e, 5.5 Protecting Your Nursing License ·
Complete the statements about checking the rights of medication administration. The nurse performs the first check . The third check is done . The documentation right is completed .
Choose the best option from each list to complete the sentence.
Correct answer: when taking the package from the dispensing machine or cart; at the bedside, right before giving the medication; immediately after the medication is given
The rights are checked three times: when the medication is removed from the dispensing machine or cart, again after it is removed and before it is poured, and a third time at the bedside right before it is given. Documentation, the sixth right, is completed immediately after the dose is given so that no one gives it a second time.
- The first check happens as the package is removed from the dispensing machine or cart, when the expiration date is also checked.
- The third check is done at the bedside immediately before the medication is given.
- Documenting right after the dose prevents a repeat dose; charting before giving it or hours later invites errors.
Learn this topic: How do nurses prevent medication errors? 5-minute lesson
Source: Open RN Nursing Skills 2e, 15.2 Basic Concepts of Administering Medications ·
A nurse is stuck with a used needle after giving an injection. The nurse has just washed the puncture with soap and water. What should the nurse do next?
Correct answer: A
After cleaning the site, the nurse reports the exposure to the supervisor immediately and seeks medical care right away to judge the risk and the need for preventive treatment. OSHA requires the employer to make a confidential evaluation and follow-up available immediately after an exposure is reported.
- A Correct: report the incident at once and seek medical care right away to determine the risk.
- B Reporting is immediate, not delayed until the end of the shift.
- C The evaluation, including testing of the source client, starts after the report; it is not a reason to delay reporting.
- D Medical evaluation is sought immediately, not left for later.
Learn this topic: How do nurses handle sharps, hazardous drugs, radiation and chemicals safely? 5-minute lesson
Source: CDC NIOSH: Bloodborne Infectious Disease Risk Factors · OSHA 29 CFR 1910.1030, Bloodborne Pathogens ·
A nurse needs information from the safety data sheet (SDS) for a disinfectant used on the unit. For each question, select the SDS section that answers it.
Section 2, Hazard(s) identification Section 4, First-aid measures Section 6, Accidental release measures Section 8, Exposure controls/personal protection Which gloves and eye protection to wear when pouring it What to do if it splashes onto the skin How to clean up a spilled container Whether it is flammable and what warnings apply Select one option in each row.
Correct answer: Which gloves and eye protection to wear when pouring it: Section 8, Exposure controls/personal protection; What to do if it splashes onto the skin: Section 4, First-aid measures; How to clean up a spilled container: Section 6, Accidental release measures; Whether it is flammable and what warnings apply: Section 2, Hazard(s) identification
OSHA requires every SDS to use the same 16 numbered sections in the same order, so information is always in the same place. Section 2 identifies hazards and warnings, section 4 gives first aid after exposure, section 6 covers spills and leaks, and section 8 lists exposure controls and personal protective equipment.
- Which gloves and eye protection to wear when pouring it Protective equipment such as gloves and eye protection is listed in section 8.
- What to do if it splashes onto the skin Initial care after skin, eye or other exposure is in section 4.
- How to clean up a spilled container Response to spills and leaks, including cleanup, is in section 6.
- Whether it is flammable and what warnings apply The chemical's hazards, classification and warnings are in section 2.
Learn this topic: How do nurses handle sharps, hazardous drugs, radiation and chemicals safely? 5-minute lesson
Source: OSHA 29 CFR 1910.1200, Hazard Communication · Open RN Nursing Fundamentals 2e, 5.9 Environmental Safety ·
After reporting a needlestick, a nurse asks about the follow-up the employer must provide under the OSHA Bloodborne Pathogens Standard. Which statements are accurate? Select all that apply.
Select all that apply.
Correct answer: A, D, E
OSHA requires employers to make a confidential post-exposure evaluation and follow-up available immediately, at no cost to the employee. It documents the route and circumstances of the exposure and tests the source individual's blood for HBV and HIV as soon as feasible after consent. The hepatitis B vaccine is offered within 10 working days of starting a job with exposure risk, not only after an exposure.
- A Correct: all evaluations and follow-up, including prophylaxis, are at no cost to the employee.
- B Incorrect: the employer provides the evaluation at no cost, with no condition about missed work.
- C Incorrect: findings stay confidential; they are not shared with coworkers.
- D Correct: the post-exposure medical evaluation is confidential.
- E Correct: the source individual's blood is tested as soon as feasible after consent is obtained.
- F Incorrect: the vaccine is offered within 10 working days of initial assignment to jobs with exposure risk.
Learn this topic: How do nurses handle sharps, hazardous drugs, radiation and chemicals safely? 5-minute lesson
Source: OSHA 29 CFR 1910.1030, Bloodborne Pathogens · CDC NIOSH: Bloodborne Infectious Disease Risk Factors ·
At her first prenatal visit, a client reports that the first day of her last menstrual period was June 24, 2026. Her cycles are regular, every 28 days. Using Naegele's rule, which date will the nurse record as the estimated date of delivery?
Correct answer: C
Naegele's rule has three steps: subtract 3 months from the first day of the last menstrual period, add 7 days, then adjust the year. June 24 minus 3 months is March 24; adding 7 days gives March 31; because the date has moved into the next calendar year, the EDD is March 31, 2027. The rule assumes a 28-day cycle and the date is plus or minus 2 weeks.
- A This applies the month and day steps correctly but skips the final step of adjusting the year.
- B This subtracts 7 days instead of adding them.
- C Correct: June 24 minus 3 months is March 24, plus 7 days is March 31, and the year advances to 2027.
- D This subtracts 3 months and adjusts the year but leaves out the 7 days.
Learn this topic: Prenatal care: what each visit checks and which signs can't wait 5-minute lesson
Source: Open RN Nursing Health Promotion, 9.7 First Prenatal Visit ·
A client at 30 weeks' gestation comes for a routine prenatal visit. Her blood pressure at the last visit was 112/70 mm Hg. For each finding, indicate whether it is expected or requires follow-up.
Expected Requires follow-up Blood pressure 146/94 mm Hg Fetal heart rate 146/min Headache since yesterday that rest has not relieved Mild swelling of both ankles at the end of the day Fundal height 30 cm Puffiness around the eyes and swollen hands Select one option in each row.
Correct answer: Blood pressure 146/94 mm Hg: Requires follow-up; Fetal heart rate 146/min: Expected; Headache since yesterday that rest has not relieved: Requires follow-up; Mild swelling of both ankles at the end of the day: Expected; Fundal height 30 cm: Expected; Puffiness around the eyes and swollen hands: Requires follow-up
Routine prenatal findings are judged against expected ranges: a fetal heart rate of 110–160/min and a fundal height in centimeters that roughly equals the weeks of gestation between about 18 and 36 weeks. Some ankle swelling is normal in pregnancy. A new blood pressure of 140/90 mm Hg or higher after 20 weeks, a headache that does not go away and swelling of the face or hands are warning signs of a hypertensive disorder such as preeclampsia and need prompt follow-up.
- Blood pressure 146/94 mm Hg Requires follow-up: a new reading of 140/90 mm Hg or higher after 20 weeks suggests a hypertensive disorder such as preeclampsia.
- Fetal heart rate 146/min Expected: the fetal heart rate is within 110–160/min.
- Headache since yesterday that rest has not relieved Requires follow-up: a headache that will not go away is an urgent maternal warning sign.
- Mild swelling of both ankles at the end of the day Expected: some swelling of the feet and ankles is normal in pregnancy.
- Fundal height 30 cm Expected: at 30 weeks a fundal height of about 30 cm matches gestational age.
- Puffiness around the eyes and swollen hands Requires follow-up: swelling of the face, around the eyes or of the hands is a sign of preeclampsia, unlike dependent ankle swelling.
Learn this topic: Prenatal care: what each visit checks and which signs can't wait 5-minute lesson
Source: Open RN Nursing Health Promotion, 9.9 Second Trimester Prenatal Care · MedlinePlus Medical Encyclopedia: Preeclampsia · CDC Hear Her: Urgent Maternal Warning Signs ·
The nurse teaches a client at 32 weeks' gestation about fetal movement counts and warning signs. Which statements by the client indicate understanding of the teaching? Select all that apply.
Select all that apply.
Correct answer: A, C, D
Daily fetal movement counts in the third trimester should reach at least 10 movements within 2 hours. If the fetus has not moved within an hour, the client can eat or drink something, lie on her left side or walk briefly, then keep counting, and she calls the provider if there are fewer than 10 movements in 2 hours. Fever of 100.4°F or higher, leaking fluid and swelling of the face or hands are urgent warning signs that need care right away, not at the next visit.
- A Correct: the expected minimum is 10 fetal movements within 2 hours.
- B Incorrect: leaking fluid may mean rupture of membranes and needs care right away.
- C Correct: eating or drinking and lying on the left side are recommended when the fetus has not moved within an hour.
- D Correct: a fever of 100.4°F or higher is an urgent maternal warning sign.
- E Incorrect: swelling of the face and hands is a warning sign of preeclampsia, not a normal finding.
- F Incorrect: fetal movement counts are done daily in the third trimester, not only when the client feels ill.
Learn this topic: Prenatal care: what each visit checks and which signs can't wait 5-minute lesson
Source: Open RN Nursing Health Promotion, 9.10 Third Trimester Prenatal Care · CDC Hear Her: Urgent Maternal Warning Signs · Open RN Nursing Health Promotion, 9.9 Second Trimester Prenatal Care ·
One minute after birth, the nurse assesses a newborn: heart rate 132/min; slow, irregular breathing with a weak cry; some flexion of the arms and legs with little movement; cries and pulls away when the soles are flicked; pink body with blue hands and feet. What is the newborn's 1-minute Apgar score?
Correct answer: B
Score each Apgar sign 0, 1 or 2 and add them. Heart rate above 100/min = 2; slow, irregular, weak breathing = 1; some flexion with little movement = 1; crying and pulling away on stimulation = 2; pink body with blue extremities (acrocyanosis) = 1. The total of 7 is in the normal 7–10 range, so routine care continues.
- A This scores the heart rate as 1, but any rate above 100/min earns 2 points.
- B Correct: 2 (heart rate) + 1 (respirations) + 1 (tone) + 2 (grimace) + 1 (color) = 7.
- C This gives 2 points for tone or respirations, but flexion with little movement and a weak, irregular cry each earn only 1.
- D This gives full points for color and tone, but blue hands and feet score 1 and little movement scores 1.
Learn this topic: Assessing the newborn right after birth: Apgar, vital signs and warmth 5-minute lesson
Source: Open RN Nursing Health Promotion, 12.5 Applying the Nursing Process and Clinical Judgment Model to Newborn Care · MedlinePlus Medical Encyclopedia: Apgar score · OpenStax Maternal-Newborn Nursing, 22.1 Apgar Scoring ·
The nurse places an undressed newborn on an unwarmed metal scale. The newborn is losing heat mainly by . The best way to prevent this type of heat loss is to . If the newborn becomes chilled, the nurse should monitor for .
Choose the best option from each list to complete the sentence.
Correct answer: conduction; cover the scale with a warmed blanket; hypoglycemia
Conduction is heat loss through direct contact with a cooler surface, such as a cold scale, hands or stethoscope; it is prevented by warming or covering surfaces before the newborn touches them. Evaporation (wet skin), convection (moving air) and radiation (nearby cold objects not in contact) have different fixes. Cold stress raises the newborn's oxygen and glucose needs, so a chilled newborn is at risk for hypoglycemia.
- Conduction is correct because the skin is in direct contact with a cold surface; evaporation needs wet skin, convection needs moving air and radiation involves objects not touching the newborn.
- Covering the scale with a warmed blanket removes the cold contact surface; drying, turning off a fan and moving away from a window target evaporation, convection and radiation.
- Hypoglycemia is correct because cold stress increases glucose use; a bulging fontanelle and high blood pressure are not effects of cold stress.
Learn this topic: Assessing the newborn right after birth: Apgar, vital signs and warmth 5-minute lesson
Source: OpenStax Maternal-Newborn Nursing, 22.3 Neutral Thermal Environment · Open RN Nursing Health Promotion, 12.5 Applying the Nursing Process and Clinical Judgment Model to Newborn Care ·
One hour after birth, the nurse assesses a term newborn. For each finding, indicate whether it is expected or requires follow-up.
Expected Requires follow-up Heart rate 148/min Nasal flaring and grunting with each breath Bluish hands and feet with a pink trunk Axillary temperature 97.0°F (36.1°C) Respiratory rate 50/min with brief pauses of 5 to 8 seconds Bluish color of the lips and tongue Select one option in each row.
Correct answer: Heart rate 148/min: Expected; Nasal flaring and grunting with each breath: Requires follow-up; Bluish hands and feet with a pink trunk: Expected; Axillary temperature 97.0°F (36.1°C): Requires follow-up; Respiratory rate 50/min with brief pauses of 5 to 8 seconds: Expected; Bluish color of the lips and tongue: Requires follow-up
Normal newborn values are a heart rate of 120–160/min, a respiratory rate of 40–60/min with periodic breathing (pauses of up to about 10 seconds), and a core temperature of 97.7–99.5°F (36.5–37.5°C). Acrocyanosis of the hands and feet is expected in the first 24–48 hours. Nasal flaring, grunting, central cyanosis and a temperature below the normal range are abnormal and must be reported and treated.
- Heart rate 148/min Expected: 148/min is within the newborn range of 120–160/min.
- Nasal flaring and grunting with each breath Requires follow-up: nasal flaring and grunting are signs of respiratory distress.
- Bluish hands and feet with a pink trunk Expected: acrocyanosis is normal in the first 24–48 hours.
- Axillary temperature 97.0°F (36.1°C) Requires follow-up: 97.0°F (36.1°C) is below the normal 97.7–99.5°F (36.5–37.5°C) range and signals heat loss.
- Respiratory rate 50/min with brief pauses of 5 to 8 seconds Expected: short pauses within an otherwise normal rate are periodic breathing; only pauses longer than 20 seconds are reported.
- Bluish color of the lips and tongue Requires follow-up: blue lips and tongue are central cyanosis, which points to poor oxygenation.
Learn this topic: Assessing the newborn right after birth: Apgar, vital signs and warmth 5-minute lesson
The nurse assesses a 9-month-old infant at a well-child visit. Which finding requires follow-up?
Correct answer: D
CDC milestones are skills most children (75% or more) can do by a given age, so a missed milestone needs follow-up and screening. By 9 months most infants sit without support, babble sounds like "mamamama," and are shy or fearful with strangers. Walking alone is listed at 18 months and saying "mama" or "dada" as a name at 1 year, so their absence at 9 months is not yet a concern.
- A Expected: shyness, clinginess or fear around strangers is a 9-month milestone.
- B Expected: walking without holding on is an 18-month milestone.
- C Expected: at 9 months infants babble; calling a parent "mama" or "dada" is a 1-year milestone.
- D Correct: sitting without support is a 9-month movement milestone, so its absence needs follow-up.
Learn this topic: Growth and development milestones from birth to adolescence 6-minute lesson
Source: CDC Milestones by 9 Months · CDC Milestones by 18 Months · CDC Learn the Signs. Act Early: Milestones ·
The nurse reviews a developmental history for a 24-month-old child. For each finding, indicate whether it is expected for age or requires follow-up.
Expected for age Requires follow-up Runs and kicks a ball No longer says the words she used at 18 months Does not walk unless holding on to furniture Puts two words together, such as "more milk" Is not yet understood by strangers most of the time Does not point to show the parent something interesting Select one option in each row.
Correct answer: Runs and kicks a ball: Expected for age; No longer says the words she used at 18 months: Requires follow-up; Does not walk unless holding on to furniture: Requires follow-up; Puts two words together, such as "more milk": Expected for age; Is not yet understood by strangers most of the time: Expected for age; Does not point to show the parent something interesting: Requires follow-up
Compare the child with the milestones most children reach by each age, and treat any loss of skills as a reason to act early. Running, kicking a ball and two-word phrases are 2-year milestones. Walking without holding on and pointing to share interest are expected by 18 months, so their absence at 24 months is a missed milestone. Being understood by others most of the time is listed at 3 years.
- Runs and kicks a ball Expected: running and kicking a ball are 2-year movement milestones.
- No longer says the words she used at 18 months Requires follow-up: losing skills a child once had always calls for early action and screening.
- Does not walk unless holding on to furniture Requires follow-up: walking without holding on is expected by 18 months.
- Puts two words together, such as "more milk" Expected: saying at least two words together is a 2-year language milestone.
- Is not yet understood by strangers most of the time Expected: talking well enough for others to understand most of the time is a 3-year milestone.
- Does not point to show the parent something interesting Requires follow-up: pointing to show something interesting is expected by 18 months.
Learn this topic: Growth and development milestones from birth to adolescence 6-minute lesson
Source: CDC Milestones by 18 Months · CDC Milestones by 2 Years · CDC Milestones by 3 Years · CDC Learn the Signs. Act Early: Milestones ·
A 4-year-old whose younger sister was just admitted with pneumonia tells the nurse, "She got sick because I yelled at her." Which response by the nurse is best?
Correct answer: A
Preschoolers are in Piaget's preoperational stage and use magical thinking, so they may believe their own behavior caused an illness. The nurse supports the child by giving a simple explanation and reassuring the child that the illness is not their fault. Detailed factual explanations fit school-age children in the concrete operational stage.
- A Correct: it gives a simple, direct reassurance that the child did not cause the illness.
- B Incorrect: a detailed explanation of infection suits a school-age child and does not address the child's guilt.
- C Incorrect: asking why the child yelled reinforces the belief that the yelling caused the illness.
- D Incorrect: postponing the conversation leaves the child's guilt unaddressed.
Learn this topic: Growth and development milestones from birth to adolescence 6-minute lesson
Source: Open RN Nursing Health Promotion, 13.2 Developmental Theories · Open RN Nursing Health Promotion, 13.3 Stages of Child Development ·
History
Priya Raman, 26 years old, G1 P0, 33 weeks' gestation. Routine prenatal visit. No history of high blood pressure or kidney disease. Prenatal course normal until today.
Nurses' Notes
Prenatal clinic, 1000: Client reports a headache since last evening that rest and acetaminophen have not relieved. States she has been "seeing spots" since waking this morning. Reports her rings feel tight and her face looks puffy. Also reports mild ankle swelling at the end of the day for the past 2 weeks. Denies vaginal bleeding, leaking of fluid or contractions. Reports fetal movement as usual. Swelling noted around both eyes and in both hands. Fundal height 33 cm. Fetal heart rate 144/min by Doppler.
Vital Signs
Time BP Pulse Resp Temp SpO2 31 weeks (last visit) 116/72 mm Hg 80/min 16/min 98.2°F (36.8°C) 99% Today 1000 152/98 mm Hg 88/min 18/min 98.4°F (36.9°C) 98% Today 1015 (repeat, seated) 154/100 mm Hg 86/min 18/min — 98% Laboratory Results (collected 1030)
Test Result Normal range Urine protein (dipstick) 2+ Negative Urine glucose (dipstick) Negative Negative Hemoglobin 12.4 g/dL 12–15 g/dL Platelets 168,000/mm³ 150,000–400,000/mm³ AST 26 U/L 5–30 U/L ALT 24 U/L 5–30 U/L Creatinine 0.9 mg/dL 0.8–1.3 mg/dL Click to highlight the findings from today's clinic visit that require immediate follow-up.
1000–1030: Client reports . States she has been since waking. Reports . Also reports for the past 2 weeks. Reports . Fetal heart rate . Repeat blood pressure . Urine dipstick .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: a headache since last evening that rest and acetaminophen have not relieved; "seeing spots"; her rings feel tight and her face looks puffy; 154/100 mm Hg; protein 2+
Recognizing cues means picking out the findings that are new, abnormal and dangerous. A headache that will not go away, vision changes, swelling of the face or hands, a blood pressure of 140/90 mm Hg or higher after 20 weeks and protein in the urine are all warning signs of a hypertensive disorder of pregnancy. Dependent ankle swelling, usual fetal movement and a fetal heart rate within 110–160/min are expected.
- a headache since last evening that rest and acetaminophen have not relieved Highlight: a headache that does not go away is an urgent maternal warning sign.
- "seeing spots" Highlight: vision changes such as seeing spots are a warning sign of preeclampsia.
- her rings feel tight and her face looks puffy Highlight: swelling of the hands and face is a warning sign, unlike ankle swelling.
- mild ankle swelling at the end of the day Do not highlight: some swelling of the feet and ankles is normal in pregnancy.
- fetal movement as usual Do not highlight: usual fetal movement is reassuring.
- 144/min Do not highlight: 144/min is within the expected fetal range of 110–160/min.
- 154/100 mm Hg Highlight: a new blood pressure of 140/90 mm Hg or higher after 20 weeks needs prompt follow-up.
- protein 2+ Highlight: protein in the urine after 20 weeks with high blood pressure suggests preeclampsia.
Learn this topic: Labor and postpartum care: the stages, the fetal heart rate and the checks after birth 6-minute lesson
Source: CDC Hear Her: Urgent Maternal Warning Signs · Open RN Nursing Health Promotion, 9.9 Second Trimester Prenatal Care · MedlinePlus Medical Encyclopedia: Preeclampsia · Open RN Nursing Health Promotion, 19.5 High Blood Pressure Disorders of Pregnancy ·
History
Priya Raman, 26 years old, G1 P0, 33 weeks' gestation. Routine prenatal visit. No history of high blood pressure or kidney disease. Prenatal course normal until today.
Nurses' Notes
Prenatal clinic, 1000: Client reports a headache since last evening that rest and acetaminophen have not relieved. States she has been "seeing spots" since waking this morning. Reports her rings feel tight and her face looks puffy. Also reports mild ankle swelling at the end of the day for the past 2 weeks. Denies vaginal bleeding, leaking of fluid or contractions. Reports fetal movement as usual. Swelling noted around both eyes and in both hands. Fundal height 33 cm. Fetal heart rate 144/min by Doppler.
Vital Signs
Time BP Pulse Resp Temp SpO2 31 weeks (last visit) 116/72 mm Hg 80/min 16/min 98.2°F (36.8°C) 99% Today 1000 152/98 mm Hg 88/min 18/min 98.4°F (36.9°C) 98% Today 1015 (repeat, seated) 154/100 mm Hg 86/min 18/min — 98% Laboratory Results (collected 1030)
Test Result Normal range Urine protein (dipstick) 2+ Negative Urine glucose (dipstick) Negative Negative Hemoglobin 12.4 g/dL 12–15 g/dL Platelets 168,000/mm³ 150,000–400,000/mm³ AST 26 U/L 5–30 U/L ALT 24 U/L 5–30 U/L Creatinine 0.9 mg/dL 0.8–1.3 mg/dL The nurse analyzes the client's data. For each finding, indicate whether it supports or does not support preeclampsia.
Supports preeclampsia Does not support preeclampsia Blood pressure rise from 116/72 to 154/100 mm Hg at 33 weeks Ankle swelling at the end of the day Urine protein 2+ Fetal heart rate 144/min Swelling around the eyes and in both hands Platelets 168,000/mm³ Select one option in each row.
Correct answer: Blood pressure rise from 116/72 to 154/100 mm Hg at 33 weeks: Supports preeclampsia; Ankle swelling at the end of the day: Does not support preeclampsia; Urine protein 2+: Supports preeclampsia; Fetal heart rate 144/min: Does not support preeclampsia; Swelling around the eyes and in both hands: Supports preeclampsia; Platelets 168,000/mm³: Does not support preeclampsia
Preeclampsia develops after 20 weeks of gestation and shows as high blood pressure (often 140/90 mm Hg or higher) with signs of organ involvement such as protein in the urine, plus symptoms such as headache, vision changes and swelling of the face and hands. Findings that are normal for pregnancy, such as end-of-day ankle swelling, a fetal heart rate of 110–160/min and a platelet count within 150,000–400,000/mm³, do not support the diagnosis.
- Blood pressure rise from 116/72 to 154/100 mm Hg at 33 weeks Supports: a new blood pressure of 140/90 mm Hg or higher after 20 weeks is the key sign of preeclampsia.
- Ankle swelling at the end of the day Does not support: some swelling of the feet and ankles is normal in pregnancy.
- Urine protein 2+ Supports: proteinuria reflects kidney involvement in preeclampsia.
- Fetal heart rate 144/min Does not support: the fetal heart rate is within the expected 110–160/min.
- Swelling around the eyes and in both hands Supports: swelling of the face, around the eyes and of the hands is a sign of preeclampsia.
- Platelets 168,000/mm³ Does not support: the platelet count is normal; a low count would suggest worsening disease.
Learn this topic: Labor and postpartum care: the stages, the fetal heart rate and the checks after birth 6-minute lesson
Source: MedlinePlus Medical Encyclopedia: Preeclampsia · OpenStax Maternal-Newborn Nursing, 12.2 Conditions Limited to Pregnancy · Open RN Nursing Health Promotion, 9.9 Second Trimester Prenatal Care · Open RN Nursing Health Promotion, Appendix A Normal Reference Ranges · Open RN Nursing Health Promotion, 19.5 High Blood Pressure Disorders of Pregnancy ·
History
Priya Raman, 26 years old, G1 P0, 33 weeks' gestation. Routine prenatal visit. No history of high blood pressure or kidney disease. Prenatal course normal until today.
Nurses' Notes
Prenatal clinic, 1000: Client reports a headache since last evening that rest and acetaminophen have not relieved. States she has been "seeing spots" since waking this morning. Reports her rings feel tight and her face looks puffy. Also reports mild ankle swelling at the end of the day for the past 2 weeks. Denies vaginal bleeding, leaking of fluid or contractions. Reports fetal movement as usual. Swelling noted around both eyes and in both hands. Fundal height 33 cm. Fetal heart rate 144/min by Doppler.
Vital Signs
Time BP Pulse Resp Temp SpO2 31 weeks (last visit) 116/72 mm Hg 80/min 16/min 98.2°F (36.8°C) 99% Today 1000 152/98 mm Hg 88/min 18/min 98.4°F (36.9°C) 98% Today 1015 (repeat, seated) 154/100 mm Hg 86/min 18/min — 98% Laboratory Results (collected 1030)
Test Result Normal range Urine protein (dipstick) 2+ Negative Urine glucose (dipstick) Negative Negative Hemoglobin 12.4 g/dL 12–15 g/dL Platelets 168,000/mm³ 150,000–400,000/mm³ AST 26 U/L 5–30 U/L ALT 24 U/L 5–30 U/L Creatinine 0.9 mg/dL 0.8–1.3 mg/dL The client is most likely experiencing , as shown by . Without treatment, the nurse is most concerned that the client will develop .
Choose the best option from each list to complete the sentence.
Correct answer: preeclampsia; new hypertension with proteinuria after 20 weeks; seizures (eclampsia)
The client had a normal blood pressure at 31 weeks and now has a pressure above 140/90 mm Hg with proteinuria, headache, vision changes and facial swelling, which fits preeclampsia rather than chronic hypertension. The priority concern is the most life-threatening complication: untreated preeclampsia can damage vital organs and progress to seizures (eclampsia). Nurses detect and report high blood pressure early so it can be managed before convulsions occur.
- Preeclampsia is correct; chronic hypertension would be present before 20 weeks, the urine glucose is negative, and a migraine does not explain the blood pressure and proteinuria.
- New hypertension with proteinuria after 20 weeks defines the picture; ankle swelling and a normal fetal heart rate are expected, and the blood pressure was normal at 31 weeks.
- Seizures (eclampsia) are the feared progression of untreated preeclampsia; Rh sensitization, hyperemesis gravidarum and placenta previa are not complications of preeclampsia.
Learn this topic: Labor and postpartum care: the stages, the fetal heart rate and the checks after birth 6-minute lesson
Source: OpenStax Maternal-Newborn Nursing, 12.2 Conditions Limited to Pregnancy · MedlinePlus Medical Encyclopedia: Preeclampsia · Open RN Nursing Health Promotion, 9.6 Prenatal Care and Reducing Maternal Mortality · Open RN Nursing Health Promotion, 9.9 Second Trimester Prenatal Care · Open RN Nursing Health Promotion, 19.5 High Blood Pressure Disorders of Pregnancy ·
History
Priya Raman, 26 years old, G1 P0, 33 weeks' gestation. Routine prenatal visit. No history of high blood pressure or kidney disease. Prenatal course normal until today.
Nurses' Notes
Prenatal clinic, 1000: Client reports a headache since last evening that rest and acetaminophen have not relieved. States she has been "seeing spots" since waking this morning. Reports her rings feel tight and her face looks puffy. Also reports mild ankle swelling at the end of the day for the past 2 weeks. Denies vaginal bleeding, leaking of fluid or contractions. Reports fetal movement as usual. Swelling noted around both eyes and in both hands. Fundal height 33 cm. Fetal heart rate 144/min by Doppler.
Vital Signs
Time BP Pulse Resp Temp SpO2 31 weeks (last visit) 116/72 mm Hg 80/min 16/min 98.2°F (36.8°C) 99% Today 1000 152/98 mm Hg 88/min 18/min 98.4°F (36.9°C) 98% Today 1015 (repeat, seated) 154/100 mm Hg 86/min 18/min — 98% Laboratory Results (collected 1030)
Test Result Normal range Urine protein (dipstick) 2+ Negative Urine glucose (dipstick) Negative Negative Hemoglobin 12.4 g/dL 12–15 g/dL Platelets 168,000/mm³ 150,000–400,000/mm³ AST 26 U/L 5–30 U/L ALT 24 U/L 5–30 U/L Creatinine 0.9 mg/dL 0.8–1.3 mg/dL The client is admitted to labor and delivery. The provider suspects preeclampsia with severe features. Which actions should the nurse include in the plan of care? Select all that apply.
Select all that apply.
Correct answer: A, C, E
A client with preeclampsia with severe features is hospitalized and monitored until blood pressure is stable or birth occurs. The nurse plans frequent vital signs and neurologic checks, because hyperreflexia and clonus warn of seizure risk, and continuous electronic fetal monitoring of the fetal heart rate and contractions as ordered. Sending the client home ignores a potentially life-threatening condition.
- A Correct: frequent blood pressure and neurologic checks detect worsening preeclampsia.
- B Incorrect: severe features require hospital monitoring, not a routine follow-up visit.
- C Correct: hyperreflexia and clonus are warning signs of seizure risk.
- D Incorrect: the glucose challenge screens for gestational diabetes and does not address this problem.
- E Correct: electronic fetal monitoring evaluates fetal heart rate and uterine contractions.
Learn this topic: Labor and postpartum care: the stages, the fetal heart rate and the checks after birth 6-minute lesson
Source: OpenStax Maternal-Newborn Nursing, 12.2 Conditions Limited to Pregnancy · MedlinePlus Medical Encyclopedia: Preeclampsia · Open RN Nursing Health Promotion, 19.5 High Blood Pressure Disorders of Pregnancy ·
History
Priya Raman, 26 years old, G1 P0, 33 weeks' gestation. Routine prenatal visit. No history of high blood pressure or kidney disease. Prenatal course normal until today.
Nurses' Notes
Prenatal clinic, 1000: Client reports a headache since last evening that rest and acetaminophen have not relieved. States she has been "seeing spots" since waking this morning. Reports her rings feel tight and her face looks puffy. Also reports mild ankle swelling at the end of the day for the past 2 weeks. Denies vaginal bleeding, leaking of fluid or contractions. Reports fetal movement as usual. Swelling noted around both eyes and in both hands. Fundal height 33 cm. Fetal heart rate 144/min by Doppler.
Vital Signs
Time BP Pulse Resp Temp SpO2 31 weeks (last visit) 116/72 mm Hg 80/min 16/min 98.2°F (36.8°C) 99% Today 1000 152/98 mm Hg 88/min 18/min 98.4°F (36.9°C) 98% Today 1015 (repeat, seated) 154/100 mm Hg 86/min 18/min — 98% Laboratory Results (collected 1030)
Test Result Normal range Urine protein (dipstick) 2+ Negative Urine glucose (dipstick) Negative Negative Hemoglobin 12.4 g/dL 12–15 g/dL Platelets 168,000/mm³ 150,000–400,000/mm³ AST 26 U/L 5–30 U/L ALT 24 U/L 5–30 U/L Creatinine 0.9 mg/dL 0.8–1.3 mg/dL Magnesium sulfate IV is prescribed to prevent seizures. Which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: B, D, E
Magnesium sulfate is a high-alert medication given to prevent preeclampsia from progressing to seizures, and its main danger is toxicity. Safe care uses an infusion pump to control the dose and rate, monitors respirations, deep tendon reflexes and urine output, and keeps calcium gluconate, the antidote, readily available. If toxicity signs appear, the nurse stops the infusion and notifies the provider; any significant change in the client or the fetal heart rate is reported right away.
- A Incorrect: a gravity infusion cannot control the rate safely; a pump is required.
- B Correct: an infusion pump sets limits and ensures the correct dose and rate.
- C Incorrect: significant fetal heart rate changes must be reported immediately, not held until the end of the shift.
- D Correct: respirations, deep tendon reflexes and urine output are monitored because respiratory depression, loss of reflexes and decreased urine output are signs of magnesium toxicity.
- E Correct: calcium gluconate is the antidote for magnesium toxicity and should be readily available, usually at the bedside.
Learn this topic: Labor and postpartum care: the stages, the fetal heart rate and the checks after birth 6-minute lesson
Source: OpenStax Maternal-Newborn Nursing, 12.2 Conditions Limited to Pregnancy · Open RN Nursing Health Promotion, 19.5 High Blood Pressure Disorders of Pregnancy ·
History
Priya Raman, 26 years old, G1 P0, 33 weeks' gestation. Routine prenatal visit. No history of high blood pressure or kidney disease. Prenatal course normal until today.
Nurses' Notes
Prenatal clinic, 1000: Client reports a headache since last evening that rest and acetaminophen have not relieved. States she has been "seeing spots" since waking this morning. Reports her rings feel tight and her face looks puffy. Also reports mild ankle swelling at the end of the day for the past 2 weeks. Denies vaginal bleeding, leaking of fluid or contractions. Reports fetal movement as usual. Swelling noted around both eyes and in both hands. Fundal height 33 cm. Fetal heart rate 144/min by Doppler.
Vital Signs
Time BP Pulse Resp Temp SpO2 31 weeks (last visit) 116/72 mm Hg 80/min 16/min 98.2°F (36.8°C) 99% Today 1000 152/98 mm Hg 88/min 18/min 98.4°F (36.9°C) 98% Today 1015 (repeat, seated) 154/100 mm Hg 86/min 18/min — 98% Laboratory Results (collected 1030)
Test Result Normal range Urine protein (dipstick) 2+ Negative Urine glucose (dipstick) Negative Negative Hemoglobin 12.4 g/dL 12–15 g/dL Platelets 168,000/mm³ 150,000–400,000/mm³ AST 26 U/L 5–30 U/L ALT 24 U/L 5–30 U/L Creatinine 0.9 mg/dL 0.8–1.3 mg/dL Four hours after the magnesium sulfate infusion and a prescribed antihypertensive medication were started, the nurse reassesses the client. For each finding, indicate whether it shows the plan is effective or requires immediate follow-up.
Effective Requires immediate follow-up Blood pressure 138/88 mm Hg Respiratory rate 10/min Headache rated 2/10, down from 7/10 Patellar reflexes absent States the spots in her vision are gone Fetal heart rate baseline 140/min Select one option in each row.
Correct answer: Blood pressure 138/88 mm Hg: Effective; Respiratory rate 10/min: Requires immediate follow-up; Headache rated 2/10, down from 7/10: Effective; Patellar reflexes absent: Requires immediate follow-up; States the spots in her vision are gone: Effective; Fetal heart rate baseline 140/min: Effective
Evaluating outcomes means comparing new data with the goals: a lower blood pressure, relief of headache and vision changes and a fetal heart rate within 110–160/min show the plan is working. At the same time the nurse watches for magnesium toxicity. A respiratory rate below 16/min and absent deep tendon reflexes are toxicity signs: the nurse stops the infusion, notifies the provider and has calcium gluconate ready.
- Blood pressure 138/88 mm Hg Effective: blood pressure has fallen below 140/90 mm Hg from 154/100 mm Hg with antihypertensive treatment.
- Respiratory rate 10/min Requires immediate follow-up: respirations should be at least 16/min during magnesium therapy, so 10/min signals respiratory depression from magnesium toxicity.
- Headache rated 2/10, down from 7/10 Effective: the headache, a warning sign of worsening preeclampsia, is easing.
- Patellar reflexes absent Requires immediate follow-up: loss of deep tendon reflexes is the first sign of magnesium toxicity.
- States the spots in her vision are gone Effective: resolution of vision changes shows improvement.
- Fetal heart rate baseline 140/min Effective: the fetal heart rate is within the expected 110–160/min.
Learn this topic: Labor and postpartum care: the stages, the fetal heart rate and the checks after birth 6-minute lesson
Source: OpenStax Maternal-Newborn Nursing, 12.2 Conditions Limited to Pregnancy · Open RN Nursing Health Promotion, 9.9 Second Trimester Prenatal Care · Open RN Nursing Health Promotion, 19.5 High Blood Pressure Disorders of Pregnancy ·
During an annual wellness visit, the nurse assesses a 78-year-old client. For each finding, indicate whether it is an expected age-related change or requires follow-up.
Expected age-related change Requires follow-up Holds the menu at arm's length to read it Reports a sudden shower of new floaters in the right eye Has trouble following conversation in a noisy restaurant Respiratory rate 26/min at rest, with visible effort to breathe Pulse takes longer than before to slow down after climbing stairs Thin skin that bruises more easily than it did years ago Select one option in each row.
Correct answer: Holds the menu at arm's length to read it: Expected age-related change; Reports a sudden shower of new floaters in the right eye: Requires follow-up; Has trouble following conversation in a noisy restaurant: Expected age-related change; Respiratory rate 26/min at rest, with visible effort to breathe: Requires follow-up; Pulse takes longer than before to slow down after climbing stairs: Expected age-related change; Thin skin that bruises more easily than it did years ago: Expected age-related change
Many changes are expected with aging: trouble focusing on near objects (presbyopia), loss of high-frequency hearing with trouble hearing over background noise (presbycusis), a slower heart-rate recovery after exercise and thinner skin with fragile vessels that bruise easily. A sudden increase in floaters can signal retinal detachment, and breathing rate usually does not change with age, so a fast, labored rate at rest needs follow-up. Separate expected aging from new or sudden changes.
- Holds the menu at arm's length to read it Expected: presbyopia, difficulty focusing on close-up objects, is the most common vision change with aging.
- Reports a sudden shower of new floaters in the right eye Requires follow-up: floaters that appear suddenly or rapidly increase can indicate a retinal detachment.
- Has trouble following conversation in a noisy restaurant Expected: presbycusis often makes conversation hard to follow when there is background noise.
- Respiratory rate 26/min at rest, with visible effort to breathe Requires follow-up: breathing rate usually does not change with age, and 26/min with effort is above the adult range of 12–20/min.
- Pulse takes longer than before to slow down after climbing stairs Expected: with aging, the pulse takes longer to rise and to slow back down after exercise.
- Thin skin that bruises more easily than it did years ago Expected: the outer skin thins and dermal blood vessels become more fragile, so older adults bruise more easily.
Source: MedlinePlus Medical Encyclopedia: Aging changes in the senses · MedlinePlus Medical Encyclopedia: Aging changes in vital signs · MedlinePlus Medical Encyclopedia: Aging changes in skin · Open RN Nursing Skills 2e, 10.3 Respiratory Assessment ·
A client in active labor is receiving an oxytocin infusion. The nurse notes repeated decreases in the fetal heart rate that begin during each contraction and return to baseline only after the contraction ends. Which action should the nurse take?
Correct answer: A
Decelerations that start during a contraction and recover only after it ends are late decelerations, which signal uteroplacental insufficiency and fetal hypoxia. Oxytocin can cause tachysystole, which reduces blood flow to the placenta. Nursing actions are to stop the oxytocin, turn the client to her left side, give fluids for maternal hypotension and notify the provider.
- A Correct: for late decelerations, the nurse stops the oxytocin and changes the client to a left lateral position, then notifies the provider.
- B Incorrect: more oxytocin can cause tachysystole and further reduce blood flow to the placenta.
- C Incorrect: early decelerations from head compression mirror the contraction; these start late and recover after it ends.
- D Incorrect: a left side-lying position improves placental blood flow; lying flat on the back does not.
Learn this topic: Labor and postpartum care: the stages, the fetal heart rate and the checks after birth 6-minute lesson
Source: Open RN Nursing Health Promotion, 10.5 Fetal Heart Rate Monitoring ·
On the first day after a vaginal birth, the nurse expects lochia . To check the fundus, the nurse places one hand on the fundus and uses the other hand to . A peripad saturated within is a heavy amount that the nurse reports promptly.
Choose the best option from each list to complete the sentence.
Correct answer: rubra, red; support the lower uterus above the pubic bone; 1 hour
Lochia rubra (red) is expected for the first 1 to 3 days, followed by pinkish-brown lochia serosa and then yellow-white lochia alba. During a fundal check, one hand supports the lower uterus near the symphysis pubis while the other locates the fundus. Saturating a peripad within 1 hour, or clots larger than a golf ball, is a heavy amount that suggests postpartum hemorrhage.
- Rubra: lochia rubra, bright to dark red, is expected during the first 1 to 3 days after birth.
- Support the lower uterus: the second hand supports the uterus near the symphysis pubis during the fundal check.
- 1 hour: a peripad saturated in 1 hour or clots larger than a golf ball are reported as suspected postpartum hemorrhage.
Learn this topic: Labor and postpartum care: the stages, the fetal heart rate and the checks after birth 6-minute lesson
Source: Open RN Nursing Health Promotion, 11.2 Postpartum Physiological Adaptations · Open RN Nursing Health Promotion, 11.5 Applying the Nursing Process and the Clinical Judgment Model to Postpartum Care ·
The nurse cares for a client in the active phase of labor at 7 cm. For each finding, indicate whether it is expected or requires follow-up.
Expected Requires follow-up Contractions every 3 minutes, lasting 60 seconds Fetal heart rate baseline 135/min with moderate variability Cannot talk during contractions and is focused inward Green-tinged amniotic fluid after the membranes rupture Gradual decelerations that mirror each contraction Fetal heart rate baseline of 172/min for the past 15 minutes Select one option in each row.
Correct answer: Contractions every 3 minutes, lasting 60 seconds: Expected; Fetal heart rate baseline 135/min with moderate variability: Expected; Cannot talk during contractions and is focused inward: Expected; Green-tinged amniotic fluid after the membranes rupture: Requires follow-up; Gradual decelerations that mirror each contraction: Expected; Fetal heart rate baseline of 172/min for the past 15 minutes: Requires follow-up
In the active phase (6 to 10 cm), contractions last 40 to 90 seconds and come every 2 to 5 minutes, and clients often turn inward and cannot talk through contractions. A baseline of 110 to 160/min with moderate variability is reassuring, and early decelerations from head compression are common in active labor. Amniotic fluid should be clear; green or yellow fluid suggests meconium, and a baseline above 160/min for 10 minutes is fetal tachycardia, often from maternal fever.
- Contractions every 3 minutes, lasting 60 seconds Expected: active-phase contractions last 40 to 90 seconds and occur every 2 to 5 minutes.
- Fetal heart rate baseline 135/min with moderate variability Expected: a baseline of 110 to 160/min with moderate variability indicates a well-oxygenated fetus.
- Cannot talk during contractions and is focused inward Expected: becoming inwardly focused and unable to talk during contractions are signs of active labor.
- Green-tinged amniotic fluid after the membranes rupture Requires follow-up: amniotic fluid should be clear; green or yellow fluid is associated with meconium.
- Gradual decelerations that mirror each contraction Expected: early decelerations from head compression mirror contractions and are common in active labor.
- Fetal heart rate baseline of 172/min for the past 15 minutes Requires follow-up: a baseline above 160/min for 10 minutes is fetal tachycardia, and maternal fever is the most common cause.
Learn this topic: Labor and postpartum care: the stages, the fetal heart rate and the checks after birth 6-minute lesson
Source: Open RN Nursing Health Promotion, 10.3 Labor · Open RN Nursing Health Promotion, 10.5 Fetal Heart Rate Monitoring · Open RN Nursing Health Promotion, 10.10 Applying the Nursing Process and Clinical Judgment Model to Labor and Delivery Care ·
Four clients are due for a vaccine at a clinic today. Which finding is a reason for the nurse to withhold the vaccine and notify the provider?
Correct answer: B
A contraindication is a condition that increases the risk of a serious adverse reaction, and a severe allergic reaction such as anaphylaxis after a previous dose or to a vaccine component is a contraindication. Mild acute illness with or without fever, current antimicrobial therapy and allergies to nonvaccine substances such as penicillin are not reasons to withhold a vaccine. Moderate or severe acute illness is a precaution, and vaccination is usually deferred.
- A Incorrect: a mild acute illness with or without fever is not a contraindication or precaution.
- B Correct: a severe allergic reaction such as anaphylaxis after a previous dose is a contraindication.
- C Incorrect: current antimicrobial therapy is not a reason to withhold a vaccine.
- D Incorrect: a penicillin allergy or other nonvaccine allergy is not a contraindication.
Learn this topic: Immunizations and adult screening: what to give, when to hold it and who to screen 6-minute lesson
Source: CDC: Contraindications and Precautions (General Best Practice Guidelines for Immunization) ·
The nurse reviews the CDC adult immunization schedule with a group of adult clients. Which teaching points are correct? Select all that apply.
Select all that apply.
Correct answer: B, C, E
The CDC adult schedule gives influenza vaccine once a year, a Td or Tdap booster every 10 years, 1 dose of Tdap during each pregnancy (preferably early in weeks 27 to 36) and 2 doses of recombinant zoster vaccine 2 to 6 months apart for adults 50 and older. MMR and varicella are live vaccines that are contraindicated during pregnancy; a nonimmune client receives them after the birth, before discharge.
- A Incorrect: MMR is contraindicated during pregnancy; it is given after birth, before discharge.
- B Correct: after the primary series and a Tdap dose, Td or Tdap is given every 10 years.
- C Correct: adults receive 1 dose of an age-appropriate influenza vaccine every year.
- D Incorrect: 1 dose of Tdap is recommended during each pregnancy.
- E Correct: adults 50 and older receive a 2-dose series of recombinant zoster vaccine 2 to 6 months apart.
- F Incorrect: varicella vaccine is contraindicated during pregnancy.
Learn this topic: Immunizations and adult screening: what to give, when to hold it and who to screen 6-minute lesson
Source: CDC: Adult Immunization Schedule Notes · CDC: Adult Immunization Schedule by Age ·
The nurse plans care for several clients. For each intervention, indicate the level of prevention it represents.
Primary Secondary Tertiary Giving a healthy adult the yearly influenza vaccine Offering hepatitis C screening to a 40-year-old with no symptoms Teaching a client with heart failure to limit sodium to avoid readmission Teaching a teen soccer team to apply sunscreen before practice Measuring blood pressure in a 30-year-old at a routine visit Showing a client with long-standing COPD how to pace daily activities Select one option in each row.
Correct answer: Giving a healthy adult the yearly influenza vaccine: Primary; Offering hepatitis C screening to a 40-year-old with no symptoms: Secondary; Teaching a client with heart failure to limit sodium to avoid readmission: Tertiary; Teaching a teen soccer team to apply sunscreen before practice: Primary; Measuring blood pressure in a 30-year-old at a routine visit: Secondary; Showing a client with long-standing COPD how to pace daily activities: Tertiary
Primary prevention stops illness before it starts, through immunizations and healthy behaviors. Secondary prevention finds disease early through screening, often before symptoms appear. Tertiary prevention reduces the severity and effects of a disease the client already has, such as by teaching self-management of a chronic condition.
- Giving a healthy adult the yearly influenza vaccine Primary: immunizations prevent disease before it occurs.
- Offering hepatitis C screening to a 40-year-old with no symptoms Secondary: screening adults aged 18 to 79 for hepatitis C detects infection early, before symptoms.
- Teaching a client with heart failure to limit sodium to avoid readmission Tertiary: teaching self-management of existing heart failure reduces the severity of established disease.
- Teaching a teen soccer team to apply sunscreen before practice Primary: sunscreen use is a healthy behavior that prevents skin damage before disease develops.
- Measuring blood pressure in a 30-year-old at a routine visit Secondary: blood pressure screening of adults 18 and older finds hypertension early.
- Showing a client with long-standing COPD how to pace daily activities Tertiary: helping a client manage an existing chronic disease maintains function and quality of life.
Learn this topic: Immunizations and adult screening: what to give, when to hold it and who to screen 6-minute lesson
Source: Open RN Nursing Health Promotion, 2.2 Health, Wellness, and Disease Prevention · Open RN Nursing Health Promotion, 2.4 Secondary Prevention · Open RN Nursing Health Promotion, 2.5 Tertiary Prevention · USPSTF: A and B Recommendations ·
A client who was just told they have breast cancer says to the nurse, "I don't know how I am going to tell my children." Which response by the nurse is best?
Correct answer: B
The best reply keeps the focus on the client and invites them to keep talking. An open-ended lead that explores the client's concern does this. False reassurance, personal advice and why questions are blocking responses that shift the focus to the nurse or put the client on the defensive.
- A This is false reassurance, which discourages the client from expressing the fear.
- B Correct: an open-ended lead explores the client's concern and lets the client direct the conversation.
- C This gives a personal opinion and takes the decision away from the client.
- D A why question can sound like a challenge and make the client defensive.
Learn this topic: How to pick the therapeutic response every time 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 2.3 Therapeutic Communication ·
A nurse is talking with clients on a behavioral health unit. For each nurse response, indicate whether it is therapeutic or nontherapeutic.
Therapeutic Nontherapeutic "You look worried today. What's on your mind?" "Everything will turn out fine, I promise." The nurse sits quietly and nods while a client cries. "You shouldn't skip group. That's not good for you." "So you stopped the medicine because it upsets your stomach. Did I get that right?" "I went through a divorce too, so I know exactly how you feel." Select one option in each row.
Correct answer: "You look worried today. What's on your mind?": Therapeutic; "Everything will turn out fine, I promise.": Nontherapeutic; The nurse sits quietly and nods while a client cries.: Therapeutic; "You shouldn't skip group. That's not good for you.": Nontherapeutic; "So you stopped the medicine because it upsets your stomach. Did I get that right?": Therapeutic; "I went through a divorce too, so I know exactly how you feel.": Nontherapeutic
Therapeutic responses keep the focus on the client: making an observation followed by an open-ended question, providing silence, and summarizing to check understanding. False reassurance, disapproval with words like "should" and "not good," and personal self-disclosure shift the focus to the nurse and block communication.
- "You look worried today. What's on your mind?" Therapeutic: the nurse makes an observation and then offers an open-ended lead.
- "Everything will turn out fine, I promise." Nontherapeutic: false reassurance discourages the client from sharing fears.
- The nurse sits quietly and nods while a client cries. Therapeutic: silence with nonverbal attention gives the client time to reflect.
- "You shouldn't skip group. That's not good for you." Nontherapeutic: disapproving imposes the nurse's values instead of exploring the client's reasons.
- "So you stopped the medicine because it upsets your stomach. Did I get that right?" Therapeutic: summarizing shows active listening and lets the client correct the nurse.
- "I went through a divorce too, so I know exactly how you feel." Nontherapeutic: self-disclosure of personal information blurs professional boundaries and shifts the focus to the nurse.
Learn this topic: How to pick the therapeutic response every time 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 2.3 Therapeutic Communication · Open RN Nursing: Mental Health and Community Concepts 2e, 1.5 Boundaries ·
A client tells the nurse, "The staff on this unit never listen to me." The nurse replies, "We are all good nurses here, and we always listen." This reply is an example of . It is nontherapeutic because it . A more therapeutic reply is .
Choose the best option from each list to complete the sentence.
Correct answer: a defensive response; discourages the client from explaining; "You feel the staff haven't listened. Tell me what happened."
Defending the staff is a defensive response: it protects the nurse and team instead of exploring the client's concern, so the client stops explaining. Listening to a complaint does not mean agreeing with it. Restating the client's feeling and asking for more information keeps the conversation open; the nurse can follow the chain of command afterward if needed.
- Defending the staff is a defensive response; presenting reality corrects distorted perceptions with facts, and restating repeats the client's own idea.
- Defensive replies discourage the client from explaining the concern; the reply is not a limit on behavior and is not a question.
- Restating the feeling and inviting more detail is therapeutic; handing the concern off avoids it, and a why question sounds accusing.
Learn this topic: How to pick the therapeutic response every time 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 2.3 Therapeutic Communication ·
A client admitted with major depressive disorder tells the nurse, "I have it all worked out. I've been saving up my pills for when the time is right." Which action will the nurse take first?
Correct answer: C
A client who describes a specific plan and has gathered the means is at high risk, so safety comes first. The nurse does not leave the client alone, gets help so the provider is notified, and then removes the saved medication and follows agency observation policy. Documentation is required but comes after the client is safe.
- A Documentation is needed, but it does not protect the client and is not the first action.
- B A group session does not address the immediate risk of a client with a plan and the means.
- C Correct: a client making suicidal statements with a plan must not be left alone, and the provider must be notified.
- D This is false reassurance; it blocks communication and ignores the immediate danger.
Learn this topic: How nurses assess suicide risk and respond to a client in crisis 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 7.5 Applying the Nursing Process to Depressive Disorders · Open RN Nursing: Mental Health and Community Concepts 2e, 1.6 Establishing Safety ·
A nurse in the emergency department is reviewing the screening note for a 47-year-old client who came in for a sprained ankle. Click to highlight the findings that increase the client's risk for suicide.
Client reports that they three weeks ago. Has . Blood pressure . Client states, . Spouse says the client last week. Client has and is . Client also reports .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: lost their job; "My family would be better off without me"; gave away a favorite guitar; a suicide attempt 5 years ago; drinking alcohol more often than usual
Suicide risk comes from what the client says, what they do and their history. Job loss, feeling like a burden, giving away important items, a previous attempt and increased alcohol use are all recognized warning signs or risk factors. Universal screening in acute care exists because clients seen for medical problems can have hidden suicide risk.
- lost their job Job or financial loss is a recognized risk factor for suicide.
- no known drug allergies Allergy status is unrelated to suicide risk.
- 128/78 mm Hg A normal blood pressure is not a suicide risk factor.
- "My family would be better off without me" Talking about being a burden to others is a warning sign of suicide.
- gave away a favorite guitar Giving away important possessions is a warning sign of suicide.
- a suicide attempt 5 years ago A previous suicide attempt is one of the most consistent risk factors.
- able to bear some weight on the ankle Ankle function relates to the injury, not to suicide risk.
- drinking alcohol more often than usual Using alcohol or drugs more often is a warning sign, and substance use is a risk factor.
Learn this topic: How nurses assess suicide risk and respond to a client in crisis 5-minute lesson
Source: NIMH: Warning Signs of Suicide · Open RN Nursing: Mental Health and Community Concepts 2e, 1.6 Establishing Safety · Open RN Nursing: Mental Health and Community Concepts 2e, 4.3 Assessment ·
A client with severe depression started an antidepressant 10 days ago. For a week the client stayed in bed and spoke little. Today the client is smiling, calm and says, "I finally know what I need to do." Which actions will the nurse take? Select all that apply.
Select all that apply.
Correct answer: B, D, F
A sudden calm or euphoric change after deep depression, especially early in antidepressant therapy, when a client may regain enough energy to act on suicidal thoughts, is a red flag for suicide risk. The nurse asks directly, reports the change so the whole team knows the risk level, and keeps the environment safe. Reducing supervision or sending the client out would increase risk.
- A A sudden mood lift after severe depression can signal higher risk, so observation should not be reduced.
- B Correct: asking directly about suicide does not increase risk and opens a safety conversation.
- C This assumes recovery and is false reassurance; it may stop the client from disclosing a plan.
- D Correct: changes that suggest suicide risk must be communicated so all team members can keep the client safe.
- E Leaving the protected setting during a possible high-risk period is unsafe.
- F Correct: removing items that could be used for self-harm is a priority safety measure.
Learn this topic: How nurses assess suicide risk and respond to a client in crisis 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 7.5 Applying the Nursing Process to Depressive Disorders · Open RN Nursing: Mental Health and Community Concepts 2e, 3.5 Crisis and Crisis Intervention · Open RN Nursing: Mental Health and Community Concepts 2e, 1.6 Establishing Safety ·
A nurse is teaching a group of new graduate nurses about the timeline of alcohol withdrawal. Mild symptoms such as tremor and sweating usually begin after the last drink. Withdrawal seizures can occur after the last drink, and delirium tremens usually begins after the last drink.
Choose the best option from each list to complete the sentence.
Correct answer: 6 to 24 hours; 6 to 48 hours; about 2 to 4 days
Alcohol withdrawal follows a clock that starts at the last drink. Mild symptoms usually begin within 6 to 24 hours, seizures can occur from 6 to 48 hours, and delirium tremens usually begins about 2 to 4 days after the last drink (MedlinePlus gives 48 to 96 hours; Open RN gives 72 to 96 hours). Knowing the window tells the nurse which complication to prepare for next.
- Mild withdrawal begins 6 to 24 hours after the last drink (not 3 to 5 days or weeks later) and often resolves in 1 to 2 days without treatment.
- Withdrawal seizures occur early, within 6 to 48 hours, not weeks later.
- Delirium tremens is a later complication, usually starting about 2 to 4 days after the last drink, not within hours and not weeks later.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Delirium tremens ·
A client with a long history of heavy alcohol use is being treated for alcohol withdrawal. The nurse notes new confusion, an unsteady gait and jerky, involuntary eye movements. Which prescription does the nurse expect the provider to give?
Correct answer: C
Confusion, ataxia and nystagmus in a client with alcohol use disorder point to Wernicke encephalopathy, an acute, life-threatening condition caused by thiamine (vitamin B1) deficiency. Thiamine replacement treats it; untreated, it can progress to Korsakoff syndrome, a chronic memory disorder. The other drugs are used for opioid overdose or opioid withdrawal.
- A Naloxone reverses opioids; it does not treat thiamine deficiency.
- B Clonidine relieves autonomic symptoms of opioid withdrawal, not Wernicke encephalopathy.
- C Correct: thiamine treats and prevents Wernicke encephalopathy, which presents with confusion, ataxia and nystagmus.
- D Buprenorphine treats opioid withdrawal and opioid use disorder, not thiamine deficiency.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Wernicke-Korsakoff syndrome · MedlinePlus Drug Information: Naloxone injection ·
A client's last drink was 20 hours ago. The client is tremulous, sweating and has vomited twice. Which actions will the nurse include in the plan of care? Select all that apply.
Select all that apply.
Correct answer: A, D, E
At 20 hours after the last drink the client is in the window for withdrawal seizures, so seizure precautions are needed: lowest bed position, padded side rails, and oxygen and suction at the bedside. The CIWA-Ar tracks severity and guides medication. A quiet, low-stimulus room is preferred, and a client with vomiting needs help to the bathroom because of fall risk.
- A Correct: a low bed with padded rails is part of seizure precautions.
- B Caffeine is avoided to protect sleep, which withdrawal already disrupts; it does not make withdrawal safer.
- C A bright, busy setting increases stimulation; a quiet, low-stimulus environment is recommended.
- D Correct: suction and oxygen must be available at the bedside during seizure precautions.
- E Correct: the CIWA-Ar is used to monitor alcohol withdrawal and guide symptom-triggered treatment.
- F Clients with vomiting or diarrhea who go to the bathroom unassisted are at increased risk for falls.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.9 Applying the Nursing Process · Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L The nurse reviews the 0600 assessment. Click to highlight the findings that require follow-up.
0600: Client awake most of the night, restless and asking to go home. . Skin . States, . Oriented to person and place; . Right lower leg red, warm and tender; . Heart rate . .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: Hands tremble when holding a cup; moist with sweat; "There are bugs crawling on the wall"; unsure of the date; 116/min
Tremor, sweating, visual hallucinations, new disorientation to time and a rising heart rate are new findings that fit early alcohol withdrawal and need follow-up. Redness that stays within the marked borders shows the cellulitis is not spreading, and an SpO2 of 96% is within the expected range. Recognizing withdrawal early matters because clients often underreport how much they drink.
- Hands tremble when holding a cup Tremor is a sign of early alcohol withdrawal.
- moist with sweat Diaphoresis is a sign of withdrawal and of autonomic overactivity.
- "There are bugs crawling on the wall" Seeing insects that are not there is a visual hallucination, typical of withdrawal 12 to 24 hours after the last drink.
- unsure of the date New disorientation to time is a change in mental status that needs follow-up.
- redness remains within the marked borders Redness staying within the marked borders means the infection is not spreading; this is reassuring.
- 116/min Heart rate rose from 84 to 116/min; tachycardia is a sign of withdrawal.
- SpO2 96% on room air An SpO2 of 96% on room air is within the expected range.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Alcohol withdrawal · MedlinePlus: Cellulitis ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L The client has two active problems. For each finding, indicate whether it is more consistent with the client's alcohol use and withdrawal or with cellulitis.
Alcohol use and withdrawal Cellulitis Hands tremble when holding a cup Warm, red skin on the right lower leg Sees bugs crawling on the wall Magnesium 1.4 mg/dL Tenderness of the right lower leg Blood pressure up from 134/82 to 164/92 mm Hg Select one option in each row.
Correct answer: Hands tremble when holding a cup: Alcohol use and withdrawal; Warm, red skin on the right lower leg: Cellulitis; Sees bugs crawling on the wall: Alcohol use and withdrawal; Magnesium 1.4 mg/dL: Alcohol use and withdrawal; Tenderness of the right lower leg: Cellulitis; Blood pressure up from 134/82 to 164/92 mm Hg: Alcohol use and withdrawal
Tremor, visual hallucinations and a rise in systolic blood pressure are signs of alcohol withdrawal, and heavy drinking depletes magnesium. Warm, red, tender skin in one area is the local picture of cellulitis. Sorting cues by cause helps the nurse avoid blaming every change on the admitting diagnosis.
- Hands tremble when holding a cup Tremor is a classic early sign of alcohol withdrawal.
- Warm, red skin on the right lower leg Warm, red skin in the affected area is a sign of cellulitis.
- Sees bugs crawling on the wall Visual hallucinations of insects are typical of alcohol withdrawal.
- Magnesium 1.4 mg/dL Low magnesium is linked to alcohol use disorder; chronic drinking depletes magnesium.
- Tenderness of the right lower leg Pain or tenderness in the affected area is a sign of cellulitis.
- Blood pressure up from 134/82 to 164/92 mm Hg Systolic hypertension is a physical sign of alcohol withdrawal.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Magnesium blood test · MedlinePlus: Potassium test · MedlinePlus: Cellulitis ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L The client is most likely experiencing . The client's last drink was about before the 0600 assessment. Based on this timing, the complication the nurse should be most prepared for during the next 24 hours is .
Choose the best option from each list to complete the sentence.
Correct answer: alcohol withdrawal; 18 hours; a withdrawal seizure
Tremor, sweating, tachycardia, rising blood pressure and visual hallucinations after heavy daily drinking point to alcohol withdrawal; the cellulitis is stable and the temperature is only slightly raised. The last drink was at 1200 on Day 1, about 18 hours before 0600. Withdrawal seizures occur 6 to 48 hours after the last drink, so the next 24 hours fall squarely in that window, while delirium tremens usually begins later, about 2 to 4 days after the last drink.
- The cluster of tremor, diaphoresis, tachycardia, hypertension and visual hallucinations after daily heavy drinking fits alcohol withdrawal; the leg redness is not spreading, and Korsakoff syndrome is a chronic memory disorder.
- From 1200 on Day 1 to 0600 on Day 2 is 18 hours; 14 hours counts from admission at 1600 instead of the last drink, and 42 hours is where the next 24 hours will end.
- From 18 to 42 hours after the last drink, the client is in the 6-to-48-hour seizure window; Korsakoff-type memory loss is chronic, and nothing suggests an antibiotic allergy.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Delirium tremens · MedlinePlus: Cellulitis ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L The nurse is planning care for the client. For each potential intervention, indicate whether it is indicated or not indicated at this time.
Indicated Not indicated Keep the room lights bright and the television on Keep the bed in its lowest position with padded side rails Place oxygen and suction equipment at the bedside Apply wrist restraints so the client cannot leave Allow the client to walk to the bathroom unassisted Assess the client with the CIWA-Ar scale Select one option in each row.
Correct answer: Keep the room lights bright and the television on: Not indicated; Keep the bed in its lowest position with padded side rails: Indicated; Place oxygen and suction equipment at the bedside: Indicated; Apply wrist restraints so the client cannot leave: Not indicated; Allow the client to walk to the bathroom unassisted: Not indicated; Assess the client with the CIWA-Ar scale: Indicated
After airway, breathing and circulation, safety is the priority in alcohol withdrawal: seizure precautions (low bed, padded rails, oxygen and suction at the bedside), fall precautions, a quiet low-stimulus room and CIWA-Ar monitoring. Restraints are a last resort when alternatives fail and safety is in danger; wanting to go home is not a reason to restrain.
- Keep the room lights bright and the television on Not indicated: a quiet, low-stimulus environment is recommended during withdrawal.
- Keep the bed in its lowest position with padded side rails Indicated: a low bed with padded side rails is part of seizure precautions.
- Place oxygen and suction equipment at the bedside Indicated: suction and oxygen must be at the bedside for seizure precautions.
- Apply wrist restraints so the client cannot leave Not indicated: restraints are used only when alternatives are not effective and safety is at risk; a restraint-free environment is the standard of care.
- Allow the client to walk to the bathroom unassisted Not indicated: clients with nausea and vomiting who go to the bathroom alone are at higher risk for falls.
- Assess the client with the CIWA-Ar scale Indicated: the CIWA-Ar measures withdrawal severity and guides symptom-triggered treatment.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.9 Applying the Nursing Process · Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · Open RN Nursing: Mental Health and Community Concepts 2e, 5.5 Patient Rights ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L At 0700, the client's CIWA-Ar score is 17. The provider prescribes lorazepam per the symptom-triggered CIWA-Ar protocol (give for a score of 10 or higher), thiamine IV daily, and magnesium sulfate IV. Which actions will the nurse take? Select all that apply.
Select all that apply.
Correct answer: A, C, E
A score of 17 meets the protocol threshold, so the nurse gives the benzodiazepine, gives thiamine to prevent Wernicke encephalopathy, and reassesses to see whether the dose worked. Agreeing with a hallucination reinforces it; the nurse instead presents reality calmly. Blaming the client is a nontherapeutic, aggressive response, and delaying treatment is unsafe.
- A Correct: benzodiazepines treat agitation and help prevent seizures and delirium tremens; the score meets the protocol threshold.
- B Agreeing with a hallucination reinforces it; the nurse presents reality without arguing.
- C Correct: thiamine is given to prevent Wernicke encephalopathy in clients with heavy alcohol use.
- D The spouse has already confirmed the history, and delaying treatment allows withdrawal to progress.
- E Correct: symptom-triggered treatment depends on repeated CIWA-Ar scoring and vital sign checks.
- F Blaming the client is a nontherapeutic response that damages trust.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · Open RN Nursing: Mental Health and Community Concepts 2e, 14.9 Applying the Nursing Process · Open RN Nursing: Mental Health and Community Concepts 2e, 2.3 Therapeutic Communication ·
History
A 54-year-old client was admitted on Day 1 at 1600 with cellulitis of the right lower leg for IV antibiotics. On admission, the client reported drinking "a couple of beers on weekends." No history of seizures.
Nurses' Notes
Day 2, 0600: Client awake most of the night, restless and asking to go home. Hands tremble when holding a cup. Skin moist with sweat. Reports nausea; vomited once at 0430. States, "There are bugs crawling on the wall." Oriented to person and place; unsure of the date. Right lower leg red, warm and tender; redness remains within the marked borders. SpO2 96% on room air.
Day 2, 0630: Spouse arrives and reports that the client drinks about a pint of liquor every day. The client's last drink was on Day 1 at about 1200, before coming to the hospital.
Vital Signs
Day 1, 1600 Day 2, 0600 Temperature 99.1°F (37.3°C) 99.9°F (37.7°C) Heart rate 84/min 116/min Blood pressure 134/82 mm Hg 164/92 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results (Day 2, 0500)
Test Result Normal range Magnesium 1.4 mg/dL 1.7–2.2 mg/dL Potassium 3.4 mEq/L 3.7–5.2 mEq/L Day 3, 0800 (about 44 hours after the client's last drink). The client has received lorazepam per protocol, thiamine and magnesium. For each finding, indicate whether it shows the client is improving or not improving.
Improving Not improving Heart rate 88/min Cannot say where they are and pulls at the IV line States, "The bugs are gone now." Magnesium 1.9 mg/dL (1.7–2.2 mg/dL) Blood pressure 168/96 mm Hg Hands steady when holding a cup Select one option in each row.
Correct answer: Heart rate 88/min: Improving; Cannot say where they are and pulls at the IV line: Not improving; States, "The bugs are gone now.": Improving; Magnesium 1.9 mg/dL (1.7–2.2 mg/dL): Improving; Blood pressure 168/96 mm Hg: Not improving; Hands steady when holding a cup: Improving
A slower heart rate, no hallucinations, steady hands and a normal magnesium level show improvement. New disorientation to place with pulling at lines, together with blood pressure that is still rising, is not improvement; the client is approaching the period when delirium tremens usually begins (about 2 to 4 days after the last drink), so the nurse reports these findings promptly.
- Heart rate 88/min Heart rate has dropped from 116 to 88/min, so autonomic overactivity is easing.
- Cannot say where they are and pulls at the IV line Worsening disorientation and agitation can signal developing delirium tremens and need prompt follow-up.
- States, "The bugs are gone now." Hallucinations have resolved.
- Magnesium 1.9 mg/dL (1.7–2.2 mg/dL) Magnesium is now within the normal range of 1.7 to 2.2 mg/dL.
- Blood pressure 168/96 mm Hg Blood pressure is higher than at 0600 on Day 2; rising blood pressure is a sign of worsening withdrawal.
- Hands steady when holding a cup Tremor has resolved.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Delirium tremens · MedlinePlus: Magnesium blood test ·
A client with schizophrenia who has a history of auditory hallucinations is sitting alone in the dayroom, whispering and glancing toward an empty corner. The client looks frightened. Which statement by the nurse is best?
Correct answer: C
Assess first: when a client shows signs of hallucinating, the nurse finds out what the client is experiencing and then asks about the content, including whether the client hears commands to harm self or others. The nurse states what they observe and asks an open question rather than referring to the voices as if they were real. False reassurance, arguing that the voices are not real or giving medication before assessing does not address the client's fear or safety.
- A False reassurance dismisses the client's fear and skips assessment of what the client is experiencing, including possible commands to harm self or others.
- B Trying to convince the client the voices are not real is not helpful; the nurse offers their own perception and empathy instead.
- C Correct: the nurse names an observed behavior and asks an open question, which starts the assessment of the hallucination without implying the voices are real.
- D Giving medication before assessing the content and the client's response skips assessment, including the check for command hallucinations.
A 6-year-old is seen in the emergency department with a bruise on the face. While the parent is out of the room, the child says, "Daddy pushed me into the door." Which documentation entry by the nurse is most appropriate?
Correct answer: C
Suspected abuse is documented thoroughly and objectively: the client's own words in quotation marks and a precise description of each injury, including size, location and color, plus photos if policy allows. Conclusions, labels and opinions about who is lying do not belong in the record. The nurse also reports the suspicion to the agency state law names; proof is not required.
- A This is a conclusion, not an observation; the nurse documents facts and lets the protective agency investigate.
- B "Most likely from abuse" and "seemed evasive" are interpretations rather than measurable findings.
- C Correct: a direct quote and an exact description of the injury are objective, factual documentation.
- D Judging the parent's honesty is an opinion; the record states what was seen and heard.
Learn this topic: How nurses recognize abuse and neglect and what they must do next 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 15.4 Abuse and Neglect · Child Welfare Information Gateway: Mandatory Reporting of Child Abuse and Neglect (State Statutes PDF, current through May 2023) ·
A home health nurse assesses several older adult clients. For each finding, indicate the type of abuse it most suggests.
Physical abuse Neglect Emotional abuse Financial abuse Grip-shaped bruises on both inner upper arms Stage 2 pressure injury, dry mucous membranes and soiled clothing while living with a paid caregiver A nephew uses the client's bank card, and her rent is unpaid even though her pension arrives monthly The caregiver threatens to "put her in a home" and keeps her friends from visiting The client's daughter calls her "useless" and mocks her in front of guests Select one option in each row.
Correct answer: Grip-shaped bruises on both inner upper arms: Physical abuse; Stage 2 pressure injury, dry mucous membranes and soiled clothing while living with a paid caregiver: Neglect; A nephew uses the client's bank card, and her rent is unpaid even though her pension arrives monthly: Financial abuse; The caregiver threatens to "put her in a home" and keeps her friends from visiting: Emotional abuse; The client's daughter calls her "useless" and mocks her in front of guests: Emotional abuse
Elder abuse includes physical, sexual and emotional abuse, neglect, financial abuse, treatment without consent and unreasonable confinement. Bruises on the inner arms suggest restraint or defensive injury; pressure injuries, dehydration and poor hygiene suggest neglect; misuse of money suggests financial abuse; threats, isolation and humiliation are emotional abuse. Suspected abuse of an older or at-risk adult is reported according to state law, often to adult protective services.
- Grip-shaped bruises on both inner upper arms Bruising on the inner upper arms can suggest defensive injuries or forceful restraint, a pattern of physical abuse.
- Stage 2 pressure injury, dry mucous membranes and soiled clothing while living with a paid caregiver A pressure injury, dehydration and poor hygiene show failure to meet basic needs, which is neglect.
- A nephew uses the client's bank card, and her rent is unpaid even though her pension arrives monthly Using the client's money for someone else's benefit is financial abuse.
- The caregiver threatens to "put her in a home" and keeps her friends from visiting Threats and keeping the client away from others (isolation) are forms of emotional abuse.
- The client's daughter calls her "useless" and mocks her in front of guests Humiliation and disrespect are verbal behaviors that cause anguish, which is emotional abuse.
Learn this topic: How nurses recognize abuse and neglect and what they must do next 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 15.4 Abuse and Neglect ·
A nurse in a prenatal clinic is screening a client for intimate partner violence. The client's partner came to the visit. Which actions by the nurse are appropriate? Select all that apply.
Select all that apply.
Correct answer: A, B, E
Routine screening for intimate partner violence happens in private, so others are asked to leave; a partner who refuses is a warning sign. The nurse assures confidentiality within the limits of mandatory reporting, asks a few open-ended questions using words like "hurt" or "afraid" rather than "victim" or "abused," never asks why the client has not left and never discusses concerns with the partner. If abuse is disclosed, the priority is a personal safety plan and resources.
- A Correct: privacy makes disclosure safer; the interview and exam happen without the partner present.
- B Correct: asking about being hurt or afraid mirrors everyday words and feels less threatening.
- C Labels such as "victim" or "abuse" can feel shaming and make disclosure less likely.
- D Asking why the client hasn't left implies blame; leaving is often the most dangerous time.
- E Correct: the nurse assures confidentiality but is honest that mandatory reporting may apply.
- F Sharing concerns with the partner could put the client in danger.
Learn this topic: How nurses recognize abuse and neglect and what they must do next 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 15.5 Intimate Partner Violence · Open RN Nursing: Mental Health and Community Concepts 2e, 15.7 Applying the Nursing Process to Clients Experiencing Trauma, Abuse, or Violence ·
A nurse is assessing clients whose spouses died 4 months ago. For each finding, indicate whether it is more consistent with normal grief or with major depression.
Normal grief Major depression Sadness comes in waves that are mixed with fond memories of the spouse Feels worthless and full of self-loathing Self-esteem is intact; says, "I was a good husband to her" Low mood all day, every day, with no ability to expect any pleasure Describes a hollow, empty feeling and longs to see the spouse again Select one option in each row.
Correct answer: Sadness comes in waves that are mixed with fond memories of the spouse: Normal grief; Feels worthless and full of self-loathing: Major depression; Self-esteem is intact; says, "I was a good husband to her": Normal grief; Low mood all day, every day, with no ability to expect any pleasure: Major depression; Describes a hollow, empty feeling and longs to see the spouse again: Normal grief
Grief and depression overlap, but they differ in pattern. In grief, painful feelings come in waves, ease over time, mix with positive memories and center on emptiness and longing, and self-esteem is usually preserved. In major depression, mood is constantly low, pleasure cannot be expected and worthlessness or self-loathing is common; depression can develop after a loss and needs referral.
- Sadness comes in waves that are mixed with fond memories of the spouse Waves of sadness mixed with positive memories are typical of the normal grieving process.
- Feels worthless and full of self-loathing Worthlessness and self-loathing point to major depression; self-esteem is usually kept in grief.
- Self-esteem is intact; says, "I was a good husband to her" Preserved self-esteem fits normal grief.
- Low mood all day, every day, with no ability to expect any pleasure A constant low mood with inability to expect pleasure is characteristic of major depression.
- Describes a hollow, empty feeling and longs to see the spouse again Emptiness and yearning for the deceased are core features of grief.
Learn this topic: How nurses tell normal grief from complicated grief and support the family 5-minute lesson
Source: National Cancer Institute: Grief, Bereavement, and Coping With Loss (PDQ) – Health Professional Version · Open RN Nursing Fundamentals 2e, 17.2 Basic Concepts (grief, loss, end of life) ·
A client who had a miscarriage at 10 weeks has told no one at work and feels she is not allowed to be sad. This is an example of grief. Another client is grieving the expected death of her father, who has terminal cancer and is still alive. This is grief. A third client's adult daughter died suddenly 14 months ago; he still cannot accept the death, blames himself and has stopped working. This suggests grief.
Choose the best option from each list to complete the sentence.
Correct answer: disenfranchised; anticipatory; complicated
Disenfranchised grief is grief over a loss that others do not recognize or validate, such as a pregnancy loss, so the person feels unable to mourn openly. Anticipatory grief begins before an expected loss, such as during a terminal illness. Complicated grief is prolonged, intense grief that impairs functioning; a sudden death and the death of a child are risk factors.
- A pregnancy loss that others do not acknowledge, leaving her unable to grieve openly, is disenfranchised grief.
- Grieving a loss that has not happened yet, during a terminal illness, is anticipatory grief.
- Grief that stays intense long after the sudden death of a child, with self-blame and an inability to work, suggests complicated grief.
Learn this topic: How nurses tell normal grief from complicated grief and support the family 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 17.2 Basic Concepts (grief, loss, end of life) · National Cancer Institute: Grief, Bereavement, and Coping With Loss (PDQ) – Health Professional Version ·
A hospice bereavement nurse reviews four family members after a loss. Which person is at highest risk for complicated grief?
Correct answer: B
Risk factors for complicated grief include sudden or traumatic death, suicide, homicide, the death of a child, a dependent relationship, multiple losses and a lack of support. Crying at reminders weeks after a death and feeling relief after a long illness are part of normal grief. The nurse monitors at-risk survivors during bereavement and refers them for counseling when grief does not ease.
- A An expected, peaceful death with active social support is a protective situation.
- B Correct: a child's death by suicide, plus few supports, combines several major risk factors for complicated grief.
- C Crying at reminders of the deceased a few weeks after the death is a normal grief response.
- D Relief is a normal emotion in grief, especially after a long illness.
Learn this topic: How nurses tell normal grief from complicated grief and support the family 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 17.2 Basic Concepts (grief, loss, end of life) · Open RN Nursing Fundamentals 2e, 17.3 Applying the Nursing Process to Grief · National Cancer Institute: Grief, Bereavement, and Coping With Loss (PDQ) – Health Professional Version ·
A client has been on bed rest for 4 days after abdominal surgery. The provider now prescribes ambulation. Which action should the nurse take first?
Correct answer: B
After days in bed, blood pools in the legs and the client is at risk for orthostatic hypotension: a systolic drop of 20 mm Hg or more, or a diastolic drop of 10 mm Hg or more, within 3 minutes of sitting or standing. Safety comes first, so every transfer or walk begins with dangling at the edge of the bed and checking for dizziness before standing.
- A Standing before a sitting check skips the step that detects dizziness and orthostatic hypotension while the client is still safe on the bed.
- B Correct: dangling for a few minutes lets the nurse check for dizziness or orthostatic hypotension before the client bears weight.
- C Walking comes later; a gait belt does not replace checking how the client tolerates sitting up first.
- D Walking alone after 4 days of bed rest is unsafe until the client's tolerance and need for help are assessed.
Learn this topic: How bed rest harms the body, and how turning and positioning prevent it 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 13.2 Mobility Basic Concepts · Open RN Nursing Fundamentals 2e, 13.3 Mobility: Applying the Nursing Process ·
A client has been immobile for 10 days after a stroke. For each assessment finding, indicate the body system in which the complication of immobility is occurring.
Cardiovascular Integumentary Musculoskeletal Gastrointestinal Right calf is red, warm, swollen and tender Intact skin over the sacrum has a red area that does not blanch Left foot rests in plantar flexion and cannot be brought to neutral Systolic blood pressure drops 24 mm Hg when the client sits up Last bowel movement 4 days ago; abdomen is distended Select one option in each row.
Correct answer: Right calf is red, warm, swollen and tender: Cardiovascular; Intact skin over the sacrum has a red area that does not blanch: Integumentary; Left foot rests in plantar flexion and cannot be brought to neutral: Musculoskeletal; Systolic blood pressure drops 24 mm Hg when the client sits up: Cardiovascular; Last bowel movement 4 days ago; abdomen is distended: Gastrointestinal
Immobility harms every system. Venous pooling causes clots (DVT) and orthostatic hypotension, pressure over bone causes pressure injuries, shortened tissue causes contractures and foot drop, and slowed peristalsis causes constipation. Sorting findings by system helps the nurse run a head-to-toe check on every immobile client.
- Right calf is red, warm, swollen and tender Cardiovascular: redness, warmth, swelling and tenderness in one leg suggest a deep vein thrombosis from venous pooling.
- Intact skin over the sacrum has a red area that does not blanch Integumentary: nonblanchable redness over intact skin is a Stage 1 pressure injury.
- Left foot rests in plantar flexion and cannot be brought to neutral Musculoskeletal: a foot fixed in plantar flexion is foot drop, a complication of immobility.
- Systolic blood pressure drops 24 mm Hg when the client sits up Cardiovascular: a systolic drop of 20 mm Hg or more with position change is orthostatic hypotension.
- Last bowel movement 4 days ago; abdomen is distended Gastrointestinal: slowed peristalsis leads to constipation, and abdominal distention is a related complication of immobility.
Learn this topic: How bed rest harms the body, and how turning and positioning prevent it 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 13.2 Mobility Basic Concepts · Open RN Nursing Fundamentals 2e, 13.3 Mobility: Applying the Nursing Process · Open RN Nursing Fundamentals 2e, 10.4 Pressure Injuries · MedlinePlus: Deep venous thrombosis ·
The nurse is planning care for a client who cannot turn without help. Which interventions help prevent complications of immobility? Select all that apply.
Select all that apply.
Correct answer: A, C, E
Regular turning, lifting with a draw sheet and two people, and supporting the feet prevent pressure injuries, shear and foot drop. Joint changes start within about 3 days, so range of motion begins as soon as possible. Long periods in high Fowler's or without turning add pressure and shear.
- A Correct: turning at least every 2 hours on a schedule relieves pressure and prevents skin breakdown.
- B High Fowler's around the clock increases pressure on the coccyx and encourages sliding, which causes shear.
- C Correct: two people and a draw sheet lift rather than drag the client, reducing shear and friction.
- D Joint changes can begin after 3 days of immobility, so range of motion should start as soon as possible.
- E Correct: positioning aids such as pillows and foot boots help prevent foot drop and contractures.
- F Skipping turns overnight leaves pressure on the same areas for hours and raises pressure injury risk.
Learn this topic: How bed rest harms the body, and how turning and positioning prevent it 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 13.2 Mobility Basic Concepts · Open RN Nursing Fundamentals 2e, 10.6 Integumentary: Applying the Nursing Process ·
A client has a nasogastric feeding tube whose placement was confirmed by X-ray yesterday. Before giving a scheduled bolus feeding, which action is the best way for the nurse to check tube position?
Correct answer: C
X-ray confirms placement after insertion. After that, the nurse checks position every 4 hours and before every feeding or medication by comparing the visible tube length with the length documented at X-ray. If the length has changed or there is doubt, the feeding is held and placement is verified per policy.
- A The air 'whoosh' test is unreliable and should not be used to verify placement.
- B Judging aspirate by its appearance is unreliable and is not an accepted way to verify placement.
- C Correct: comparing the external length with the documented length is the recommended routine check before each use.
- D pH can support a check, but it should never be the only method used to confirm placement.
Learn this topic: How to give tube feedings safely: placement checks and aspiration prevention 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 17.5 Checklist for NG Tube Enteral Feeding by Gravity With Irrigation ·
For a client receiving continuous tube feeding, the nurse keeps the head of the bed at and checks tube position every hours. If the external tube length is longer than the documented length, the nurse should .
Choose the best option from each list to complete the sentence.
Correct answer: 30 to 45 degrees; 4; hold the feeding and verify placement
To reduce aspiration, the head of the bed stays at 30 to 45 degrees unless contraindicated, and tube position is checked every 4 hours and before each feeding or medication. A change in external length means the tube may have moved, so the feeding is held until placement is verified; if in doubt, an X-ray is obtained.
- 30 to 45 degrees is the recommended head-of-bed angle during tube feeding; lower angles raise aspiration risk.
- Tube position is checked every 4 hours and before every feeding or medication; waiting 6 or 24 hours leaves a migrated tube undetected for too long, and every 2 hours is more often than recommended.
- A changed length means the tube may be out of position, so the feeding is held until placement is verified rather than adjusted blindly or ignored.
Learn this topic: How to give tube feedings safely: placement checks and aspiration prevention 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Fundamentals 2e, 14.3 Nutrition: Applying the Nursing Process ·
The nurse reviews the 1200 note for a client receiving continuous tube feeding. Click to highlight the findings that require follow-up.
1200: Head of bed at . Client has had since 1100. External tube length is . Abdomen is ; bowel sounds . Client reports . Gastric residual volume . Skin at the nare .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: a new cough; 6 cm longer than the documented length; bloated; three loose stools this morning
A new cough and a change in external tube length both suggest the tube may be out of position and the client may be aspirating, so the feeding is held and the provider notified. Bloating and diarrhea are signs of feeding intolerance that are reported so the formula or rate can be changed. A residual under 500 mL with no other signs is not by itself a reason to stop.
- 40 degrees A head of bed at 40 degrees is within the recommended 30 to 45 degrees.
- a new cough Requires follow-up: new respiratory symptoms may signal aspiration; hold feedings until placement is verified.
- 6 cm longer than the documented length Requires follow-up: a longer external length means the tube may have moved out of the stomach.
- bloated Requires follow-up: abdominal bloating is a sign of feeding intolerance to report.
- present in all four quadrants Bowel sounds in all four quadrants are an expected finding.
- three loose stools this morning Requires follow-up: diarrhea is a sign of feeding intolerance to report to the provider.
- 150 mL A residual of 150 mL is well under 500 mL and, with no other signs, does not by itself call for stopping the feeding.
- intact without redness Intact skin at the nare is expected; the site is still assessed daily.
Learn this topic: How to give tube feedings safely: placement checks and aspiration prevention 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 17.3 Assessments Related to Enteral Tubes ·
The nurse reviews four clients who have new prescriptions for an indwelling urinary catheter. Which client has an appropriate indication for the catheter?
Correct answer: D
CDC-approved indications include urinary retention, hourly output monitoring in critically ill clients, selected surgeries, healing sacral or perineal wounds with incontinence, prolonged immobilization and end-of-life care. When a request does not meet an indication, the nurse contacts the provider and advocates for another approach.
- A Using a catheter in place of nursing care for incontinence is an inappropriate reason.
- B A client who can void should give a culture specimen without a catheter.
- C Prolonged postoperative use without an indication is inappropriate; catheters are removed as soon as possible after surgery.
- D Correct: hourly output monitoring in a critically ill client is a CDC-approved indication.
Learn this topic: How to care for an indwelling urinary catheter and prevent CAUTI 5-minute lesson
Source: Open RN Nursing Skills 2e, 21.3 Preventing CAUTI · CDC: CAUTI Guideline, Summary of Recommendations ·
The nurse is reviewing care for a client with an indwelling urinary catheter. For each action, indicate whether it is indicated or not indicated to prevent catheter-associated urinary tract infection (CAUTI).
Indicated Not indicated Keep the drainage bag below the level of the bladder and off the floor Clean the area around the urethra with antiseptic solution each shift Empty the bag into a separate clean container used only for this client Irrigate the catheter every day to keep it open Replace the catheter every 7 days on a set schedule Secure the catheter to the thigh to prevent movement Select one option in each row.
Correct answer: Keep the drainage bag below the level of the bladder and off the floor: Indicated; Clean the area around the urethra with antiseptic solution each shift: Not indicated; Empty the bag into a separate clean container used only for this client: Indicated; Irrigate the catheter every day to keep it open: Not indicated; Replace the catheter every 7 days on a set schedule: Not indicated; Secure the catheter to the thigh to prevent movement: Indicated
CAUTI prevention depends on a closed system, free urine flow, a low bag, clean emptying and a secured catheter. CDC does not recommend antiseptic periurethral cleaning, routine irrigation, or changing catheters at fixed intervals; routine hygiene during bathing and changes for clinical reasons are used instead.
- Keep the drainage bag below the level of the bladder and off the floor Indicated: a bag below the bladder keeps urine flowing away from the bladder; the floor contaminates it.
- Clean the area around the urethra with antiseptic solution each shift Not indicated: antiseptics are not used on the periurethral area while the catheter is in; routine hygiene is enough.
- Empty the bag into a separate clean container used only for this client Indicated: a separate clean container for each client prevents cross-contamination when emptying.
- Irrigate the catheter every day to keep it open Not indicated: routine irrigation is not recommended unless obstruction is expected.
- Replace the catheter every 7 days on a set schedule Not indicated: catheters are changed for clinical reasons, not at fixed intervals.
- Secure the catheter to the thigh to prevent movement Indicated: securing the catheter prevents movement and urethral traction.
Learn this topic: How to care for an indwelling urinary catheter and prevent CAUTI 5-minute lesson
Source: CDC: CAUTI Guideline, Summary of Recommendations · Open RN Nursing Skills 2e, 21.4 Inserting and Managing Indwelling Urinary Catheters ·
A client's indwelling urinary catheter was removed at 0800. At 1430 the client reports lower abdominal fullness and has been unable to void despite trying. A bladder scan shows 420 mL. Which action should the nurse take next?
Correct answer: A
After removal, the goal is a void within 6 hours. A client who cannot void or reports bladder fullness is checked with a bladder scan, and a retained volume over 300 mL is reported to the provider, who usually orders a straight catheterization. An indwelling catheter is avoided when possible to lower CAUTI risk.
- A Correct: 420 mL retained in a client who cannot void is urinary retention; a volume over 300 mL is reported to the provider, who typically prescribes straight catheterization.
- B More fluid adds to a bladder that already cannot empty and delays treatment of retention.
- C An indwelling catheter needs a prescription and is avoided when possible; straight catheterization is the usual order.
- D Being unable to void 6 hours after removal with 420 mL retained is not expected; it signals urinary retention.
Learn this topic: How to care for an indwelling urinary catheter and prevent CAUTI 5-minute lesson
Source: Open RN Nursing Skills 2e, 21.6 Removing an Indwelling Urinary Catheter · Open RN Nursing Fundamentals 2e, 16.5 Urinary Retention ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL The nurse reviews the 0730 assessment. Click to highlight the findings that require immediate follow-up.
0730: Client is . Lung sounds: . External NG tube length . Abdomen . Urine . Temperature . SpO2 . Blood pressure . Sodium .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: coughing intermittently; crackles in the right lower lobe; 46 cm; 100.8°F (38.2°C); 91% on room air
The tube is 8 cm farther out than its X-ray-confirmed length, and the client now has a cough, crackles, a new fever and an SpO2 below 95%. Together these suggest the feeding may have entered the airway. Airway and breathing findings come first, so they need immediate follow-up; the abdomen, urine, blood pressure and sodium are within expected limits.
- coughing intermittently Requires follow-up: coughing in a client receiving tube feeding is a respiratory symptom that can signal aspiration.
- crackles in the right lower lobe Requires follow-up: crackles are adventitious sounds seen with pneumonia and fluid in the airways.
- 46 cm Requires follow-up: 46 cm is 8 cm longer than the 38 cm documented at X-ray, so the tube may have moved out of the stomach.
- soft with bowel sounds in all four quadrants A soft abdomen with bowel sounds in all four quadrants is expected.
- clear yellow, 40 mL/hr Clear yellow urine at 40 mL/hr meets the expected output of at least 30 mL/hr.
- 100.8°F (38.2°C) Requires follow-up: this is a new fever compared with 98.6°F the evening before.
- 91% on room air Requires follow-up: an SpO2 below 95% means oxygenation is compromised, and it has fallen from 97%.
- 132/78 mm Hg This blood pressure is close to the client's prior reading and needs no immediate action.
- 141 mEq/L Sodium 141 mEq/L is within the 135 to 145 mEq/L normal range.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 10.3 Respiratory Assessment · MedlinePlus: Aspiration pneumonia · Open RN Nursing Skills 2e, 21.8 Applying the Nursing Process to Catheterization · MedlinePlus: Sodium blood test ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL For each finding, indicate whether it is more consistent with aspiration pneumonia or with a pressure injury.
Aspiration pneumonia Pressure injury Crackles in the right lower lobe Braden Scale score of 11 Head of bed found nearly flat while the feeding was running 3-cm area of nonblanchable redness over the sacrum Temperature 100.8°F (38.2°C) Respirations 24/min, up from 18/min the evening before Select one option in each row.
Correct answer: Crackles in the right lower lobe: Aspiration pneumonia; Braden Scale score of 11: Pressure injury; Head of bed found nearly flat while the feeding was running: Aspiration pneumonia; 3-cm area of nonblanchable redness over the sacrum: Pressure injury; Temperature 100.8°F (38.2°C): Aspiration pneumonia; Respirations 24/min, up from 18/min the evening before: Aspiration pneumonia
Being fed while not upright is a risk factor for aspiration, and fever, crackles and a rising respiratory rate are consistent with pneumonia. A Braden score of 12 or less means high pressure injury risk, and nonblanchable redness over intact skin is a Stage 1 pressure injury. Linking each cue to the right problem lets the nurse treat both.
- Crackles in the right lower lobe Aspiration pneumonia: crackles occur with pneumonia and fluid in the airways.
- Braden Scale score of 11 Pressure injury: a Braden total of 12 or less represents high risk for pressure injury.
- Head of bed found nearly flat while the feeding was running Aspiration pneumonia: being fed when not upright raises the risk of aspiration.
- 3-cm area of nonblanchable redness over the sacrum Pressure injury: localized nonblanchable redness over intact skin is a Stage 1 pressure injury.
- Temperature 100.8°F (38.2°C) Aspiration pneumonia: fever is a symptom of aspiration pneumonia.
- Respirations 24/min, up from 18/min the evening before Aspiration pneumonia: a rate above 20/min is tachypnea, which signals compromised breathing and fits a developing lung infection.
Learn this topic: How bed rest harms the body, and how turning and positioning prevent it 5-minute lesson
Source: MedlinePlus: Aspiration pneumonia · Open RN Nursing Skills 2e, 10.3 Respiratory Assessment · Open RN Nursing Fundamentals 2e, 10.5 Braden Scale · Open RN Nursing Fundamentals 2e, 10.4 Pressure Injuries ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL The client's priority problem is , most likely because .
Choose the best option from each list to complete the sentence.
Correct answer: aspiration pneumonia; the tube migrated and feeding ran with the bed flat
Use airway-breathing-circulation (ABC) priority: a problem that threatens breathing comes before skin or urinary problems. The tube is 8 cm out of its confirmed position and the feeding ran while the client lay nearly flat; now the client has a cough, crackles, fever and an SpO2 of 91%. Aspiration pneumonia, the most serious complication of tube feeding, is therefore the priority.
- By ABC priority, aspiration pneumonia comes first because it threatens breathing; the sacral injury is real but lower priority, urine is clear with adequate output, and no orthostatic data are given.
- A tube out of position plus feeding while not upright explains the new respiratory findings; the catheter, weakness and sacral redness do not.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · MedlinePlus: Aspiration pneumonia · Open RN Nursing Skills 2e, 10.3 Respiratory Assessment ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL For each potential nursing action, indicate whether it is indicated or not indicated for the client's care at this time.
Indicated Not indicated Stop the feeding pump until tube placement is verified Instill air through the tube and listen over the stomach Report the new lung findings and tube change to the provider Keep the head of the bed flat to take pressure off the sacrum Ask the provider whether the urinary catheter can be removed Increase the feeding rate later to make up the missed volume Select one option in each row.
Correct answer: Stop the feeding pump until tube placement is verified: Indicated; Instill air through the tube and listen over the stomach: Not indicated; Report the new lung findings and tube change to the provider: Indicated; Keep the head of the bed flat to take pressure off the sacrum: Not indicated; Ask the provider whether the urinary catheter can be removed: Indicated; Increase the feeding rate later to make up the missed volume: Not indicated
Safety and breathing come first: when respiratory signs suggest aspiration, feedings are withheld, the provider is notified, and placement is verified, usually by X-ray when in doubt. The head of the bed stays at 30 to 45 degrees. The catheter was placed for incontinence, which is not an appropriate indication, so the nurse also advocates for its removal.
- Stop the feeding pump until tube placement is verified Indicated: feedings are withheld until placement is verified when aspiration is suspected.
- Instill air through the tube and listen over the stomach Not indicated: the air 'whoosh' test is unreliable and should not be used to check placement.
- Report the new lung findings and tube change to the provider Indicated: respiratory symptoms that suggest aspiration are reported to the provider right away.
- Keep the head of the bed flat to take pressure off the sacrum Not indicated: a flat bed raises aspiration risk; the order is 30 to 45 degrees, and turning relieves the sacrum.
- Ask the provider whether the urinary catheter can be removed Indicated: incontinence alone is not an appropriate reason for an indwelling catheter, so the nurse advocates for removal.
- Increase the feeding rate later to make up the missed volume Not indicated: feeding stays on hold until placement is confirmed, and catching up on volume is not the current goal.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 21.3 Preventing CAUTI · Open RN Nursing Fundamentals 2e, 10.6 Integumentary: Applying the Nursing Process ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL The nurse has notified the provider, who prescribes a portable X-ray to check the tube position. Which actions should the nurse take while waiting for the X-ray? Select all that apply.
Select all that apply.
Correct answer: A, D, E
When aspiration is suspected, feedings and medications are withheld until the X-ray verifies placement. Keeping the head of the bed raised lowers aspiration risk, and turning to the side relieves pressure on the sacrum while keeping the turning schedule. pH alone never confirms placement.
- A Correct: feedings are withheld until placement is verified.
- B Feedings and medications are withheld until placement is verified, because anything given through a misplaced tube can enter the airway.
- C pH can support a check but should never be the only method of confirming placement.
- D Correct: a head of bed at 30 to 45 degrees lowers the risk of aspiration.
- E Correct: the lateral position relieves pressure on the coccyx and sacral area, and turning every 2 hours prevents pressure injury progression.
- F The cough stopping does not confirm placement; feeding resumes only after the position is verified.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 17.5 Checklist for NG Tube Enteral Feeding by Gravity With Irrigation · Open RN Nursing Fundamentals 2e, 13.2 Mobility Basic Concepts · Open RN Nursing Fundamentals 2e, 10.6 Integumentary: Applying the Nursing Process ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL The next day, the tube is replaced, X-ray confirms its position, and the feeding is resumed. The indwelling urinary catheter was removed at 0800. For each finding, indicate whether it shows that care has been effective or not effective.
Effective Not effective SpO2 96% on room air; respirations 18/min External tube length matches the length documented after the new X-ray At 1500 the client has not voided; bladder scan shows 450 mL Head of bed at 35 degrees with the feeding running Temperature 101.3°F (38.5°C) with new crackles in the left lower lobe Turning record shows position changes every 2 hours Select one option in each row.
Correct answer: SpO2 96% on room air; respirations 18/min: Effective; External tube length matches the length documented after the new X-ray: Effective; At 1500 the client has not voided; bladder scan shows 450 mL: Not effective; Head of bed at 35 degrees with the feeding running: Effective; Temperature 101.3°F (38.5°C) with new crackles in the left lower lobe: Not effective; Turning record shows position changes every 2 hours: Effective
Normal oxygen saturation and respiratory rate, a stable tube length, a raised head of bed and a kept turning schedule show the plan is working. A rising fever with new crackles suggests the lung problem is worsening. Being unable to void 7 hours after removal with 450 mL retained is urinary retention, which is reported to the provider.
- SpO2 96% on room air; respirations 18/min Effective: SpO2 95 to 100% and respirations 12 to 20/min are within normal limits.
- External tube length matches the length documented after the new X-ray Effective: a length that matches the documented length suggests the tube has not moved.
- At 1500 the client has not voided; bladder scan shows 450 mL Not effective: the goal is to void within 6 hours, and a residual over 300 mL is reported to the provider.
- Head of bed at 35 degrees with the feeding running Effective: 35 degrees is within the 30 to 45 degrees that lowers aspiration risk.
- Temperature 101.3°F (38.5°C) with new crackles in the left lower lobe Not effective: rising fever and new crackles suggest worsening pneumonia.
- Turning record shows position changes every 2 hours Effective: turning at least every 2 hours follows the plan to prevent pressure injuries.
Learn this topic: How to care for an indwelling urinary catheter and prevent CAUTI 5-minute lesson
Source: Open RN Nursing Skills 2e, 10.3 Respiratory Assessment · Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 21.6 Removing an Indwelling Urinary Catheter · Open RN Nursing Fundamentals 2e, 16.5 Urinary Retention · Open RN Nursing Fundamentals 2e, 10.6 Integumentary: Applying the Nursing Process ·
A client with osteoarthritis of the left knee is learning to walk with a single-tip cane. Which statement by the client shows correct understanding of the teaching?
Correct answer: B
A cane is held in the hand opposite the weak or painful leg, and the cane and the weak leg move forward together so the cane takes some of the load off that leg. The handle should be at wrist level with the elbow slightly bent. On a step or curb, the stronger leg leads going up; going down, the cane is set on the lower level first and the weaker leg follows.
- A The cane goes in the hand opposite the weak leg, so this client should hold it in the right hand.
- B Correct: the cane and the weaker leg advance together, then the stronger leg steps past the cane.
- C Going up a step or curb, the stronger (right) leg leads and the cane and weaker leg follow.
- D The handle belongs at wrist level so the elbow is slightly bent; elbow height is too tall.
Source: MedlinePlus: Using a cane · Open RN Nursing Assistant, 8.5 Assisting With Ambulation ·
A speech-language pathologist recommends a food texture for a client with dysphagia that needs no biting or chewing, cannot be drunk from a cup and holds its shape on a spoon. Which IDDSI level matches this description?
Correct answer: D
The IDDSI framework has 8 levels: drinks run from Level 0 to Level 4 and foods from Level 3 to Level 7. Level 4 Pureed (Extremely Thick for drinks) is eaten with a spoon, cannot be drunk from a cup or sucked through a straw, needs no chewing and holds its shape. Level 3 still flows from a cup, and Levels 5 and 6 need some chewing.
- A Level 3 Liquidised can be drunk from a cup and does not hold its shape.
- B Level 5 Minced & Moist has small soft lumps and needs minimal chewing.
- C Level 6 Soft & Bite-Sized needs chewing before swallowing.
- D Correct: Level 4 Pureed needs no biting or chewing, cannot be drunk from a cup and holds its shape on a spoon.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: IDDSI: The IDDSI Framework · IDDSI: Complete IDDSI Framework Detailed Definitions 2.2 (2026) ·
A client with dysphagia after a stroke is prescribed IDDSI Level 5 Minced & Moist foods and Level 2 Mildly Thick drinks. Which actions should the nurse include in the client's meal plan? Select all that apply.
Select all that apply.
Correct answer: A, C, D
Aspiration precautions keep the client upright for meals (at least 45 degrees, as straight as possible) and for 30 to 45 minutes afterward, and use small bites of 1 teaspoon or less. The client gets only the prescribed textures: solids are not washed down with thin liquids, and mixed thin-thick foods such as cereal in milk are a choking risk. Talking while swallowing is avoided.
- A Correct: the client sits upright, at least 45 degrees and as straight as possible, while eating.
- B Washing solids down with sips of thin liquid is avoided unless the swallowing therapist approves, and thin liquids are not prescribed.
- C Correct: small bites of less than 1 teaspoon (5 mL) are easier to control.
- D Correct: the client stays upright for 30 to 45 minutes after eating.
- E Cereal in milk is a mixed thin-thick texture and a choking risk; the milk is also a thin liquid.
- F Talking and swallowing at the same time is avoided; caregivers are asked not to talk to the client while they eat.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: MedlinePlus: Swallowing problems · Open RN Nursing Assistant, 5.22 Skills Checklist: Preparing Clients for Meals and Assisting With Feeding · IDDSI: Complete IDDSI Framework Detailed Definitions 2.2 (2026) ·
A client admitted with a stroke passed a swallow screen yesterday and is eating lunch. The nurse reviews the lunch note. Click to highlight the findings that suggest a swallowing problem.
1215: Client is for lunch. after each spoonful of soup. after sips of the thickened juice. Tray . Voice sounds after swallowing. and has eaten 20% of the meal in 30 minutes. Temperature . Client is .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: Coughs; Clears throat repeatedly; wet and gurgly; Chews very slowly
Coughing or choking during or after eating, throat clearing after drinking, a wet or gurgly voice and slow chewing are signs of dysphagia, even in a client who passed an earlier screen. When they appear, the nurse stops the meal and notifies the provider so the speech-language pathologist can assess. A normal temperature does not rule out aspiration, which can be silent.
- sitting upright in a chair Sitting upright in a chair is the correct position for eating.
- Coughs Highlight: coughing during or after eating is a sign of a swallowing problem.
- Clears throat repeatedly Highlight: throat clearing after drinking is a symptom of dysphagia.
- matches the diet card A tray that matches the diet card is correct practice.
- wet and gurgly Highlight: a wet or gurgly voice during or after eating is a sign of dysphagia.
- Chews very slowly Highlight: slow chewing or eating is a symptom of a swallowing problem.
- 98.6°F (37.0°C) A normal temperature does not rule out aspiration, but it is not itself a sign of a swallowing problem.
- alert and follows commands Being alert and following commands is a reassuring finding.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: MedlinePlus: Swallowing problems · ASHA Practice Portal: Adult Dysphagia · Open RN Nursing Fundamentals 2e, 14.3 Nutrition: Applying the Nursing Process ·
The nurse needs to assess pain in a client with advanced dementia who can no longer communicate verbally. Which tool is most appropriate?
Correct answer: A
The Pain Assessment in Advanced Dementia (PAINAD) scale scores breathing, negative vocalization, facial expression, body language and consolability from 0 to 2 each, for a total of 0 to 10. It is designed for noncommunicative clients with advanced dementia. Self-report tools such as the 0–10 numeric scale and the FACES scale need the client to choose a rating.
- A Correct: PAINAD is a valid, reliable tool for noncommunicative clients with advanced dementia.
- B The numeric scale depends on the client's self-report, which this client cannot give.
- C With the FACES scale, the client chooses the face; the nurse does not pick one based on appearance.
- D The COMFORT Behavioral Scale is validated for children receiving mechanical ventilation.
Learn this topic: How nurses assess pain and relieve it with comfort measures beyond medication 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 11.3 Pain Assessment Methods · Open RN Nursing Fundamentals 2e, 11.5 Comfort: Applying the Nursing Process ·
The nurse reviews comfort measures planned for clients on a medical unit. For each planned measure, indicate whether it is safe or unsafe.
Safe Unsafe Place a thin towel between an ice pack and the skin of a sprained wrist Leave a heating pad on a client's sore shoulder for 45 minutes Give a 3- to 5-minute back massage to a client with muscle tension Massage a client's red, swollen calf to ease the ache Check the skin under a cold pack every 5 minutes for a client who cannot speak Apply a warm pack over the site of an implanted pain pump Select one option in each row.
Correct answer: Place a thin towel between an ice pack and the skin of a sprained wrist: Safe; Leave a heating pad on a client's sore shoulder for 45 minutes: Unsafe; Give a 3- to 5-minute back massage to a client with muscle tension: Safe; Massage a client's red, swollen calf to ease the ache: Unsafe; Check the skin under a cold pack every 5 minutes for a client who cannot speak: Safe; Apply a warm pack over the site of an implanted pain pump: Unsafe
Heat is applied for 5 to 20 minutes and cold for no longer than 20 minutes, with a thin barrier such as a towel between the pack and the skin, and neither is placed over medication patches or implanted devices. If the client cannot communicate, the skin is checked every 5 minutes. A massage lasts about 3 to 5 minutes and is never given over red or swollen areas.
- Place a thin towel between an ice pack and the skin of a sprained wrist Safe: a thin barrier such as a towel prevents tissue damage from cold.
- Leave a heating pad on a client's sore shoulder for 45 minutes Unsafe: heat is applied for 5 to 20 minutes, depending on tolerance.
- Give a 3- to 5-minute back massage to a client with muscle tension Safe: a back massage of about 3 to 5 minutes relieves tension and soreness.
- Massage a client's red, swollen calf to ease the ache Unsafe: massage is never given over red or swollen areas.
- Check the skin under a cold pack every 5 minutes for a client who cannot speak Safe: for a client who cannot communicate, the skin under a heat or cold pack is checked every 5 minutes.
- Apply a warm pack over the site of an implanted pain pump Unsafe: heat and cold are not applied over medication patches or implanted devices.
Learn this topic: How nurses assess pain and relieve it with comfort measures beyond medication 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 11.4 Pain Management · Open RN Nursing Assistant, 6.4 Comfort Measures ·
A client recovering from surgery set a comfort-function goal of 2/10 to do deep-breathing and coughing exercises. At 0900, before the exercises, the client rates pain 5/10. Complete the following sentences. The nurse and then reassesses the client's pain within . If the pain is still above the client's goal at reassessment, the nurse .
Choose the best option from each list to complete the sentence.
Correct answer: gives a prescribed intervention such as an analgesic or cold pack; 1 hour; takes further action, such as notifying the provider
A comfort-function goal is the pain level the client needs to reach to do recovery activities, here breathing and coughing exercises. When pain is above the goal, the nurse intervenes, for example with a prescribed analgesic, a cold pack or relaxation, and follows up within 1 hour (or a time frame based on the medication's route and onset). If the intervention does not work, more interventions are needed, which may include contacting the provider.
- Correct: pain above the goal calls for an intervention such as prescribed medication, cold or relaxation before the activity; waiting for the client to ask or canceling activity leaves the pain untreated.
- Correct: the nurse follows up within 1 hour to see whether the intervention worked.
- Correct: ineffective pain control requires follow-up interventions, which may include notifying the provider; the goal is not lowered or ignored.
Learn this topic: How nurses assess pain and relieve it with comfort measures beyond medication 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 11.3 Pain Assessment Methods · Open RN Nursing Fundamentals 2e, 11.5 Comfort: Applying the Nursing Process ·
A client is prescribed amoxicillin 375 mg by mouth every 8 hours. The pharmacy supplies amoxicillin oral suspension 250 mg/5 mL. How many mL will the nurse give for one dose? Round to the nearest tenth if needed.
Correct answer: 7.5
Set up with dimensional analysis, starting from the goal unit (mL): 5 mL / 250 mg x 375 mg = 1,875 / 250 = 7.5 mL. Check: 7.5 mL contains 1.5 times 250 mg, which is 375 mg. Starting with the label fraction keeps mg in the denominator so it cancels with the ordered mg.
Learn this topic: How to calculate oral, liquid, weight-based and IV doses 5-minute lesson
Source: Open RN Nursing Skills 2e, 5.9 Liquid Concentrations · Open RN Nursing Skills 2e, 5.5 Rounding ·
A client who weighs 150 lb is prescribed gentamicin 1.5 mg/kg IV. The vial is labeled 40 mg/mL. How many mL will the nurse draw up? Do not round until the final answer, then round to the nearest tenth.
Correct answer: 2.6
Convert pounds to kilograms by dividing by 2.2: 150 / 2.2 = 68.18 kg. Dose: 1.5 mg/kg x 68.18 kg = 102.27 mg. Volume: 1 mL / 40 mg x 102.27 mg = 2.557 mL, which rounds to 2.6 mL. In one chain: 1 mL/40 mg x 1.5 mg/kg x 1 kg/2.2 lb x 150 lb = 2.6 mL.
Learn this topic: How to calculate oral, liquid, weight-based and IV doses 5-minute lesson
Source: Open RN Nursing Skills 2e, 5.11 Weight-Based Calculations · Open RN Nursing Skills 2e, 5.5 Rounding ·
A client is prescribed 1,000 mL of 0.9% sodium chloride IV over 8 hours. If an infusion pump is used, the nurse programs it at . If the pump fails and the nurse runs the fluid by gravity using tubing with a drop factor of 15 gtt/mL, the nurse regulates the drip at .
Choose the best option from each list to complete the sentence.
Correct answer: 125 mL/hr; 31 gtt/min
A pump is set in mL/hr: 1,000 mL / 8 hr = 125 mL/hr. A gravity drip is set in gtt/min: 125 mL/hr x 15 gtt/mL / 60 min = 31.25, rounded to 31 gtt/min because drops are counted as whole numbers. Always check which unit the device needs before you calculate.
- 1,000 mL divided by 8 hours is 125 mL/hr; 83 mL/hr would be a 12-hour rate, 8 mL/hr confuses the number of hours with the rate, and 62.5 mL/hr would take 16 hours.
- 125 mL/hr x 15 gtt/mL / 60 min = 31.25, so 31 gtt/min; 125 gtt/min assumes 60 gtt/mL microdrip tubing, 8 gtt/min divides 125 by 15, and 1,875 gtt/min forgets to divide by 60 minutes.
Learn this topic: How to calculate oral, liquid, weight-based and IV doses 5-minute lesson
Source: Open RN Nursing Skills 2e, 5.15 IV Infusion by Pump · Open RN Nursing Skills 2e, 5.14 IV Infusion by Gravity · Open RN Nursing Skills 2e, 5.5 Rounding ·
A client with type 2 diabetes is scheduled to receive insulin lispro 6 units subcutaneously with breakfast. At 0730 the client is sweaty and shaky but alert and able to swallow. Point-of-care blood glucose is 62 mg/dL (fasting 70–99 mg/dL). Which action should the nurse take first?
Correct answer: C
A glucose below 70 mg/dL with shakiness and sweating is hypoglycemia, and a client who can swallow is treated right away with 15 g of fast-acting carbohydrate per the agency protocol. Treating the immediate physiological threat comes before notifying the provider, which is still done to discuss the cause and insulin changes. Giving the scheduled rapid-acting insulin now would push the glucose even lower.
- A Giving rapid-acting insulin to a client whose glucose is already 62 mg/dL would drive it lower and could cause severe hypoglycemia.
- B Waiting 15 minutes delays treatment of symptomatic hypoglycemia; the recheck comes after the carbohydrate is given.
- C Correct: an alert client who can swallow receives 15 g of rapidly absorbed carbohydrate immediately per the hypoglycemia protocol.
- D The provider should be notified, but treating the low glucose comes first because the client is symptomatic now.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 9.4 Antidiabetics · MedlinePlus: Blood sugar test ·
The nurse reviews laboratory results for five clients receiving anticoagulants. For each result, indicate whether it is expected for the client's therapy or requires follow-up.
Expected Requires follow-up Continuous IV heparin: aPTT 62 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Warfarin for atrial fibrillation: INR 4.8 (normal 0.8–1.1; prescribed target 2.0–3.0) Continuous IV heparin, day 6: platelets 96,000/mm³ (normal 150,000–400,000/mm³; baseline 220,000/mm³) Warfarin for atrial fibrillation: INR 2.6 (normal 0.8–1.1; prescribed target 2.0–3.0) Continuous IV heparin: aPTT 30 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Select one option in each row.
Correct answer: Continuous IV heparin: aPTT 62 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds): Expected; Warfarin for atrial fibrillation: INR 4.8 (normal 0.8–1.1; prescribed target 2.0–3.0): Requires follow-up; Continuous IV heparin, day 6: platelets 96,000/mm³ (normal 150,000–400,000/mm³; baseline 220,000/mm³): Requires follow-up; Warfarin for atrial fibrillation: INR 2.6 (normal 0.8–1.1; prescribed target 2.0–3.0): Expected; Continuous IV heparin: aPTT 30 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds): Requires follow-up
On IV heparin the aPTT is meant to be prolonged, roughly 1.5 to 2 times normal, inside the target set by the facility protocol in the order. On warfarin the INR is meant to sit inside the prescribed target, usually 2.0 to 3.0. Results above the target raise bleeding risk, results below it mean the drug is not protecting the client, and a platelet drop of 30% or more on heparin suggests heparin-induced thrombocytopenia.
- Continuous IV heparin: aPTT 62 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Expected: an aPTT of 62 seconds is prolonged on purpose and falls inside the protocol target of 46–70 seconds.
- Warfarin for atrial fibrillation: INR 4.8 (normal 0.8–1.1; prescribed target 2.0–3.0) Requires follow-up: an INR of 4.8 is well above the 2.0–3.0 target and puts the client at high risk for bleeding.
- Continuous IV heparin, day 6: platelets 96,000/mm³ (normal 150,000–400,000/mm³; baseline 220,000/mm³) Requires follow-up: platelets fell by more than half from baseline (a drop of 30% or more suggests heparin-induced thrombocytopenia) and are below 100,000/mm³, the level at which the heparin label calls for stopping heparin and evaluating for HIT.
- Warfarin for atrial fibrillation: INR 2.6 (normal 0.8–1.1; prescribed target 2.0–3.0) Expected: an INR of 2.6 is inside the prescribed 2.0–3.0 target for warfarin therapy.
- Continuous IV heparin: aPTT 30 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Requires follow-up: an aPTT of 30 seconds is in the normal range, so the heparin is below the protocol target and the dose needs adjustment per protocol.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · MedlinePlus: Partial thromboplastin time (PTT) · MedlinePlus: Prothrombin time (PT) · MedlinePlus: Platelet count ·
The nurse is preparing insulin and heparin for several clients. Which actions reflect safe practice for these high-alert medications? Select all that apply.
Select all that apply.
Correct answer: A, C, F
ISMP lists all insulin and the anticoagulants as high-alert medications, so their use is built around redundant checks. Before subcutaneous insulin the nurse reviews the current glucose and tells the client the product, dose and purpose. Heparin comes in many strengths, so the label is checked against the order every time.
- A Correct: ISMP guidance has the nurse assess the most current blood glucose before subcutaneous insulin.
- B Incorrect: an insulin pen is never used for more than one client, even with a new needle, because of bloodborne pathogen exposure.
- C Correct: fatal heparin errors have come from choosing the wrong strength, so the product is checked against the order.
- D Incorrect: U-500 insulin is measured only with a U-500 syringe to avoid a dosing error.
- E Incorrect: a verbally reported glucose is never the only source of information for an insulin dose.
- F Correct: telling the client the product name, dose and intended action is part of ISMP's safe insulin practice and gives the client a chance to catch an error.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 9.4 Antidiabetics · Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · ISMP List of High-Alert Medications in Acute Care Settings (2024) ·
A client with symptomatic anemia is prescribed 1 unit of packed red blood cells. Consent is signed and the crossmatch is complete. Before the nurse calls for the unit, the client's temperature is 101.0°F (38.3°C); it was 98.6°F (37.0°C) four hours ago. What is the best action by the nurse?
Correct answer: D
A pre-transfusion temperature above 100.4°F (37.8°C) is reported to the provider before the blood is picked up. A new fever would hide the main early sign of a transfusion reaction, and once a unit leaves the blood bank it must be started within about 30 minutes and can't be returned. Clarifying first is the safe choice when data change before a high-risk procedure.
- A Starting with a new fever means a reaction fever couldn't be told apart from the baseline fever, and the provider hasn't been told about the change.
- B Blood is never stored in a unit refrigerator; it must start within about 30 minutes of leaving the blood bank.
- C Acetaminophen has not been prescribed, and treating the fever without telling the provider skips the needed clarification.
- D Correct: a febrile client is reported to the provider before the unit is obtained, because blood can't go back to the bank once it is picked up.
Learn this topic: How nurses give blood safely and spot transfusion reactions 5-minute lesson
Source: Open RN Nursing Advanced Skills, 3.3 Applying the Nursing Process · Open RN Nursing Advanced Skills, 3.4 Checklist: Administer Blood Products ·
Four clients develop new findings while receiving packed red blood cells. For each client, indicate the transfusion reaction the findings are most consistent with.
Acute hemolytic Febrile non-hemolytic Mild allergic Circulatory overload (TACO) At 2 hours: crackles in both lung bases, dyspnea, distended neck veins, BP 172/96 mm Hg (baseline 134/80 mm Hg) At 10 minutes: chills, low back pain, pain along the IV vein, HR 124/min, BP 86/50 mm Hg At 90 minutes: itchy raised welts on the chest; vital signs and breathing unchanged from baseline At 2 hours: temperature 100.9°F (38.3°C) from a baseline of 98.8°F (37.1°C), chills, headache; BP and breathing unchanged Select one option in each row.
Correct answer: At 2 hours: crackles in both lung bases, dyspnea, distended neck veins, BP 172/96 mm Hg (baseline 134/80 mm Hg): Circulatory overload (TACO); At 10 minutes: chills, low back pain, pain along the IV vein, HR 124/min, BP 86/50 mm Hg: Acute hemolytic; At 90 minutes: itchy raised welts on the chest; vital signs and breathing unchanged from baseline: Mild allergic; At 2 hours: temperature 100.9°F (38.3°C) from a baseline of 98.8°F (37.1°C), chills, headache; BP and breathing unchanged: Febrile non-hemolytic
Timing and blood pressure separate these reactions. Acute hemolytic reactions from ABO or Rh mismatch begin within about 15 minutes with chills, back or flank pain, pain along the vein, tachycardia and hypotension. TACO brings crackles, jugular vein distension and hypertension; a febrile non-hemolytic reaction raises the temperature more than 1°C above baseline; a mild allergic reaction causes itching and hives with stable vital signs.
- At 2 hours: crackles in both lung bases, dyspnea, distended neck veins, BP 172/96 mm Hg (baseline 134/80 mm Hg) TACO: crackles, dyspnea, jugular vein distension and a rising blood pressure point to volume overload.
- At 10 minutes: chills, low back pain, pain along the IV vein, HR 124/min, BP 86/50 mm Hg Acute hemolytic: back pain, pain along the vein, tachycardia and hypotension within the first 15 minutes suggest ABO or Rh incompatibility.
- At 90 minutes: itchy raised welts on the chest; vital signs and breathing unchanged from baseline Mild allergic: hives and itching with unchanged vital signs and breathing fit a mild allergic reaction to donor proteins.
- At 2 hours: temperature 100.9°F (38.3°C) from a baseline of 98.8°F (37.1°C), chills, headache; BP and breathing unchanged Febrile non-hemolytic: a temperature rise of more than 1°C from baseline with chills and headache, but stable blood pressure, fits this reaction.
Learn this topic: How nurses give blood safely and spot transfusion reactions 5-minute lesson
Source: Open RN Nursing Advanced Skills, 3.2 Basic Concepts (blood products) · MedlinePlus: Hemolytic transfusion reaction ·
Ten minutes after a unit of packed red blood cells is started, the client reports chills and low back pain. BP is 88/52 mm Hg, down from 128/76 mm Hg. Which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: A, C, D
Chills, back pain and hypotension in the first 15 minutes suggest an acute hemolytic reaction. The nurse stops the transfusion, keeps the vein open with saline through new tubing attached at the hub, and notifies the provider and blood bank. The bag and tubing are saved and sent to the lab with blood and urine samples so the cause can be found.
- A Correct: stopping the transfusion immediately limits how much incompatible blood the client receives.
- B Incorrect: flushing the old tubing would push the blood left in the line into the client.
- C Correct: new primed tubing with 0.9% sodium chloride keeps IV access without giving any more of the blood product.
- D Correct: the provider and the blood bank are notified so treatment and the reaction work-up can begin.
- E Incorrect: the bag and tubing are kept and sent to the lab per policy, not thrown away.
- F Incorrect: slowing the rate still delivers incompatible blood; a suspected reaction calls for stopping, not slowing.
Learn this topic: How nurses give blood safely and spot transfusion reactions 5-minute lesson
Source: Open RN Nursing Advanced Skills, 3.2 Basic Concepts (blood products) · Open RN Nursing Advanced Skills, 3.3 Applying the Nursing Process · MedlinePlus: Hemolytic transfusion reaction ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ The nurse reviews the 0730 assessment. Click to highlight the findings that require immediate follow-up.
Client states feeling . Passed at 0640. Left calf swollen and tender, . Urine is . Client is . Temperature . Heparin pump display reads .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: lightheaded when sitting up; one large black, tarry stool; pink-tinged; 144 mL/hr
Tarry stool and pink urine are signs of bleeding, and lightheadedness with a falling blood pressure and rising heart rate suggests the bleeding is affecting circulation. The ordered dose is 18 units/kg/hr x 80 kg = 1,440 units/hr; the bag holds 25,000 units/250 mL = 100 units/mL, so the correct rate is 14.4 mL/hr. A pump running at 144 mL/hr is delivering 10 times the prescribed dose of a high-alert drug.
- lightheaded when sitting up Requires follow-up: new lightheadedness with tachycardia and a lower blood pressure can signal blood loss.
- one large black, tarry stool Requires follow-up: black, tarry stool is a sign of gastrointestinal bleeding, the chief adverse effect of heparin.
- circumference unchanged from admission Expected: an unchanged calf circumference fits the known DVT and shows no new change.
- pink-tinged Requires follow-up: blood in the urine is a listed sign of heparin overdose.
- alert and oriented x4 Expected: the client is oriented, so there is no new neurological change.
- 98.4°F (36.9°C) Expected: the temperature is normal and similar to admission.
- 144 mL/hr Requires follow-up: the correct rate is 14.4 mL/hr, so 144 mL/hr is a tenfold overdose of heparin.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: DailyMed: Heparin Sodium in Dextrose Injection label · MedlinePlus: Heparin injection · Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · Open RN Nursing Skills 2e, 5.15 IV Infusion by Pump ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ For each finding, indicate whether it supports or does not support that the client is bleeding because of excess heparin effect.
Supports Does not support aPTT 142 seconds Platelets 236,000/mm³ (admission 248,000/mm³) Hemoglobin 10.9 g/dL, down from 14.6 g/dL Temperature 98.4°F (36.9°C) Heart rate 114/min with blood pressure 100/62 mm Hg Left calf circumference unchanged from admission Select one option in each row.
Correct answer: aPTT 142 seconds: Supports; Platelets 236,000/mm³ (admission 248,000/mm³): Does not support; Hemoglobin 10.9 g/dL, down from 14.6 g/dL: Supports; Temperature 98.4°F (36.9°C): Does not support; Heart rate 114/min with blood pressure 100/62 mm Hg: Supports; Left calf circumference unchanged from admission: Does not support
An aPTT of 142 seconds is about four times the upper normal limit and far above the protocol target, showing excess heparin effect. A falling hemoglobin and a rising heart rate with a falling blood pressure show that blood is being lost. The platelet count is normal and has dropped only about 5%, which argues against heparin-induced thrombocytopenia, and the temperature and calf findings are unchanged.
- aPTT 142 seconds Supports: the aPTT is far above both the normal range (25–35 seconds) and the protocol target (46–70 seconds).
- Platelets 236,000/mm³ (admission 248,000/mm³) Does not support: the count is normal and fell less than 30%, so it is not evidence of bleeding or of heparin-induced thrombocytopenia.
- Hemoglobin 10.9 g/dL, down from 14.6 g/dL Supports: a drop of 3.7 g/dL in less than a day, below the normal range, points to active blood loss.
- Temperature 98.4°F (36.9°C) Does not support: a normal, unchanged temperature does not point to bleeding.
- Heart rate 114/min with blood pressure 100/62 mm Hg Supports: a rising heart rate with a falling blood pressure is a sign of internal bleeding.
- Left calf circumference unchanged from admission Does not support: the unchanged calf reflects the known DVT, not bleeding.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · MedlinePlus: Partial thromboplastin time (PTT) · MedlinePlus: Hemoglobin · MedlinePlus: Platelet count ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ Complete the statement. The client is most likely experiencing caused by . The nurse's priority is to prevent .
Choose the best option from each list to complete the sentence.
Correct answer: bleeding from excess anticoagulation; a tenfold infusion rate error; shock from blood loss
The findings fit bleeding from too much heparin: the pump is delivering 144 mL/hr (14,400 units/hr) instead of 14.4 mL/hr (1,440 units/hr), and the aPTT is 142 seconds. The client already has tachycardia, a lower blood pressure and lightheadedness, so circulation is the priority (airway, breathing, circulation). A new clot is a real risk but is less immediate than ongoing blood loss.
- Bleeding from excess anticoagulation fits the tarry stool, pink urine, falling hemoglobin and very high aPTT; platelets are normal, which argues against HIT, and nothing suggests infection or clot extension.
- The pump is running at 144 mL/hr, 10 times the calculated 14.4 mL/hr; the platelet drop is only about 5%, and the very high aPTT shows too much heparin, not too little.
- Tachycardia, lower blood pressure and lightheadedness show blood loss is affecting circulation, which takes priority over clot or skin concerns.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · Open RN Nursing Skills 2e, 5.15 IV Infusion by Pump ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ The nurse plans care for the client. Which actions should the nurse include? Select all that apply.
Select all that apply.
Correct answer: A, C, E
New bleeding on heparin is reported to the provider immediately. Protamine sulfate, given by slow IV infusion, is the reversal agent for heparin, and frequent vital signs and bleeding checks show whether the client is stabilizing. Vitamin K reverses warfarin, aspirin adds to bleeding risk, and heparin is avoided in major bleeding unless the provider decides the benefit outweighs the risk.
- A Correct: new signs of bleeding and vital sign changes on heparin are reported to the provider immediately.
- B Incorrect: vitamin K reverses warfarin, not heparin.
- C Correct: protamine sulfate by slow infusion neutralizes heparin when bleeding requires reversal.
- D Incorrect: heparin is avoided during major bleeding unless the provider judges the benefit greater than the risk; restarting is not the nurse's decision.
- E Correct: frequent vital signs and bleeding assessment track whether the hemorrhage is slowing.
- F Incorrect: aspirin is avoided with heparin because it increases bleeding risk.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ The nurse confirms that the pump is infusing heparin at 144 mL/hr. Which action should the nurse take first?
Correct answer: C
Safety principle: when an infusion is actively harming the client, remove the source of harm first. The pump is delivering 10 times the prescribed dose of a high-alert anticoagulant to a client who is already bleeding, and the heparin label says heparin should be discontinued promptly when the clotting test is unduly prolonged or hemorrhage occurs. Stopping the pump is within the nurse's scope, while reversal with protamine sulfate needs a provider's order, so the provider is notified immediately after; the error report comes once the client is safe.
- A The provider must be called right away, but every minute the pump runs delivers about 240 units of heparin instead of the prescribed 24, so stopping it comes first.
- B A repeat aPTT delays action; the current aPTT and the bleeding already confirm excess heparin effect.
- C Correct: stopping the infusion ends the overdose immediately, which is the safety priority.
- D The error must be reported, but paperwork never comes before protecting the client.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: DailyMed: Heparin Sodium in Dextrose Injection label · Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · ISMP List of High-Alert Medications in Acute Care Settings (2024) ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ The heparin infusion was stopped at 0735, and protamine sulfate was given by slow IV infusion as prescribed at 0800. At 1200, the nurse reassesses the client. For each finding, indicate whether it shows improvement or needs further follow-up.
Improved Needs further follow-up aPTT 38 seconds (25–35 seconds) Urine in urinal still pink-tinged Heart rate 90/min, blood pressure 124/78 mm Hg Hemoglobin 10.7 g/dL (13.8–17.2 g/dL) Client says the lightheadedness is gone New 4-cm bruise on the left upper arm under the blood pressure cuff Select one option in each row.
Correct answer: aPTT 38 seconds (25–35 seconds): Improved; Urine in urinal still pink-tinged: Needs further follow-up; Heart rate 90/min, blood pressure 124/78 mm Hg: Improved; Hemoglobin 10.7 g/dL (13.8–17.2 g/dL): Needs further follow-up; Client says the lightheadedness is gone: Improved; New 4-cm bruise on the left upper arm under the blood pressure cuff: Needs further follow-up
The aPTT has fallen from 142 to 38 seconds and the heart rate, blood pressure and lightheadedness have returned toward baseline, so the overdose has been reversed. Ongoing blood in the urine, a hemoglobin that is still low and a new bruise show that bleeding has not fully resolved and still need monitoring and reporting.
- aPTT 38 seconds (25–35 seconds) Improved: the aPTT dropped from 142 to 38 seconds, close to normal, showing the heparin effect has been reversed.
- Urine in urinal still pink-tinged Needs follow-up: pink urine means some bleeding continues.
- Heart rate 90/min, blood pressure 124/78 mm Hg Improved: heart rate and blood pressure are back near the admission values, showing better circulation.
- Hemoglobin 10.7 g/dL (13.8–17.2 g/dL) Needs follow-up: hemoglobin is still well below normal and has not recovered, so the provider needs this trend.
- Client says the lightheadedness is gone Improved: the lightheadedness has resolved along with the blood pressure, suggesting circulation has improved.
- New 4-cm bruise on the left upper arm under the blood pressure cuff Needs follow-up: a new bruise is a sign of ongoing bleeding tendency and must be monitored.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · MedlinePlus: Partial thromboplastin time (PTT) · MedlinePlus: Hemoglobin ·
A client returns from abdominal surgery with patient-controlled analgesia (PCA) delivering IV morphine. Which actions by the nurse are appropriate? Select all that apply.
Select all that apply.
Correct answer: B, C, D
A PCA is safe because a client who is too sedated cannot press the button, so no one else, not even the nurse, presses it. A second RN verifies the programming when the PCA starts, and the nurse monitors respiratory rate, SpO2, sedation level and mental status, because sedation usually comes before respiratory depression. Uncontrolled pain is reported to the provider rather than handled by changing the pump limits.
- A "PCA by proxy" defeats the safety design and can cause oversedation and respiratory depression.
- B Correct: the client must be alert enough to press the button, which is the built-in safeguard against overdose.
- C Correct: agency policy has another RN verify the order and pump programming when a PCA is started.
- D Correct: clients on PCA opioids are watched closely for oversedation and respiratory depression.
- E A bowel program is started with the first opioid dose and continued, because opioids slow peristalsis.
- F The lockout and hourly limits are prescribed safety settings; ongoing pain is reported to the provider, not fixed by changing the limits.
Source: Open RN Nursing Advanced Skills, 1.7 Specialized Infusions · Open RN Nursing Fundamentals 2e, 11.4 Pain Management ·
A client's central venous catheter was placed 9 days ago for IV antibiotics. The last dose was given yesterday, and no further IV therapy is planned. Which action by the nurse best reduces the client's risk of a central line-associated bloodstream infection (CLABSI)?
Correct answer: C
Every day a central line stays in is another day of CLABSI risk, so the line's necessity is reviewed daily and a catheter that is no longer essential is removed promptly. Extra flushing, daily dressing changes and scheduled catheter replacement add handling without lowering risk. The nurse advocates for removal by raising it with the provider.
- A Flushing keeps an unneeded line in place and adds handling; it does not reduce infection risk.
- B Transparent dressings are changed at least every 7 days and when damp, loose or soiled, not every day.
- C Correct: CDC recommends promptly removing any intravascular catheter that is no longer essential.
- D CDC advises against routinely replacing central lines to prevent infection.
Learn this topic: How nurses care for central lines and keep TPN safe 5-minute lesson
Source: CDC: Summary of Recommendations, Guidelines for the Prevention of Intravascular Catheter-Related Infections · Open RN Nursing Advanced Skills, 4.2 Basic Concepts (central venous access devices) · Open RN Nursing Advanced Skills, 4.3 Applying the Nursing Process (central venous access devices) ·
A client has received total parenteral nutrition (TPN) through a peripherally inserted central catheter (PICC) for 4 days. For each finding, indicate whether it is expected (acceptable for safe TPN care) or requires follow-up.
Expected Requires follow-up Capillary blood glucose 118 mg/dL (random; usually 125 mg/dL or lower) Temperature 101.4°F (38.6°C) with chills Transparent dressing dated 2 days ago, clean, dry and intact Current TPN bag hung 30 hours ago and still infusing Capillary blood glucose 262 mg/dL Upper arm circumference unchanged from baseline Select one option in each row.
Correct answer: Capillary blood glucose 118 mg/dL (random; usually 125 mg/dL or lower): Expected; Temperature 101.4°F (38.6°C) with chills: Requires follow-up; Transparent dressing dated 2 days ago, clean, dry and intact: Expected; Current TPN bag hung 30 hours ago and still infusing: Requires follow-up; Capillary blood glucose 262 mg/dL: Requires follow-up; Upper arm circumference unchanged from baseline: Expected
TPN care centers on three risks: hyperglycemia from the dextrose, infection because the nutrients support microbial growth, and problems with the line itself. A normal glucose, a current intact dressing and an unchanged arm circumference are reassuring. Fever with chills, a glucose well above the usual range and a bag that has hung longer than 24 hours all need action.
- Capillary blood glucose 118 mg/dL (random; usually 125 mg/dL or lower) Expected: a random glucose of 125 mg/dL or lower is in the usual range.
- Temperature 101.4°F (38.6°C) with chills Requires follow-up: fever and chills can be early signs of infection in a client receiving TPN.
- Transparent dressing dated 2 days ago, clean, dry and intact Expected: transparent dressings are changed at least every 7 days and when damp, loose or soiled.
- Current TPN bag hung 30 hours ago and still infusing Requires follow-up: the label says to complete the infusion within 24 hours, so a bag still running after 30 hours is past that limit.
- Capillary blood glucose 262 mg/dL Requires follow-up: dextrose given faster than it can be used causes hyperglycemia, which is monitored and treated.
- Upper arm circumference unchanged from baseline Expected: an increase of 3 cm or more would suggest thrombosis; no change is reassuring.
Learn this topic: How nurses care for central lines and keep TPN safe 5-minute lesson
Source: DailyMed: Clinimix E (amino acids with electrolytes in dextrose with calcium) injection label · Open RN Nursing Advanced Skills, 4.3 Applying the Nursing Process (central venous access devices) · MedlinePlus: Blood sugar test ·
A subclavian central venous catheter is placed at the bedside without fluoroscopy. Before the catheter is used, the nurse makes sure that . Two hours later, the client reports sharp chest pain that worsens with each breath and shortness of breath; SpO2 is 88%. All lumens are capped and clamped, and no line has been opened. The nurse suspects and should .
Choose the best option from each list to complete the sentence.
Correct answer: a chest X-ray confirms the tip position; a pneumothorax; stay, call for help and give oxygen
When fluoroscopy is not used during insertion, a chest X-ray confirms the catheter tip position and also checks for a pneumothorax, which can happen if the needle punctures the lung. Sharp, stabbing chest pain that worsens on inspiration with dyspnea after a neck or chest insertion points to pneumothorax rather than air embolism, especially with a closed system. The nurse stays with the client, calls for help and the rapid response team, and gives high-flow oxygen.
- A post-procedure chest X-ray confirms tip placement when fluoroscopy was not used; a dated dressing and a normal glucose do not show where the tip is.
- Sharp chest pain that worsens with breathing after a subclavian insertion fits pneumothorax; air embolism needs air entry through an open line, and CLABSI causes fever, not sudden pleuritic pain.
- For pneumothorax, the nurse stays, calls for help and gives high-flow oxygen; the left-side, head-down position is for air embolism, and flushing does not treat a collapsed lung.
Learn this topic: How nurses care for central lines and keep TPN safe 5-minute lesson
Source: Open RN Nursing Advanced Skills, 4.2 Basic Concepts (central venous access devices) · Open RN Nursing Advanced Skills, 4.3 Applying the Nursing Process (central venous access devices) ·
For each anticoagulant, indicate the agent used to reverse it when serious bleeding or an overdose occurs.
Protamine sulfate Vitamin K (phytonadione) Idarucizumab Continuous IV heparin Warfarin Dabigatran Enoxaparin Select one option in each row.
Correct answer: Continuous IV heparin: Protamine sulfate; Warfarin: Vitamin K (phytonadione); Dabigatran: Idarucizumab; Enoxaparin: Protamine sulfate
Each anticoagulant has its own reversal plan. Protamine sulfate neutralizes heparin and partly neutralizes enoxaparin, vitamin K reverses warfarin, and idarucizumab reverses only dabigatran. Giving the wrong agent wastes time and adds its own risks.
- Continuous IV heparin Protamine sulfate: protamine by slow infusion neutralizes heparin.
- Warfarin Vitamin K (phytonadione): warfarin blocks vitamin K-dependent clotting factors, so vitamin K is its reversal agent.
- Dabigatran Idarucizumab: it is the specific reversal agent for dabigatran and has no effect on other anticoagulants.
- Enoxaparin Protamine sulfate: slow IV protamine largely neutralizes enoxaparin, although anti-factor Xa activity is never fully reversed.
Learn this topic: How nurses keep clients on anticoagulants from bleeding 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Enoxaparin Sodium Injection label · DailyMed: Idarucizumab injection label · DailyMed: Dabigatran etexilate capsules label ·
A client who had spinal anesthesia for knee surgery will give enoxaparin injections at home. Which statements by the client show correct understanding? Select all that apply.
Select all that apply.
Correct answer: B, D, E
Enoxaparin goes into a pinched fold of abdominal skin, using the whole needle and holding the fold during the injection, and sites alternate between the left and right sides. The air bubble in the prefilled syringe stays in to avoid losing drug, and the site is not rubbed, which limits bruising. After spinal anesthesia, numbness, tingling or leg weakness is reported immediately because it can signal a spinal hematoma, and NSAIDs are avoided because they add to bleeding risk.
- A The label says not to expel the air bubble from the prefilled syringe, to avoid losing drug.
- B Correct: the whole needle goes into a skin fold on the abdomen that is held throughout the injection.
- C Rubbing the site after the injection increases bruising and is avoided.
- D Correct: injections alternate between the left and right sides of the abdomen.
- E Correct: numbness, tingling or leg weakness after spinal anesthesia can signal a spinal or epidural hematoma and is reported at once.
- F NSAIDs such as ibuprofen increase bleeding risk with enoxaparin and are avoided unless the provider approves.
Learn this topic: How nurses keep clients on anticoagulants from bleeding 5-minute lesson
Source: DailyMed: Enoxaparin Sodium Injection label · MedlinePlus: Enoxaparin Injection · Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers ·
A client with atrial fibrillation starts apixaban 5 mg by mouth twice daily. Which statement by the client shows that the teaching was effective?
Correct answer: D
Stopping apixaban early raises the risk of stroke and other clots, so the client does not stop it without the prescriber's direction. A missed dose is taken the same day as soon as remembered, and the dose is never doubled. Routine PT/INR checks are not useful for monitoring apixaban, but bleeding signs such as black stools or pink urine are reported.
- A The label says a missed dose should not be doubled; it is taken the same day as soon as possible.
- B Minor bruising is expected with anticoagulants; stopping the drug on one's own raises the risk of stroke and clots.
- C Changes in PT, INR and aPTT with apixaban are small and variable, so they are not used to monitor or adjust the dose.
- D Correct: premature discontinuation increases the risk of thrombotic events, so the drug is stopped only on the prescriber's advice.
Learn this topic: How nurses keep clients on anticoagulants from bleeding 5-minute lesson
Source: DailyMed: Apixaban tablets label · MedlinePlus: Apixaban ·
The nurse reviews morning laboratory results for four clients. Which result requires the nurse's immediate follow-up?
Correct answer: C
Potassium governs the heart's electrical activity, so hyperkalemia can cause dysrhythmias and cardiac arrest. Among several abnormal results, the one that threatens circulation most is the priority. Mild sodium and calcium deviations matter but are not immediately life-threatening in an otherwise stable client.
- A A sodium only slightly below range is a concern to report, but it is far less immediately dangerous than a potassium that can stop the heart.
- B A calcium just above range can cause nausea or constipation over time; it is not the most urgent result here.
- C Correct: a potassium of 6.2 mEq/L is well above range and can cause life-threatening dysrhythmias, so it needs immediate follow-up.
- D An INR of 1.0 is within the normal range for a client who is not taking warfarin.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · MedlinePlus: High potassium level · MedlinePlus: Prothrombin time (PT) ·
The nurse is reviewing laboratory results on a medical unit. For each result, indicate whether it is within the expected range or requires follow-up.
Within expected range Requires follow-up INR 2.5 for a client taking warfarin for atrial fibrillation (target 2.0–3.0) INR 4.2 for a client taking warfarin (target 2.0–3.0) Platelets 42,000/mcL (150,000–400,000/mcL) Fasting glucose 92 mg/dL (70–99 mg/dL) Capillary glucose 58 mg/dL in a client receiving insulin (low: below 70 mg/dL) Potassium 4.4 mEq/L (3.5–5.1 mEq/L) Select one option in each row.
Correct answer: INR 2.5 for a client taking warfarin for atrial fibrillation (target 2.0–3.0): Within expected range; INR 4.2 for a client taking warfarin (target 2.0–3.0): Requires follow-up; Platelets 42,000/mcL (150,000–400,000/mcL): Requires follow-up; Fasting glucose 92 mg/dL (70–99 mg/dL): Within expected range; Capillary glucose 58 mg/dL in a client receiving insulin (low: below 70 mg/dL): Requires follow-up; Potassium 4.4 mEq/L (3.5–5.1 mEq/L): Within expected range
Interpret each value against the range that applies to that client. For a client on warfarin, the therapeutic INR target (usually 2.0–3.0) replaces the normal 0.8–1.1 range, so 2.5 is on target and 4.2 means higher bleeding risk. A platelet count under 50,000/mcL and a glucose under 70 mg/dL both need prompt action.
- INR 2.5 for a client taking warfarin for atrial fibrillation (target 2.0–3.0) Within expected range: an INR of 2.5 is inside the usual warfarin target of 2.0–3.0.
- INR 4.2 for a client taking warfarin (target 2.0–3.0) Requires follow-up: an INR above 3.0 on warfarin puts the client at higher risk of bleeding.
- Platelets 42,000/mcL (150,000–400,000/mcL) Requires follow-up: below 50,000/mcL, bleeding risk is high even with everyday activity.
- Fasting glucose 92 mg/dL (70–99 mg/dL) Within expected range: a fasting glucose of 70–99 mg/dL is normal.
- Capillary glucose 58 mg/dL in a client receiving insulin (low: below 70 mg/dL) Requires follow-up: a glucose below 70 mg/dL is hypoglycemia and needs treatment now.
- Potassium 4.4 mEq/L (3.5–5.1 mEq/L) Within expected range: 4.4 mEq/L is inside the 3.5–5.1 mEq/L range.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: MedlinePlus: Prothrombin time (PT) · MedlinePlus: Platelet count · MedlinePlus: Blood sugar test · MedlinePlus: Low blood sugar · Open RN Nursing Fundamentals 2e, 15.4 Electrolytes ·
A client with type 2 diabetes who receives insulin reports feeling shaky and sweaty before lunch. The client is alert and able to swallow. The capillary glucose is 62 mg/dL (low: below 70 mg/dL). The nurse should first and then .
Choose the best option from each list to complete the sentence.
Correct answer: give 15–20 g of fast-acting carbohydrate; recheck the glucose in 15 minutes
A glucose below 70 mg/dL is hypoglycemia. For an alert client who can swallow, the treatment is 15–20 g of fast-acting carbohydrate, a recheck in 15 minutes, and repeat treatment until the glucose is back in range. Glucagon is reserved for severe lows when oral treatment is not possible.
- Fast-acting carbohydrate (o2) raises the glucose quickly in an alert client; insulin would lower it further, glucagon is for severe lows, and withholding food delays treatment.
- Recheck in 15 minutes (o3) shows whether the treatment worked; waiting 1 hour is too long, a second dose before rechecking is not based on data, and the episode cannot be called resolved without a recheck.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: NIDDK: Low Blood Glucose (Hypoglycemia) · MedlinePlus: Low blood sugar ·
A client had abdominal surgery 6 hours ago. Over the last 2 hours the heart rate has risen from 82 to 114/min and the blood pressure has fallen from 132/80 to 96/62 mm Hg. The abdominal dressing shows a spreading area of bright red drainage. Which action should the nurse take first?
Correct answer: D
Rising heart rate, falling blood pressure and fresh bleeding at the site point to postoperative hemorrhage, a threat to circulation. The first action is to control bleeding with pressure while staying with the client and calling for help so the surgeon is notified at once. Circulation problems come before comfort and documentation.
- A Waiting 30 minutes delays care for a client whose trend already shows hemorrhage.
- B Removing the dressing delays bleeding control; the first step for active bleeding is pressure over the site.
- C Pain relief matters, but it does not address the bleeding that threatens circulation.
- D Correct: applying pressure is the first step for active postoperative bleeding, followed by calling for help and notifying the surgeon.
Learn this topic: Which postoperative complications should a nurse watch for? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 27.3 Hospitalized Postoperative Patient · OpenStax Fundamentals of Nursing, 31.4 Postoperative Phase · OpenStax Medical-Surgical Nursing, 23.2 Hypovolemic Shock ·
The nurse is planning care for a client on the first day after open abdominal surgery. Which actions help prevent atelectasis? Select all that apply.
Select all that apply.
Correct answer: A, C, D
Atelectasis develops when pain, anesthesia and immobility keep the client from breathing deeply. Incentive spirometry, deep breathing and coughing, frequent repositioning and early ambulation help keep the alveoli open. Splinting the incision with a pillow supports it while the client coughs.
- A Correct: the incentive spirometer encourages deep breaths that re-expand the alveoli.
- B Lying flat and still reduces lung expansion and raises the risk of atelectasis.
- C Correct: early ambulation improves lung expansion and also reduces DVT risk.
- D Correct: deep breathing and coughing clear secretions and open the airways; splinting eases pain.
- E Frequent repositioning helps prevent atelectasis, so limiting position changes increases risk.
Learn this topic: Which postoperative complications should a nurse watch for? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 27.3 Hospitalized Postoperative Patient · OpenStax Medical-Surgical Nursing, 27.4 Postoperative Nursing Care Plan · OpenStax Fundamentals of Nursing, 31.4 Postoperative Phase ·
The nurse is assessing several clients on a surgical unit. For each finding, indicate the postoperative complication it most likely suggests.
Atelectasis Deep vein thrombosis Paralytic ileus Wound dehiscence Diminished breath sounds at the lung bases and SpO2 lower than baseline Swelling, warmth, redness and pain in the right calf only Distended abdomen with no bowel sounds heard Incision edges pulling apart with a sudden increase in drainage Shallow, rapid breathing in a client who avoids the incentive spirometer Nausea and vomiting with a firm, bloated abdomen Select one option in each row.
Correct answer: Diminished breath sounds at the lung bases and SpO2 lower than baseline: Atelectasis; Swelling, warmth, redness and pain in the right calf only: Deep vein thrombosis; Distended abdomen with no bowel sounds heard: Paralytic ileus; Incision edges pulling apart with a sudden increase in drainage: Wound dehiscence; Shallow, rapid breathing in a client who avoids the incentive spirometer: Atelectasis; Nausea and vomiting with a firm, bloated abdomen: Paralytic ileus
Each complication has a signature: atelectasis shows decreased breath sounds, low SpO2, dyspnea and tachypnea; DVT shows one-sided leg swelling, pain, warmth and redness; paralytic ileus shows abdominal distension, absent bowel sounds, nausea and vomiting; dehiscence shows wound edges separating with increased drainage. Matching the finding to the body system narrows the hypothesis quickly.
- Diminished breath sounds at the lung bases and SpO2 lower than baseline Atelectasis: collapsed alveoli reduce breath sounds and oxygen saturation.
- Swelling, warmth, redness and pain in the right calf only Deep vein thrombosis: one-sided calf swelling, warmth, redness and pain are classic DVT findings.
- Distended abdomen with no bowel sounds heard Paralytic ileus: a distended abdomen with absent bowel sounds means the bowel is not moving.
- Incision edges pulling apart with a sudden increase in drainage Wound dehiscence: separation of the incision edges with more drainage defines dehiscence.
- Shallow, rapid breathing in a client who avoids the incentive spirometer Atelectasis: shallow breathing and not using the incentive spirometer let alveoli collapse; tachypnea is a sign.
- Nausea and vomiting with a firm, bloated abdomen Paralytic ileus: nausea and vomiting with abdominal distension fit a bowel that has stopped moving.
Learn this topic: Which postoperative complications should a nurse watch for? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 27.3 Hospitalized Postoperative Patient · OpenStax Fundamentals of Nursing, 31.4 Postoperative Phase ·
The nurse reviews vital-sign trends for four adult clients on a medical unit. Which trend should the nurse follow up on immediately?
Correct answer: B
A change in respiratory rate is an early sign that a client is deteriorating, and new restlessness can reflect low oxygen or high carbon dioxide. A rate of 26/min is above the adult range of 12–20/min, so this client needs a full assessment and prompt reporting. The other trends stay within normal limits or have an obvious harmless cause.
- A Both temperatures are within the normal oral range, so this small rise is not urgent.
- B Correct: a rising respiratory rate above 20/min with new restlessness is an early warning of deterioration.
- C A small rise in blood pressure that stays near normal does not need immediate action.
- D A modest rise in heart rate right after activity is expected and stays within 60–100/min.
Learn this topic: How do vital-sign trends warn you that a client is getting worse? 5-minute lesson
Source: Open RN Nursing Skills 2e, 10.3 Respiratory Assessment · Open RN Nursing Skills 2e, 1.3 Vital Signs ·
Over 4 hours after surgery, a client's heart rate rises from 78 to 96 to 112/min while the blood pressure stays 128/78, 126/80 and 118/76 mm Hg. The client says, "I feel anxious." The nurse recognizes that the near-normal blood pressure , because in early blood loss the body . A urine output of would show that perfusion has become inadequate.
Choose the best option from each list to complete the sentence.
Correct answer: does not rule out bleeding; speeds up the heart and constricts blood vessels; 22 mL/hr
When blood volume falls, the sympathetic nervous system speeds up the heart and constricts blood vessels, which holds blood pressure near normal at first. That is why a climbing heart rate and anxiety can be the earliest clues, and blood pressure falls later. Urine output of 30 mL/hr or less is a sign of advanced hypovolemic shock.
- A near-normal blood pressure does not rule out bleeding (o2); compensation can hide early blood loss, and pain alone does not explain a steady climb with anxiety.
- The compensatory response speeds up the heart and constricts vessels (o3); the heart does not slow, and vessels constrict rather than dilate.
- 22 mL/hr (o1) is below the minimum of 30 mL/hr; 45 and 60 mL/hr meet the target.
Learn this topic: How do vital-sign trends warn you that a client is getting worse? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.1 Shock Overview · OpenStax Medical-Surgical Nursing, 23.2 Hypovolemic Shock ·
A 72-year-old client who started a new blood pressure medication reports light-headedness when getting out of bed. The nurse measures orthostatic vital signs. Click to highlight the findings that require follow-up.
Lying for 5 minutes: blood pressure , pulse . After standing for 3 minutes: blood pressure , pulse . The client . Temperature . SpO2 on room air.
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: 92/66 mm Hg; 110/min; says she feels light-headed and grabs the bed rail
Orthostatic hypotension is a fall of at least 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing, and a pulse rise of 30/min or more is also significant. Here the systolic pressure falls 24 mm Hg and the pulse rises 34/min, and the client has symptoms. Orthostatic hypotension raises the risk of falls, especially in older adults, so these findings need follow-up.
- 116/74 mm Hg A lying blood pressure of 116/74 mm Hg is in the normal range.
- 76/min A lying pulse of 76/min is within 60–100/min.
- 92/66 mm Hg Requires follow-up: a systolic drop from 116 to 92 mm Hg (24 mm Hg) on standing meets the definition of orthostatic hypotension.
- 110/min Requires follow-up: a pulse rise from 76 to 110/min (34/min) on standing is a significant change.
- says she feels light-headed and grabs the bed rail Requires follow-up: light-headedness on standing with a drop in pressure puts the client at risk of falling.
- 98.4°F (36.9°C) 98.4°F (36.9°C) is a normal oral temperature.
- 97% An SpO2 of 97% is within 95–100%.
Learn this topic: How do vital-sign trends warn you that a client is getting worse? 5-minute lesson
Source: Open RN Nursing Skills 2e, 3.2 Blood Pressure Basics · Open RN Nursing Skills 2e, 1.3 Vital Signs · Open RN Nursing Skills 2e, 10.3 Respiratory Assessment ·
An alert, oriented client scheduled for a cardiac catheterization is handed the consent form and says, "I'm not really sure what they are going to do to me." What should the nurse do?
Correct answer: D
The provider explains the procedure and its risks and is legally responsible for that teaching; the nurse confirms that the client understands before the form is signed. A client who does not understand the procedure is not ready to sign, so the nurse holds the form and tells the provider the client needs more information.
- A Explaining the procedure and its risks is the provider's responsibility, not the nurse's.
- B A signature without understanding is not informed consent, however common the procedure.
- C This alert, oriented client is the person who gives consent; a family member does not sign in their place.
- D Correct: the nurse confirms understanding and returns the teaching to the provider when it is missing.
Learn this topic: How do you keep a client safe before and after a diagnostic procedure? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 20.4 Disorders of the Prostate · MedlinePlus: Cardiac catheterization ·
The nurse is caring for four clients after diagnostic procedures. For each procedure, indicate the post-procedure nursing action that applies to it.
Withhold food and fluids until the gag reflex returns Keep the client lying flat for a few hours and check the groin site Check the urine for heavy bleeding Esophagogastroduodenoscopy (EGD) Arteriogram through the femoral artery in the groin Percutaneous kidney biopsy Cardiac catheterization through the femoral artery Select one option in each row.
Correct answer: Esophagogastroduodenoscopy (EGD): Withhold food and fluids until the gag reflex returns; Arteriogram through the femoral artery in the groin: Keep the client lying flat for a few hours and check the groin site; Percutaneous kidney biopsy: Check the urine for heavy bleeding; Cardiac catheterization through the femoral artery: Keep the client lying flat for a few hours and check the groin site
After-care follows the route of the procedure. After an EGD the throat may be numb and the scope may cause gagging, so food and fluids wait until the gag reflex returns to prevent choking. After a groin artery puncture (arteriogram or cardiac catheterization), the client lies flat for a few hours to prevent bleeding. After a kidney biopsy, urine is checked for heavy bleeding, although a small amount of blood is expected.
- Esophagogastroduodenoscopy (EGD) EGD: no food or liquid until the gag reflex returns so the client does not choke.
- Arteriogram through the femoral artery in the groin Arteriogram through the groin: lying flat for a few hours helps avoid bleeding at the puncture site.
- Percutaneous kidney biopsy Kidney biopsy: the urine is checked for heavy bleeding, the main risk after this biopsy.
- Cardiac catheterization through the femoral artery Femoral cardiac catheterization: lying flat for a few to several hours helps avoid bleeding at the groin.
Learn this topic: How do you keep a client safe before and after a diagnostic procedure? 5-minute lesson
Source: MedlinePlus: EGD - esophagogastroduodenoscopy · MedlinePlus: Arteriogram · MedlinePlus: Kidney biopsy · MedlinePlus: Cardiac catheterization ·
A client is preparing for a colonoscopy next week. The nurse teaches the client to have on the day before the test. The client takes an iron supplement and is told to stop it a few days before the test, as instructed, because iron can . When the client asks about stopping daily aspirin, the nurse explains that the client should .
Choose the best option from each list to complete the sentence.
Correct answer: clear liquids only; turn the stool dark black and hide the bowel lining; follow the provider's instructions and not stop it on their own
The bowel must be completely clean so problems are not missed, so the client takes clear liquids only the day before and completes the bowel prep. Iron makes the stool dark black, which makes it harder to see the inside of the bowel. Aspirin and other blood thinners are often continued; the client follows the provider's instructions and does not stop them without talking to the provider, especially with a heart problem.
- Clear liquids only (o2) the day before helps empty and clean the bowel.
- Iron turns the stool dark black (o3), which makes it harder for the doctor to see inside the bowel.
- Aspirin is stopped only if the provider says so (o1); many times it is continued, and ibuprofen is another drug the client may be told to stop.
Learn this topic: How do you keep a client safe before and after a diagnostic procedure? 5-minute lesson
Source: MedlinePlus: Colonoscopy ·
A client had a chest tube placed for a hemothorax 3 hours ago. For each of the last 2 hours, 250 mL of bright red drainage has collected in the drainage unit. What should the nurse do?
Correct answer: C
A sudden increase in bright red drainage of more than 200 mL per hour may mean a vascular injury that needs surgical repair. The nurse obtains vital signs, assesses the client's heart and lung status and reports the amount and color of the drainage to the provider. Clamping, stripping and lifting the unit above the chest are all unsafe.
- A Routine clamping is not recommended because it risks a tension pneumothorax.
- B Stripping creates high pressure in the tube that can cause a life-threatening pneumothorax.
- C Correct: more than 200 mL/hour of bright red drainage is assessed and reported at once.
- D The unit stays below the chest so drainage does not flow back into the chest.
Learn this topic: How do you manage a chest tube and know when something is wrong? 5-minute lesson
Source: Open RN Nursing Advanced Skills, 6.4 Troubleshooting Problems and Complications · Open RN Nursing Advanced Skills, 6.3 Nursing Responsibilities for Clients With Chest Tube Drainage Systems ·
A client's chest tube was removed by the provider at 1000. The nurse reviews the 1030 assessment. Click to highlight the findings that require follow-up.
1030: Client reports . Respirations . SpO2 on room air (97% before removal). Skin around the site . Occlusive dressing . Trachea . Rates pain at the site , the same as before removal.
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: new shortness of breath; 26/min and shallow; 90%; puffy and crackles when pressed
After a chest tube is removed, the nurse checks the client at least every 15 minutes for the first hour, listens to the lungs and feels around the site for subcutaneous emphysema. New dyspnea, fast shallow breathing, a falling SpO2 and crackling under the skin are signs of respiratory distress and subcutaneous emphysema, so they are reported to the provider right away. A dry dressing, a midline trachea and unchanged pain are reassuring.
- new shortness of breath Requires follow-up: new shortness of breath after removal is a sign of respiratory distress.
- 26/min and shallow Requires follow-up: rapid, shallow breathing is a change from the expected unlabored respirations.
- 90% Requires follow-up: SpO2 has dropped from 97% to 90%.
- puffy and crackles when pressed Requires follow-up: puffiness and crackling under the skin are signs of subcutaneous emphysema.
- dry and intact A dry, intact occlusive dressing is expected.
- midline A midline trachea is normal; a shift would suggest a tension pneumothorax.
- 3/10 Pain that is unchanged and low is not a new concern.
Learn this topic: How do you manage a chest tube and know when something is wrong? 5-minute lesson
Source: Open RN Nursing Advanced Skills, 6.8 Assisting With Chest Tube Removal · Open RN Nursing Advanced Skills, 6.3 Nursing Responsibilities for Clients With Chest Tube Drainage Systems · Open RN Nursing Advanced Skills, 6.4 Troubleshooting Problems and Complications · Open RN Nursing Advanced Skills, 6.2 Basic Concepts (tension pneumothorax) ·
A client with a chest tube connected to wall suction is going to the radiology department by stretcher. Which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: B, C, D
For transport, the chest tube is not clamped. The suction tubing is disconnected from the wall source, and the system keeps draining fluid by gravity and air through the water seal. The unit stays upright and below the chest, and the emergency supplies go with the client.
- A The tube is not clamped for transport, because clamping risks a tension pneumothorax.
- B Correct: disconnecting from wall suction lets the system work by gravity and water seal.
- C Correct: an upright unit below the chest prevents backflow and loss of the water seal.
- D Correct: safety equipment stays with the client, including during transport.
- E A unit at or above chest level lets fluid flow back into the chest.
Learn this topic: How do you manage a chest tube and know when something is wrong? 5-minute lesson
Source: Open RN Nursing Advanced Skills, 6.3 Nursing Responsibilities for Clients With Chest Tube Drainage Systems · Open RN Nursing Advanced Skills, 6.5 Checklist: Manage a Closed Chest Tube Drainage System ·
The nurse reviews a client's morning electrolyte results. Which result is within the normal range?
Correct answer: D
Compare each value with the range printed next to it. Only the potassium falls inside its range. The sodium, calcium and magnesium are all below range and need follow-up.
- A A sodium of 132 mEq/L is below the 136–145 mEq/L range (hyponatremia).
- B A calcium of 7.9 mg/dL is below the 8.6–10.2 mg/dL range (hypocalcemia).
- C A magnesium of 1.4 mg/dL is below the 1.7–2.2 mg/dL range (hypomagnesemia).
- D Correct: 4.2 mEq/L is inside the 3.5–5.1 mEq/L potassium range.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · MedlinePlus: Magnesium blood test ·
A client with heart failure takes digoxin and furosemide. Today's results are potassium 3.1 mEq/L (3.5–5.1 mEq/L) and digoxin 1.2 ng/mL (0.8–2.0 ng/mL). Why does the nurse report the potassium result promptly?
Correct answer: B
Safety first: hypokalemia increases the effect of digoxin and can lead to digoxin toxicity, even when the digoxin level itself is in range. A potassium below 3.5 mEq/L in a client on digoxin should be reported to the provider right away.
- A The risk with low potassium is a stronger digoxin effect and toxicity, not a false lab value.
- B Correct: hypokalemia increases digoxin's effect and the risk of toxicity, so it must be reported.
- C The digoxin level of 1.2 ng/mL is inside the 0.8–2.0 ng/mL range, so nothing suggests the dose is too low.
- D Diuretics that waste potassium can lower it, but a low potassium is not safe for a client taking digoxin.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.7 Cardiac Glycosides · Open RN Nursing Fundamentals 2e, 15.4 Electrolytes ·
The nurse reviews four abnormal results. For each result, indicate what it mainly tells the nurse about.
Kidney function Liver cell injury Breathing (CO₂ removal) Bleeding risk Creatinine 2.1 mg/dL (0.7–1.3 mg/dL for males) ALT 112 U/L (4–36 U/L) PaCO₂ 54 mm Hg (35–45 mm Hg) Platelets 48,000/mcL (150,000–400,000/mcL) Select one option in each row.
Correct answer: Creatinine 2.1 mg/dL (0.7–1.3 mg/dL for males): Kidney function; ALT 112 U/L (4–36 U/L): Liver cell injury; PaCO₂ 54 mm Hg (35–45 mm Hg): Breathing (CO₂ removal); Platelets 48,000/mcL (150,000–400,000/mcL): Bleeding risk
Link each lab to the organ or process it reflects. The kidneys remove creatinine, ALT leaks from injured liver cells, the lungs control PaCO₂ through breathing rate and depth, and a low platelet count raises the risk of bleeding.
- Creatinine 2.1 mg/dL (0.7–1.3 mg/dL for males) Kidney function: creatinine is removed by the kidneys, so a high level suggests the kidneys are not working well.
- ALT 112 U/L (4–36 U/L) Liver cell injury: ALT is an enzyme found mostly in the liver and is released into the blood when liver cells are injured.
- PaCO₂ 54 mm Hg (35–45 mm Hg) Breathing: the lungs regulate CO₂ by changing the rate and depth of breathing, so a high PaCO₂ means CO₂ is not being removed.
- Platelets 48,000/mcL (150,000–400,000/mcL) Bleeding risk: below 50,000/mcL, bleeding can happen even with everyday activities.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: MedlinePlus: Creatinine blood test · MedlinePlus: Alanine transaminase (ALT) blood test · Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · MedlinePlus: Platelet count ·
A female client's results are WBC 15,200/mcL (4,500–11,000/mcL), hemoglobin 13.9 g/dL (12.1–15.1 g/dL for females) and platelets 260,000/mcL (150,000–400,000/mcL). The result outside the normal range is the , which can be a sign of .
Choose the best option from each list to complete the sentence.
Correct answer: WBC count; infection
Only the WBC count is outside its range. A high WBC count (leukocytosis) can be caused by infection, most often bacterial, as well as inflammation, stress or some medicines.
- The WBC count of 15,200/mcL is above 11,000/mcL; the hemoglobin and platelets are both within range.
- Infection is a common cause of a high WBC count. This client's hemoglobin and platelets are normal, which does not point to anemia or a bleeding problem.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: MedlinePlus: WBC count · MedlinePlus: Hemoglobin · MedlinePlus: Platelet count ·
A client who does not take warfarin or other blood thinners has an INR of 1.6 (0.8–1.1). How should the nurse interpret this result?
Correct answer: C
For a client not taking a blood thinner, the normal INR is 0.8–1.1. An INR above 1.1 means the blood is clotting more slowly than normal. The 2.0–3.0 target applies only to clients taking warfarin.
- A A higher INR means slower clotting, not faster clotting.
- B The 2.0–3.0 target is for clients on warfarin; this client takes no blood thinner, so 0.8–1.1 applies.
- C Correct: an INR above 1.1 in a client not taking warfarin means the blood clots more slowly than normal.
- D The INR measures clotting time; the platelet count is a separate test.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: MedlinePlus: Prothrombin time (PT) ·
A client with no history of diabetes has an A1C of 6.1% (normal: below 5.7%). How should the nurse interpret this result?
Correct answer: B
When A1C is used to screen for diabetes, below 5.7% is normal, 5.7% to 6.4% is prediabetes and 6.5% or higher is diabetes. A result of 6.1% falls in the prediabetes range.
- A 6.1% is above the normal cutoff of below 5.7%.
- B Correct: 6.1% is inside the 5.7%–6.4% prediabetes range.
- C The diabetes range starts at 6.5%.
- D A1C reflects average blood sugar over time; a high A1C does not mean low blood sugar.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: MedlinePlus: A1C test ·
The nurse reviews results for a female client. Which results are outside the normal range for this client? Select all that apply.
Select all that apply.
Correct answer: B, C, D
Some ranges differ by sex, so use the female range for a female client. The creatinine and hematocrit would be normal for a male but are high for a female, and the WBC count is above range for everyone.
- A 12.6 g/dL is inside the female range of 12.1–15.1 g/dL, even though it would be low for a male.
- B Outside: 1.2 mg/dL is above the female range of 0.5–0.95 mg/dL.
- C Outside: 13,200/mcL is above 11,000/mcL.
- D Outside: 46% is above the female range of 34%–43%.
- E 210,000/mcL is inside the 150,000–400,000/mcL range.
- F 4.6 million/mcL is inside the female range of 3.8–5.1 million/mcL.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: MedlinePlus: Hemoglobin · MedlinePlus: Creatinine blood test · MedlinePlus: WBC count · MedlinePlus: Hematocrit · MedlinePlus: Platelet count · MedlinePlus: RBC count ·
A client has a urine specific gravity of 1.034 (1.005–1.030) and a BUN of 24 mg/dL (6–20 mg/dL). Which condition do these results most likely point to?
Correct answer: D
Both results are high. Loss of body fluid (dehydration) can raise urine specific gravity because the urine is concentrated, and it can also raise the BUN. Dehydration is the only choice that fits both results.
- A Drinking too much fluid lowers urine specific gravity and can lower the BUN.
- B Liver failure is a cause of a low BUN, not a high one.
- C Diabetes insipidus causes dilute urine with a low specific gravity.
- D Correct: dehydration can raise both urine specific gravity and BUN.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: MedlinePlus: Urine specific gravity test · MedlinePlus: BUN - blood test ·
The nurse reviews laboratory results for four clients. Which result should the nurse report to the provider first?
Correct answer: B
Report the result with the greatest immediate risk to life first. A lithium level above 2.5 mEq/L is a medical emergency, even if the client has no symptoms. The other results are only slightly outside their ranges.
- A A BUN slightly above range needs follow-up, but it is not as urgent as a toxic lithium level.
- B Correct: a lithium level above 2.5 mEq/L is a medical emergency, even without symptoms.
- C A slightly low albumin needs follow-up, but it is not an emergency.
- D A slightly high bilirubin needs follow-up, but it is not as urgent as lithium toxicity.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 6.4 Mood Stabilizers · MedlinePlus: BUN - blood test · MedlinePlus: Albumin blood (serum) test · MedlinePlus: Bilirubin blood test ·
A client's sodium is 128 mEq/L (136–145 mEq/L). Which findings should the nurse watch for?
Correct answer: A
Low sodium (hyponatremia) mainly affects the brain. Watch for headache and confusion, which can progress to coma.
- A Correct: headache and confusion are signs of hyponatremia.
- B Chvostek and Trousseau signs point to low calcium, not low sodium.
- C Hunger and sweating are signs of low blood sugar.
- D Visual changes such as halos are a sign of digoxin toxicity.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · MedlinePlus: Low blood sugar · Open RN Nursing Pharmacology, 6.7 Cardiac Glycosides ·
A client is admitted with community-acquired pneumonia. For each finding, indicate whether it is a cue that the client may be developing sepsis or is not a sepsis cue.
Sepsis cue Not a sepsis cue Temperature 35.7°C (96.3°F) Heart rate 108/min Respiratory rate 16/min WBC 3,600/mm³ (4,500–11,000/mm³) Urine output 55 mL/hour New disorientation to place and date Select one option in each row.
Correct answer: Temperature 35.7°C (96.3°F): Sepsis cue; Heart rate 108/min: Sepsis cue; Respiratory rate 16/min: Not a sepsis cue; WBC 3,600/mm³ (4,500–11,000/mm³): Sepsis cue; Urine output 55 mL/hour: Not a sepsis cue; New disorientation to place and date: Sepsis cue
Sepsis is an infection-triggered, body-wide inflammatory response, so the nurse looks for a cluster of inflammatory cues in a client with an infection. Temperature over 38°C or under 36°C, heart rate over 90/min, respiratory rate over 20/min, and WBC over 12,000 or under 4,000/mm³ are the classic cues. New confusion and urine output under 30 mL/hour point to poor perfusion. Remember that a low temperature and a low WBC count are sepsis cues too.
- Temperature 35.7°C (96.3°F) A temperature under 36°C (96.8°F) is a sepsis cue; sepsis can lower body temperature as well as raise it.
- Heart rate 108/min A heart rate over 90/min is one of the inflammatory-response cues.
- Respiratory rate 16/min A respiratory rate of 16/min is within normal limits; the cue is a rate over 20/min.
- WBC 3,600/mm³ (4,500–11,000/mm³) A WBC under 4,000/mm³ is a sepsis cue, just like a WBC over 12,000/mm³.
- Urine output 55 mL/hour Urine output of 55 mL/hour is above the 30 mL/hour threshold, so kidney perfusion is adequate.
- New disorientation to place and date A new change in mental status can be an early sign of sepsis from poor brain perfusion.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) · OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · MedlinePlus Medical Encyclopedia: WBC count ·
A client with a urinary tract infection has a temperature of 38.9°C (102°F), a heart rate of 116/min, and a blood pressure of 98/60 mm Hg. The provider prescribes blood cultures, a broad-spectrum IV antibiotic, a lactate level, and an IV crystalloid bolus. The bolus is already infusing. Which action should the nurse take next?
Correct answer: B
In suspected sepsis, blood cultures are obtained before broad-spectrum antibiotics so the organism can be identified and the antibiotic adjusted to it later, and the first antibiotic dose is then given immediately because each hour of delay raises mortality. Culture results take 1 to 3 days, so waiting for them is unsafe. Fluids come before vasopressors.
- A Cultures are drawn before the first dose so the organism can still be identified; giving the antibiotic first reverses the required order.
- B Correct: cultures before the antibiotic, then the antibiotic right away, follows the time-sensitive sepsis bundle.
- C Blood cultures take 1 to 3 days; delaying the antibiotic that long increases the risk of death.
- D IV fluids are given first for hypotension in sepsis; a vasopressor such as norepinephrine is added if pressure stays low after fluids.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · CDC: Caring for Patients with Sepsis ·
A client with sepsis has received the full prescribed IV crystalloid bolus. Blood pressure is now 82/44 mm Hg (MAP 57 mm Hg), and lactate is 4.6 mmol/L (less than 2 mmol/L). The client is most likely experiencing . The nurse should anticipate a prescription for , titrated to keep the mean arterial pressure at or above .
Choose the best option from each list to complete the sentence.
Correct answer: septic shock; norepinephrine; 65 mm Hg
Septic shock is sepsis with low blood pressure that persists despite adequate IV fluids; a lactate above 4 mmol/L signals severe hypoperfusion. Once fluids have been given, norepinephrine is the first-line vasopressor. The usual goal is a mean arterial pressure of 65 mm Hg, the level that indicates adequate perfusion pressure.
- Hypotension that persists after adequate fluid resuscitation in a client with sepsis defines septic shock; nothing suggests bleeding or pump failure, and a falling MAP with rising lactate is not a response to treatment.
- Norepinephrine is the first-line vasopressor after fluids; furosemide would remove volume, insulin does not raise pressure, and bicarbonate does not treat the cause of hypotension.
- The treatment target is a MAP of 65 mm Hg or higher; 55 mm Hg is too low to perfuse organs, and 90 or 110 mm Hg are not the standard goal.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) ·
A client with chronic kidney disease has a serum potassium of 6.6 mEq/L (3.5–5.1 mEq/L). The cardiac monitor shows tall, peaked T waves and a widened QRS complex. All of the following are prescribed. Which should the nurse give first?
Correct answer: C
Hyperkalemia with ECG changes can progress to dysrhythmias and cardiac arrest, so the immediate threat to circulation comes first. IV calcium gluconate protects the heart muscle from the effects of potassium within minutes; it is temporary and does not lower the level, which buys time for treatments that remove or shift potassium. Diet changes and binders work too slowly for an emergency.
- A The binder removes potassium through the GI tract, but it acts slowly and does not protect the heart right now.
- B A loop diuretic helps the kidneys excrete potassium, but it does not protect the heart right now, so it is not the first step when the ECG is changing.
- C Correct: calcium gluconate stabilizes cardiac muscle immediately, addressing the most life-threatening problem first.
- D Dietary restriction helps prevent future hyperkalemia but does nothing for a dangerous level that is affecting the heart now.
Learn this topic: How sodium and potassium imbalances show up and what the nurse does 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · OpenStax Medical-Surgical Nursing, 10.3 Electrolyte Imbalance · MedlinePlus Medical Encyclopedia: High potassium level ·
A client taking furosemide has a serum potassium of 2.9 mEq/L (3.5–5.1 mEq/L). Which findings should the nurse expect? Select all that apply.
Select all that apply.
Correct answer: A, C, D, F
Loop diuretics such as furosemide cause potassium loss in the urine. Low potassium weakens muscle contraction and changes cardiac repolarization, giving weakness, lethargy, a thready pulse, dysrhythmias and prominent U waves. Peaked T waves belong to high potassium, and intense thirst with sticky mucous membranes points to high sodium.
- A Muscle weakness is a classic sign of hypokalemia because potassium is needed for muscle contraction.
- B Tall, peaked T waves are the ECG sign of hyperkalemia, the opposite imbalance.
- C A prominent U wave after the T wave is commonly associated with hypokalemia.
- D A weak, thready pulse is listed among hypokalemia signs.
- E Severe thirst and sticky mucous membranes describe hypernatremia, not low potassium.
- F Lethargy is one of the expected signs of hypokalemia.
Learn this topic: How sodium and potassium imbalances show up and what the nurse does 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · OpenStax Pharmacology for Nurses, 5.2 Electrolytes · Open RN Nursing Advanced Skills, 7.3 A Systematic Approach to Interpreting an ECG ·
A client with the syndrome of inappropriate antidiuretic hormone (SIADH) has a serum sodium of 121 mEq/L (136–145 mEq/L) and reports a headache. For each nursing action, indicate whether it is indicated or contraindicated.
Indicated Contraindicated Limit free-water intake as prescribed Encourage the client to drink extra water Infuse 0.45% sodium chloride (a hypotonic fluid) Assess orientation and monitor for seizure activity Raise the sodium to 136 mEq/L within 2 hours Measure intake and output Select one option in each row.
Correct answer: Limit free-water intake as prescribed: Indicated; Encourage the client to drink extra water: Contraindicated; Infuse 0.45% sodium chloride (a hypotonic fluid): Contraindicated; Assess orientation and monitor for seizure activity: Indicated; Raise the sodium to 136 mEq/L within 2 hours: Contraindicated; Measure intake and output: Indicated
SIADH makes the body hold too much water, which dilutes sodium and swells brain cells, causing headache, confusion and seizures. Care limits water, avoids hypotonic fluids, and watches neurologic status and fluid balance. Sodium must be raised slowly: an increase faster than about 0.5 mEq/L per hour risks osmotic demyelination syndrome.
- Limit free-water intake as prescribed Limiting water intake treats dilutional hyponatremia by letting the sodium concentration rise.
- Encourage the client to drink extra water Extra water would dilute the sodium further and worsen brain swelling.
- Infuse 0.45% sodium chloride (a hypotonic fluid) Hypotonic IV fluid adds free water and can cause or worsen hyponatremia.
- Assess orientation and monitor for seizure activity Water moving into brain cells causes confusion and seizures, so neurologic checks are essential.
- Raise the sodium to 136 mEq/L within 2 hours A 15 mEq/L rise in 2 hours is far faster than about 0.5 mEq/L per hour and risks osmotic demyelination syndrome.
- Measure intake and output Accurate intake and output shows whether the water restriction is working.
Learn this topic: How sodium and potassium imbalances show up and what the nurse does 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · OpenStax Medical-Surgical Nursing, 10.3 Electrolyte Imbalance · MedlinePlus Medical Encyclopedia: Low blood sodium ·
The nurse is caring for clients admitted with hyperglycemic crises. For each finding, indicate whether it is consistent with diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), or both.
DKA HHS Both Deep, rapid, labored breathing Glucose 920 mg/dL (fasting 70–99 mg/dL) with arterial pH 7.38 (7.35–7.45) Fruity odor on the breath Excessive thirst and frequent urination Large amount of ketones in the blood and urine Symptoms building over 10 days in an older adult with type 2 diabetes Select one option in each row.
Correct answer: Deep, rapid, labored breathing: DKA; Glucose 920 mg/dL (fasting 70–99 mg/dL) with arterial pH 7.38 (7.35–7.45): HHS; Fruity odor on the breath: DKA; Excessive thirst and frequent urination: Both; Large amount of ketones in the blood and urine: DKA; Symptoms building over 10 days in an older adult with type 2 diabetes: HHS
DKA comes from a near-total lack of insulin, so fat breakdown produces ketones and metabolic acidosis, with Kussmaul breathing and fruity breath. HHS occurs when some insulin remains, so ketones stay low and pH stays normal, but glucose climbs very high (often above 600 mg/dL) over days to weeks. Both cause thirst and frequent urination from high glucose.
- Deep, rapid, labored breathing Kussmaul respirations are the lungs blowing off CO2 to offset ketoacidosis, a DKA finding.
- Glucose 920 mg/dL (fasting 70–99 mg/dL) with arterial pH 7.38 (7.35–7.45) Extreme glucose with a normal pH fits HHS, where there is little or no ketoacidosis.
- Fruity odor on the breath Fruity breath comes from ketones, so it points to DKA.
- Excessive thirst and frequent urination High glucose causes thirst and urination in both crises.
- Large amount of ketones in the blood and urine Large amounts of ketones in blood and urine define DKA; in HHS ketones are absent or only mild.
- Symptoms building over 10 days in an older adult with type 2 diabetes HHS develops slowly over days to weeks and is typical of type 2 diabetes, often in older adults.
Learn this topic: Diabetic ketoacidosis vs hyperosmolar hyperglycemic state 5-minute lesson
Source: Open RN Health Alterations, 7.5 Diabetes Mellitus · OpenStax Medical-Surgical Nursing, 21.2 Diabetes Mellitus · MedlinePlus Medical Encyclopedia: Blood sugar test · Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance ·
A client with diabetic ketoacidosis has received 1 L of 0.9% sodium chloride. Current results: glucose 486 mg/dL (fasting 70–99 mg/dL), arterial pH 7.18 (7.35–7.45), potassium 3.1 mEq/L (3.5–5.1 mEq/L). A continuous IV insulin infusion is prescribed. Which action should the nurse take first?
Correct answer: B
Insulin and correction of acidosis drive potassium into the cells, so serum potassium falls during DKA treatment. When potassium is already below 3.5 mEq/L, insulin is delayed and potassium is replaced first (per protocol or after notifying the provider) to prevent dangerous dysrhythmias and muscle weakness. Safety of the heart comes before lowering glucose.
- A Starting insulin now would push the already low potassium even lower and risk life-threatening dysrhythmias.
- B Correct: current guidance delays insulin and replaces potassium first when potassium is below 3.5 mEq/L.
- C Bicarbonate is not routine in DKA and is considered only when pH is below 7.0; it would also lower potassium.
- D Dextrose is added only after glucose falls below about 250 mg/dL; at 486 mg/dL it is not indicated.
Learn this topic: Diabetic ketoacidosis vs hyperosmolar hyperglycemic state 5-minute lesson
Source: Umpierrez GE et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care 2024 (PMC) · Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · Open RN Health Alterations, 7.5 Diabetes Mellitus ·
A client is receiving an IV insulin infusion for diabetic ketoacidosis. Four hours later, the glucose is 236 mg/dL (fasting 70–99 mg/dL), arterial pH is 7.26 (7.35–7.45), and bicarbonate is 13 mEq/L (22–26 mEq/L). The nurse anticipates because .
Choose the best option from each list to complete the sentence.
Correct answer: adding 5–10% dextrose to the IV fluid; the ketoacidosis has not yet resolved
Glucose usually falls faster than ketoacidosis clears. Once glucose drops below 250 mg/dL, 5–10% dextrose is added to the IV fluid and the insulin rate is lowered, so insulin can keep clearing ketones without causing hypoglycemia. A pH of 7.26 and bicarbonate of 13 mEq/L show the acidosis is still present.
- Adding dextrose lets the insulin infusion continue safely; stopping insulin would let ketoacidosis persist, a 50% dextrose bolus treats hypoglycemia that is not present, and doubling insulin would drive glucose too low.
- The pH and bicarbonate are still low, so the ketoacidosis has not resolved; glucose is above normal, the client is not hypoglycemic, and ketone clearance is incomplete.
Learn this topic: Diabetic ketoacidosis vs hyperosmolar hyperglycemic state 5-minute lesson
Source: Umpierrez GE et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care 2024 (PMC) · Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · MedlinePlus Medical Encyclopedia: Blood sugar test ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L The nurse reviews the 0700 note. Click to highlight the findings that require follow-up.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the . Reports . Skin warm and flushed. Lung sounds . Skin over the sacrum . Urine in the drainage bag is cloudy, dark amber and ; in the past 4 hours. Capillary refill . Provider notified.
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: place or date; chills; foul-smelling; 90 mL
The client was oriented last evening, so new disorientation is an acute change and, in an older adult, can be one of the first signs of sepsis. Chills and foul-smelling cloudy urine in a client with a long-term catheter point to a spreading urinary infection. Ninety mL in 4 hours is about 22 mL/hour, below the 30 mL/hour that signals adequate kidney perfusion.
- place or date New disorientation compared with last evening is an acute mental status change that needs immediate follow-up.
- chills Chills with a rising temperature are a sign of sepsis.
- clear bilaterally Clear lung sounds are a normal finding and make the lungs an unlikely source.
- intact Intact sacral skin is a normal finding.
- foul-smelling Foul-smelling, cloudy urine in a client with an indwelling catheter suggests the urinary tract is the infection source.
- 90 mL About 22 mL/hour is below 30 mL/hour and signals poor kidney perfusion.
- 2 seconds A capillary refill of 2 seconds is within normal limits.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) · OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · OpenStax Medical-Surgical Nursing, 23.1 Shock Overview · CDC: About Sepsis · MedlinePlus Medical Encyclopedia: Septic shock · MedlinePlus Medical Encyclopedia: WBC count ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L For each finding, indicate whether it mainly reflects the infection and inflammatory response or decreased tissue perfusion.
Infection or inflammatory response Decreased tissue perfusion Temperature 39.1°C (102.4°F) WBC 16,800/mm³ (4,500–11,000/mm³) Cloudy, foul-smelling urine Lactate 3.4 mmol/L (less than 2 mmol/L) 90 mL of urine in 4 hours New disorientation to place and date Select one option in each row.
Correct answer: Temperature 39.1°C (102.4°F): Infection or inflammatory response; WBC 16,800/mm³ (4,500–11,000/mm³): Infection or inflammatory response; Cloudy, foul-smelling urine: Infection or inflammatory response; Lactate 3.4 mmol/L (less than 2 mmol/L): Decreased tissue perfusion; 90 mL of urine in 4 hours: Decreased tissue perfusion; New disorientation to place and date: Decreased tissue perfusion
Fever, a high WBC count and infected urine show the infection and the body-wide inflammatory response. When perfusion falls, cells switch to anaerobic metabolism and lactate rises, the kidneys make less urine, and the brain becomes confused or agitated. Perfusion cues tell the nurse that sepsis is affecting organs and that shock may follow.
- Temperature 39.1°C (102.4°F) Fever is part of the inflammatory response to infection.
- WBC 16,800/mm³ (4,500–11,000/mm³) A WBC over 12,000/mm³ reflects the immune response to infection.
- Cloudy, foul-smelling urine Cloudy, foul-smelling urine is a local sign of the urinary infection.
- Lactate 3.4 mmol/L (less than 2 mmol/L) Lactate rises when poorly perfused cells switch to anaerobic metabolism.
- 90 mL of urine in 4 hours Output of about 22 mL/hour, under 30 mL/hour, reflects poor kidney perfusion.
- New disorientation to place and date Agitation and confusion appear as brain perfusion drops.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · OpenStax Medical-Surgical Nursing, 23.1 Shock Overview · Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L Complete the following sentences. The client's findings are most consistent with that most likely began in the . Without prompt treatment, the client is at highest risk for progressing to .
Choose the best option from each list to complete the sentence.
Correct answer: sepsis; urinary tract; septic shock
A client with an infection who develops fever, tachycardia, tachypnea, a high WBC count, new confusion, low urine output and a rising lactate has sepsis. The catheter, cloudy foul-smelling urine and clear lungs point to a urinary source. With a borderline blood pressure and a lactate above 2 mmol/L, the most urgent risk is septic shock, which is why this hypothesis is ranked first.
- The cluster of inflammatory and perfusion cues in an infected client is sepsis; there are no ketone or glucose data to support DKA, and delirium or simple dehydration would not explain the fever and high WBC count.
- The long-term catheter and abnormal urine identify the urinary tract; lungs are clear, and there are no skin or GI findings.
- Falling blood pressure with rising lactate signals progression toward septic shock; potassium is normal, and nothing suggests fluid overload or low glucose.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) · OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · MedlinePlus Medical Encyclopedia: Septic shock · CDC: About Sepsis ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Actions to take (choose 2)
Condition most likely (choose 1)
Parameters to monitor (choose 2)
Correct answer: Sepsis; Draw blood cultures before the antibiotic; Infuse the prescribed crystalloid bolus; Hourly urine output; Serum lactate
The client has sepsis from a urinary source. Early actions are blood cultures before the first antibiotic dose and IV crystalloid to restore perfusion. Lactate and hourly urine output show whether tissue perfusion is improving, with targets of lactate below 2 mmol/L and urine output of at least 30 mL/hour.
- Diabetic ketoacidosis There are no ketone, pH or glucose data supporting DKA.
- Acute pulmonary edema Lung sounds are clear and SpO2 is 95%, so pulmonary edema is unlikely.
- Sepsis Correct: infection plus fever, tachycardia, tachypnea, high WBC, confusion, low urine output and high lactate indicate sepsis.
- Restrict fluids to 1,000 mL per day Fluid restriction would worsen hypoperfusion in sepsis.
- Draw blood cultures before the antibiotic Correct: cultures are drawn before broad-spectrum antibiotics so the organism can be identified.
- Start a continuous IV infusion of regular insulin An insulin infusion treats DKA or HHS, not sepsis.
- Give furosemide by IV push A diuretic would remove volume from a client who needs fluid resuscitation.
- Infuse the prescribed crystalloid bolus Correct: IV crystalloid restores intravascular volume and perfusion in sepsis.
- Serum ketones Ketones monitor DKA, which this client does not have.
- Hourly urine output Correct: hourly urine output reflects kidney perfusion; the goal is at least 30 mL/hour.
- Hemoglobin A1C Hemoglobin A1C reflects glucose control over months and does not track acute sepsis.
- Serum lactate Correct: a falling lactate shows that cells are getting enough oxygen again.
- Peak expiratory flow rate Peak flow monitors airway obstruction such as asthma, not sepsis.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · Open RN Nursing Fundamentals 2e, 9.4 Infection (Bacteremia, SIRS, Sepsis, and Septic Shock) · CDC: Caring for Patients with Sepsis ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L The provider prescribes 2 sets of blood cultures, a broad-spectrum IV antibiotic, a repeat lactate level in 2 hours, and a 0.9% sodium chloride IV bolus. Which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: A, C, D, F
The sepsis bundle is time-sensitive: obtain cultures before antibiotics, give the first antibiotic dose immediately, restore volume with IV crystalloid, and monitor perfusion closely. Hourly urine output is a simple bedside measure of kidney perfusion. Delaying the antibiotic or relying on oral fluids in a confused, hypotensive client is unsafe.
- A Cultures are drawn before the first antibiotic dose so the organism can be identified and the antibiotic adjusted to it later.
- B Culture results take 1 to 3 days; delaying antibiotics that long increases mortality.
- C The first antibiotic dose should be given immediately once cultures are obtained.
- D IV crystalloid is the first treatment for sepsis-related hypotension and hypoperfusion.
- E A confused client with low blood pressure needs IV volume; oral fluids are too slow and unsafe for a client who is not fully alert.
- F Hourly output tracks kidney perfusion; less than 30 mL/hour must be reported.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · CDC: Caring for Patients with Sepsis ·
History
74-year-old client with type 2 diabetes. Indwelling urinary catheter for 3 weeks after hip surgery. Admitted yesterday evening from a rehabilitation facility with a suspected urinary tract infection. Urine culture pending. No known allergies.
Nurses' Notes
2000 (day 1): Client alert and oriented to person, place and time. Reports lower abdominal discomfort. Urine in the drainage bag cloudy. Skin warm and dry.
0700 (day 2): Daughter says the client is "not acting like herself." Client is restless and does not know the place or date. Reports chills. Skin warm and flushed. Lung sounds clear bilaterally. Skin over the sacrum intact. Urine in the drainage bag is cloudy, dark amber and foul-smelling; 90 mL in the past 4 hours. Capillary refill 2 seconds. Provider notified.
Vital Signs
2000 (day 1) 0700 (day 2) Temperature 37.4°C (99.3°F) 39.1°C (102.4°F) Heart rate 88/min 118/min Respiratory rate 18/min 26/min Blood pressure 132/78 mm Hg 94/52 mm Hg (MAP 66 mm Hg) SpO2 97% on room air 95% on room air Laboratory Results (0715, day 2)
Test Result Normal range WBC 16,800/mm³ 4,500–11,000/mm³ Lactate 3.4 mmol/L less than 2 mmol/L Sodium 141 mEq/L 136–145 mEq/L Potassium 4.4 mEq/L 3.5–5.1 mEq/L Three hours after treatment began, the nurse reassesses the client. For each finding, indicate whether it shows that treatment has been effective or ineffective.
Effective Ineffective Blood pressure 104/58 mm Hg (MAP 73 mm Hg) Urine output 45 mL in the past hour Repeat lactate 3.9 mmol/L (less than 2 mmol/L) Oriented to person, place and date New mottling of the skin over both knees Select one option in each row.
Correct answer: Blood pressure 104/58 mm Hg (MAP 73 mm Hg): Effective; Urine output 45 mL in the past hour: Effective; Repeat lactate 3.9 mmol/L (less than 2 mmol/L): Ineffective; Oriented to person, place and date: Effective; New mottling of the skin over both knees: Ineffective
Treatment goals in sepsis are a MAP of at least 65 mm Hg, urine output of at least 30 mL/hour, a falling lactate and a return to baseline mental status. A lactate that rises from 3.4 to 3.9 mmol/L and new skin mottling are signs of worsening perfusion even when blood pressure improves, so the nurse reports them right away.
- Blood pressure 104/58 mm Hg (MAP 73 mm Hg) A MAP of 73 mm Hg meets the goal of 65 mm Hg or higher.
- Urine output 45 mL in the past hour Output of 45 mL/hour exceeds the 30 mL/hour goal, showing better kidney perfusion.
- Repeat lactate 3.9 mmol/L (less than 2 mmol/L) Lactate has risen from 3.4 mmol/L instead of falling, so tissue hypoperfusion is not resolving.
- Oriented to person, place and date Return to the client's baseline orientation shows improved brain perfusion.
- New mottling of the skin over both knees Mottled skin is a sign of worsening (cold) shock and poor peripheral perfusion.
Learn this topic: How to recognize sepsis early and what the nurse does first 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 23.3 Septic Shock · OpenStax Medical-Surgical Nursing, 23.1 Shock Overview ·
A client lying in bed begins a generalized tonic-clonic seizure. The nurse removes the extra pillows, raises the side rails and should . If the seizure continues for more than , the nurse calls for emergency assistance because the client is in status epilepticus. When the jerking stops, the nurse places the client .
Choose the best option from each list to complete the sentence.
Correct answer: note the time the seizure started; 5 minutes; on one side
During a seizure the nurse protects the client from injury and observes: nothing goes in the mouth, the client is not restrained, and the start and end times are recorded. A seizure lasting more than 5 minutes is status epilepticus, an emergency that needs immediate help. Afterward, the client is kept on one side to prevent aspiration.
- Recording the start time is a key nursing action; objects in the mouth can break teeth or injure the tongue, restraining the client causes injury, and moving a convulsing client into a chair is unsafe.
- Status epilepticus is a seizure lasting more than 5 minutes (or repeated seizures without recovery between them); waiting 15 or 30 minutes delays emergency care, and 1 minute is shorter than a typical tonic-clonic seizure, which lasts about 2 to 5 minutes.
- Keeping the client on one side is the recommended position to prevent aspiration; lying on the back, sitting upright and lying face down are not the recommended position after a seizure.
Source: Open RN Health Alterations, 9.7 Seizures and Epilepsy ·
A client on a medical unit was seen by the assistive personnel at 0545 talking normally and asking for water. At 0720 the nurse finds the client with a drooping mouth on the left side and slurred speech. The client cannot say when the symptoms started. Which time should the nurse report to the stroke team as the onset of symptoms?
Correct answer: B
Stroke onset is counted from the time the client was last known well, meaning last seen without symptoms. Here that is 0545, when the client was talking normally. The time symptoms were discovered (0720) is later than the true onset, and using it could make the client look eligible for time-sensitive treatment when they are not.
- A 0720 is when the symptoms were found, not the last time the client was known to be well.
- B Correct: 0545 is the last time the client was seen acting normally, so it is the time last known well.
- C The time of the stroke response call does not tell the team when the brain lost its blood flow.
- D The time of the previous evening's assessment is not the most recent time the client was known to be well.
Learn this topic: How do you recognize an acute stroke and what does the nurse do first? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 15.2 Ischemic Stroke · CDC, Signs and Symptoms of Stroke ·
A stroke alert is called for a client with sudden right arm weakness and trouble speaking that began 50 minutes ago. While the stroke team is on the way, which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: A, C, D, F
In a suspected stroke, the nurse gathers time-critical data and keeps the client safe. A fingerstick glucose rules out hypoglycemia, which can mimic stroke. The client stays NPO, including oral medications such as scheduled aspirin, until a swallow screen is done. Two large-bore IV lines and an accurate weight are needed before a thrombolytic, because its dose is weight-based.
- A Correct: hypoglycemia can mimic a stroke, so glucose is checked early.
- B Nothing is given by mouth, including medications, until a swallow screen shows it is safe.
- C Correct: an accurate weight is needed because thrombolytic doses are weight-based.
- D Correct: the client is kept NPO to prevent aspiration until a trained nurse or speech-language pathologist completes a swallow screen.
- E Giving water to test swallowing before a formal swallow screen risks aspiration.
- F Correct: two large-bore IV lines are part of preparing for imaging and possible thrombolytic therapy.
Learn this topic: How do you recognize an acute stroke and what does the nurse do first? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 15.2 Ischemic Stroke · Open RN Health Alterations, 9.9 Cerebrovascular Accident ·
A client with an ischemic stroke is 1 hour into an IV alteplase infusion. Before treatment the client had right arm weakness. For each finding, indicate whether it requires the nurse's immediate action or can be addressed with continued routine monitoring.
Immediate action Routine monitoring New severe headache and vomiting Blood pressure 168/94 mm Hg Swelling of the tongue and lips Right arm weakness unchanged from before the infusion Client, alert before the infusion, now opens eyes only to a loud voice Select one option in each row.
Correct answer: New severe headache and vomiting: Immediate action; Blood pressure 168/94 mm Hg: Routine monitoring; Swelling of the tongue and lips: Immediate action; Right arm weakness unchanged from before the infusion: Routine monitoring; Client, alert before the infusion, now opens eyes only to a loud voice: Immediate action
The major risk of a thrombolytic is bleeding, especially into the brain. A new severe headache with vomiting or a falling level of consciousness can mean hemorrhagic transformation, and lip or tongue swelling is angioedema; the label says to stop the infusion for serious bleeding or angioedema, so these need immediate action. A blood pressure within the 180/105 mm Hg limit and weakness unchanged from before treatment are monitored routinely.
- New severe headache and vomiting Immediate action: a sudden severe headache with vomiting may be bleeding in the brain.
- Blood pressure 168/94 mm Hg Routine monitoring: 168/94 mm Hg is within the limit of 180/105 mm Hg or lower used for clients receiving a thrombolytic.
- Swelling of the tongue and lips Immediate action: swelling of the tongue and lips during alteplase is angioedema, a reason to stop the infusion.
- Right arm weakness unchanged from before the infusion Routine monitoring: weakness that is unchanged from before treatment is not a new deficit.
- Client, alert before the infusion, now opens eyes only to a loud voice Immediate action: a falling level of consciousness is a new neurologic decline that may signal bleeding.
Learn this topic: How do you recognize an acute stroke and what does the nurse do first? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 15.2 Ischemic Stroke · DailyMed, Alteplase for injection prescribing information · Open RN Health Alterations, 9.9 Cerebrovascular Accident ·
A client who has had severe diarrhea for 3 days has these arterial blood gas results: pH 7.29 (7.35–7.45), PaCO2 30 mm Hg (35–45 mm Hg), HCO3 16 mEq/L (22–26 mEq/L). How should the nurse interpret these results?
Correct answer: C
Start with the pH: 7.29 is acidosis. HCO3 is low and moves in the same direction as the pH, so the cause is metabolic (Metabolic Equal); severe diarrhea removes bicarbonate. PaCO2 is also low because the lungs are blowing off CO2 to compensate, but the pH is still abnormal, so the compensation is partial.
- A Respiratory acidosis would need a PaCO2 above 45 mm Hg; here PaCO2 is low.
- B Uncompensated would mean PaCO2 is still normal; here it is already below 35 mm Hg.
- C Correct: pH and HCO3 are both low (metabolic acidosis), and the low PaCO2 shows the lungs are compensating while the pH is still abnormal.
- D Full compensation would bring the pH back into the 7.35–7.45 range.
Learn this topic: How do you read an arterial blood gas step by step? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · OpenStax Medical-Surgical Nursing, 10.4 Acid-Base Imbalance ·
A client with a fractured femur is in severe pain, breathing 30 times per minute and reports numb, tingling fingers. ABG results: pH 7.50 (7.35–7.45), PaCO2 29 mm Hg (35–45 mm Hg), HCO3 24 mEq/L (22–26 mEq/L). The nurse interprets the results as that is . In addition to giving the prescribed analgesic, the nurse should .
Choose the best option from each list to complete the sentence.
Correct answer: respiratory alkalosis; uncompensated; coach slow abdominal breathing with a longer exhale
A high pH with a low PaCO2 (moving opposite to the pH) is respiratory alkalosis, caused here by pain-driven hyperventilation. HCO3 is still normal, so the kidneys have not begun to compensate. Treatment targets the cause: relieve the pain, reassure the client and coach slow abdominal breathing; rebreathing into a paper bag is no longer recommended because it can cause hypoxemia.
- PaCO2 is low and moves opposite to the high pH, so the cause is respiratory alkalosis; metabolic alkalosis would need a high HCO3, and acidosis would need a low pH.
- HCO3 is still in the normal range, so the imbalance is uncompensated; partial compensation would show a low HCO3, and full compensation would bring the pH back to normal.
- Slow abdominal breathing with a longer exhale reduces CO2 loss; a paper bag can cause hypoxemia, deep breathing to blow off CO2 worsens alkalosis, and bicarbonate would add base.
Learn this topic: How do you read an arterial blood gas step by step? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · OpenStax Medical-Surgical Nursing, 10.4 Acid-Base Imbalance · MedlinePlus, Respiratory alkalosis ·
For each client, indicate the acid–base imbalance the nurse should anticipate.
Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis A client who received several doses of an opioid has a respiratory rate of 7/min A client in shock has a serum lactate of 5.1 mmol/L (less than 2 mmol/L) A sedated client on a mechanical ventilator has a set rate that is too high for the client A client taking a high-dose loop diuretic has a potassium of 2.9 mEq/L (3.5–5.1 mEq/L) Select one option in each row.
Correct answer: A client who received several doses of an opioid has a respiratory rate of 7/min: Respiratory acidosis; A client in shock has a serum lactate of 5.1 mmol/L (less than 2 mmol/L): Metabolic acidosis; A sedated client on a mechanical ventilator has a set rate that is too high for the client: Respiratory alkalosis; A client taking a high-dose loop diuretic has a potassium of 2.9 mEq/L (3.5–5.1 mEq/L): Metabolic alkalosis
Match the imbalance to the cause. Too little breathing retains CO2 (respiratory acidosis); too much breathing removes CO2 (respiratory alkalosis). Acid build-up such as lactic acid from poor perfusion causes metabolic acidosis, while loss of hydrogen ions through the urine with diuretics or a shift of hydrogen into cells in hypokalemia causes metabolic alkalosis.
- A client who received several doses of an opioid has a respiratory rate of 7/min Respiratory acidosis: opioid oversedation slows breathing, so CO2 builds up.
- A client in shock has a serum lactate of 5.1 mmol/L (less than 2 mmol/L) Metabolic acidosis: poor tissue oxygenation in shock produces lactic acid.
- A sedated client on a mechanical ventilator has a set rate that is too high for the client Respiratory alkalosis: a ventilator rate that is too high removes too much CO2.
- A client taking a high-dose loop diuretic has a potassium of 2.9 mEq/L (3.5–5.1 mEq/L) Metabolic alkalosis: diuretics cause loss of hydrogen ions in the urine, and hypokalemia shifts hydrogen ions into cells.
Learn this topic: How do you read an arterial blood gas step by step? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · OpenStax Medical-Surgical Nursing, 10.4 Acid-Base Imbalance · OpenStax Medical-Surgical Nursing, 23.2 Hypovolemic Shock · Open RN Nursing Fundamentals 2e, 15.4 Electrolytes ·
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NCLEX-RN format
| Client needs category | Share of the exam |
|---|---|
| Management of Care | 15–21% |
| Safety and Infection Prevention and Control | 10–16% |
| Health Promotion and Maintenance | 6–12% |
| Psychosocial Integrity | 6–12% |
| Basic Care and Comfort | 6–12% |
| Pharmacological and Parenteral Therapies | 13–19% |
| Reduction of Risk Potential | 9–15% |
| Physiological Adaptation | 11–17% |
The exam has 85 to 150 questions in up to 5 hours, including 15 unscored pretest questions and three unfolding case studies. An on-screen calculator is provided.
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Are these real NCLEX questions?
No. These are original practice questions we wrote to the public 2026 test plan. They are not real exam questions.
Does this test stop early like the real NCLEX?
No. Ours has a fixed set of questions. The real exam is adaptive and can end anywhere from 85 to 150 questions.
How long does it take?
This set has 179 questions. Practice mode has no timer, so take as long as you need. With full access, exam mode gives you 352 minutes.
Can I stop and finish later?
Yes. Your answers save in this browser, so you can close the page and pick up where you left off.
Is this medical advice?
No. These questions are for exam study only.
Is it free?
Yes. No card. Start without an account; after 15 questions, a free account saves your progress. A paid plan unlocks all 717 verified NCLEX-RN questions, timed exam mode, sets on one topic and a score for every topic.