Uworld P1 Test Bank

Uworld P1 Test Bank After listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? 1. 1-year-old with dyspnea, drooling, and a swollen tongue after eating part of a houseplant [2%] 2. 2-year-old who is crying and has a large forehead hematoma after falling out of a chair [5%] 3. 3-year-old with second-degree burns on the face after pulling a cup of hot tea off the table [3%] 4. 5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree [87%] Explanation: The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory reporting. Signs of abuse may include: • Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures) • Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid • Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4) • Injuries to genitalia • Lapsed time between the injury and the time when care is sought • Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental age, mechanism of injury) (Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg, aspiration or poisoning from foreign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table). The injuries and caregivers' explanations are reasonable for these clients. Prior to discharge, the nurse should instruct caregivers on child safety measures within the home to prevent future injury. Educational objective: The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to state or provincial laws. Copyright © UWorld. All rights reserved. The charge nurse is responsible for making room assignments for multiple clients. Which pair of client assignments to a shared room is appropriate? Client with blood loss anemia and client with intractable diarrhea [11%] 1. 2. Client with gastroenteritis and client with chemotherapy-induced nausea and vomiting [6%] Client who had a bowel resection 1 day ago and client with asthma exacerbation [80%] 3. 4. Client who had a total hip arthroplasty 2 days ago and client with influenza [1%] Explanation: When making room assignments, it is important to remember that a client with an active or suspected infection should not be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma exacerbation does not have an infection and is not at risk for spreading infection to a client who had recent bowel resection surgery (Option 3). (Option 1) A client with uncontained or excessive excretions, drainage, or secretions (eg, profuse diarrhea, draining wounds) is more likely to spread infection, if present, and therefore should be assigned to a private room. (Option 2) The client who has chemotherapy-induced nausea and vomiting is likely immunocompromised secondary to the chemotherapy and is therefore vulnerable to infection from a client with gastroenteritis. (Option 4) A client who has a fresh surgical wound has an increased risk of infection and should not be paired with a client with an active influenza infection, which is transmitted through the droplet route. Educational objective: When preparing room assignments, the nurse should not place a client who has a fresh surgical wound or is immunocompromised in a room with a client who has an active or suspected infection. Copyright © UWorld. All rights reserved. Advance directives Leadership & Management Concepts Test Id: QId: 34718 () 3 of 75 The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult child states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at this time? 1. Call for help to initiate cardiopulmonary resuscitation [10%] 2. Call the health care provider to confirm the DNR status [6%] Explain the client's wishes to the client's child [79%] 3. 4. Offer to call the hospital chaplain to provide support [4%] Explanation: Advance directives outline the client's choices for medical care (eg, cardiopulmonary resuscitation [CPR], mechanical ventilation) ahead of time. This allows the family and care team to follow the client's wishes at the end of life, when the client may be unable to make choices known. Clients can sign a do not resuscitate (DNR) directive instructing that CPR and other life-saving measures be withheld. With an advance directive in place, the client's wishes are followed, even if they conflict with the wishes of loved ones (Option 3). This is different from a medical power of attorney (health care proxy) in which the client designates a person to make decisions on their behalf. (Option 1) Initiating CPR on a client with a DNR status does not respect the wishes of the client to forgo life-saving measures and allow natural death. Nurses must advocate for clients' wishes, even if family members are in disagreement. (Option 2) The client has a terminal illness and in an advance directive expressed wishes that were verified prior to initiating DNR status; therefore, there is no need to clarify with a health care provider. (Option 4) The client's child should be offered support from the hospital chaplain after the client's wishes are explained. Educational objective: Advance directives outline the client's choices for medical care at the end of life, including resuscitation status. Client's wishes for medical care are honored over the wishes of family members. Copyright © UWorld. All rights reserved. The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? 1. "I lost my imipramine prescription. Could I have a refill?" [2%] "I plan to attend my granddaughter's graduation next month." [78%] 2. 3. "I seem to have a lot more energy since I started therapy." [3%] 4. "I will sign a 'no-suicide' contract at today's appointment." [14%] Explanation: Suicide risk & protective factors Risk factors • Psychiatric disorders, prior suicide attempts • Hopelessness • Never married, divorced, separated • Living alone • Elderly white man • Unemployed or unskilled • Physical illness • Family history of suicide, family discord • Access to firearms • Substance abuse, impulsivity Protective factors • Social support/family connectedness • Pregnancy • Parenthood • Religion & participation in religious activities Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing suicidal intent. During a client interview, the nurse should assess: • Access to psychiatric medications • Availability of help during a crisis (eg, counselor, family) • Future goals and plans • Home and work environment risks • Overall affect and level of energy • Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to commit suicide (Option 2). (Option 1) Imipramine (Tofranil) is a tricyclic antidepressant, an overdose of which is extremely dangerous and likely fatal. Although the nurse may interpret the client's report of having lost the prescription as an attempt to be compliant, the nurse must also be aware that the client may be stockpiling medication for a suicide attempt. (Option 3) Clients often feel more energetic after beginning treatment, yet thoughts of suicide may not have fully resolved and the client may now have the energy to follow through with suicide plans. (Option 4) "No-harm/no-suicide" contracts are widely used in clinical practice to support a client's ability to avoid acting on suicidal thoughts. These agreements do not guarantee safety and are not the best indicator of decreased suicide risk. Educational objective: Nursing care for clients with suicidal ideation includes assessment of home and work environments, access to psychiatric medications, overall affect, availability of help, access to weapons, and energy level. Clients who articulate long-term personal goals and family milestones are less likely to commit suicide. Copyright © UWorld. All rights reserved. The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing? 1. BMI of 29.5 kg/m 2 [10%] 2. Family history of osteoporosis [13%] 3. History of a daily glass of wine [0%] Peripheral arterial disease [75%] 4. Explanation: Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing (Option 4). (Option 1) A BMI of 25-29.9 kg/m2 indicates that the client is overweight. A sedentary lifestyle often leads to elevated BMI and also correlates with decreased bone density, which places the client at risk for fractures. However, neither sedentary lifestyle nor elevated BMI directly affects bone healing. (Option 2) Osteoporosis (low bone density) increases the risk of fractures and delays bone healing. Although a family history does increase the risk of osteoporosis, the family history itself would not directly hinder bone healing as this client has not been diagnosed with osteoporosis. (Option 3) Heavy alcohol use is associated with inadequate nutrition and can decrease osteoblastic activity (ie, bone formation). However, a single serving of alcohol (ie, 12 oz of beer, 5 oz of wine, 1.5 oz of liquor) per day is considered moderate usage and is not a risk factor for delayed healing. Educational objective: Bone healing after fracture depends on multiple factors, including age, nutritional status, and perfusion. A client with peripheral arterial disease is at risk for impaired bone healing. Copyright © UWorld. All rights reserved. Basic Care & Comfort/Pain Management Pressure injury Test Id: QId: 30215 () 6 of 75 Exhibit Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information. 1. Stage 1 [10%] Stage 2 [75%] 2. 3. Stage 3 [12%] 4. Stage 4 [1%] Explanation: Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most appropriate and effective wound treatments. • Stage 1: Intact skin with nonblanchable redness • Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry • Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present • Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present • Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar Educational objective: Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or shallow crater). The skin blisters or forms an open sore, and the area around the sore may be red and irritated. Copyright © UWorld. All rights reserved. Exhibit A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? Click on the exhibit button for additional information. 1. Administer 25 units of NPH insulin now and then 12 units of regular insulin after the morning meal [4%] 2. Administer 37 units of insulin: 25 units of NPH insulin and 12 units of regular insulin in 2 separate injections [9%] Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the NPH into the syringe first [10%] 3. 4. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first [75%] Explanation: Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (lispro, aspart) insulins in one syringe (Option 4). Due to the client's blood glucose reading (322 mg/dL [17.9 mmol/L]), 12 units of regular insulin are needed along with the scheduled 25 units of NPH insulin. Prepare the mixed dose: 1. Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the solution. 2. Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles. 3. Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the entire quantity. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and typically are packaged in prefilled injection pens. (Option 1) The two insulins can be safely given together before the meal as regular insulin has a rapid onset of action, whereas NPH has a slower onset but longer duration. (Option 2) The insulins can be given as two separate injections; however, this increases client discomfort and infection risk. (Option 3) Regular insulin should be drawn up first to avoid contaminating the regular insulin vial with NPH insulin (mnemonic – RN: Regular before NPH). Educational objective: NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials (mnemonic – RN: Regular before NPH). Copyright © UWorld. All rights reserved. The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition presents the most concern as a safety hazard in the child's home environment? 1. Family lives in a rural area [0%] House is heated by a wood-burning stove [75%] 2. House was built in 1983 [17%] 3. 4. Parents are unemployed with limited financial resources [6%] Explanation: The safety of the home environment should be assessed prior to discharge of pediatric clients, especially those with illnesses requiring continuing health care services in the home. The nurse can prioritize safety risks according to Maslow's hierarchy of needs. An open wood-burning stove is a fire hazard that may cause physiological damage from smoke inhalation or burns (Option 2). The nurse should investigate the family's access to other utilities and determine whether the stove is the home's only source of heat. (Option 1) Rural environments do not inherently risk the safety of the child. However, follow-up may be required to make sure that the client has access to resources (eg, grocery store, hospital). (Option 3) Houses built before 1978 have a high probability of containing lead-based paint. Active renovations can significantly increase the amount of lead released into the home environment, causing lead poisoning (eg, neurological and motor impairment). Living in a house built in 1983 is not associated with increased risk of lead exposure. (Option 4) Unemployment and limited financial resources can cause increased stress and would require further evaluation but would not take priority over a physical safety hazard. Educational objective: A wood-burning stove is a fire, burn, and smoke-inhalation hazard with the potential to cause physiological damage. The nurse should assess all clients' access to utilities and resources. Education on lead-based paint should be provided to those living in homes built before 1978. Copyright © UWorld. All rights reserved. While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? 1. Activate the hospital emergency response system [2%] 2. Apply supplemental oxygen and quickly transport to the new unit [4%] 3. Check the client's respiratory pattern and effort and oxygen saturation [18%] Firmly cover the insertion site with the palm of a clean, gloved hand [74%] 4. Explanation: Chest tubes are inserted into the pleural cavity to facilitate drainage of air (pneumothorax), blood (hemothorax), or other fluids. Chest tubes are sutured in place, but dislodgement can occur. If this happens, a sterile occlusive dressing (eg, petrolatum gauze) must immediately be placed over the insertion site until the health care provider can assess the client and insert a new chest tube. If such dressings are not immediately available, the nurse should cover the insertion site with something clean and occlusive (eg, gloved hand) to prevent air from entering the pleural cavity. (Option 1) The nurse should cover the site and assess the client prior to activating the emergency response system. (Option 2) It may be necessary to provide supplemental oxygen if a chest tube is accidentally dislodged. This intervention would be done after the site is occluded. (Option 3) After the chest tube insertion site is covered, the client should be reassessed. The nurse should not delay covering the chest tube site as pneumothorax or tension pneumothorax may occur quickly. Educational objective: Chest tubes are inserted into the pleural cavity to drain air (pneumothorax), blood (hemothorax), or other fluids. If the tube is accidentally dislodged, a sterile occlusive dressing is placed over the site. If such dressings are not immediately available, a clean gloved hand can be placed over the site to prevent air entry into the pleural space. After dressing the site, the nurse should reassess the client and notify the health care provider immediately. Copyright © UWorld. All rights reserved. Exhibit The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority intervention? Click the exhibit button for additional information. Administer potassium replacement [74%] 1. 2. Administer the dose of amiodarone [10%] 3. Attach cardiac defibrillator pads [5%] 4. Notify the health care provider [10%] Explanation: In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by administering the prescribed potassium replacement (Option 1). Health care providers (HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight <99.2 lb [45 kg]). (Option 2) Amiodarone is an antiarrhythmic medication with a long duration of action (ie, 13-107 days). An acute drop in the drug level is not likely the cause of the ectopy. The nurse should administer amiodarone as prescribed after initiating the potassium replacement. (Option 3) Correcting the electrolyte imbalance should resolve the client's ectopy, preventing the need for defibrillation. (Option 4) The HCP should be notified; however, the nurse should first assess the client and initiate potassium replacement. Educational objective: Myocardial injury can predispose a client to premature ventricular contractions (PVCs), placing the client at risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. Treatment of the underlying cause is the priority. Copyright © UWorld. All rights reserved. A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? 1. Client 2 months post heart transplant with sustained sinus tachycardia of 110/min at rest [8%] Client 3 hours post coronary artery stent placement via femoral approach and reporting severe back pain [73%] 2. 3. Client receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F (38.6 C) [3%] 4. Client who had coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft [14%] Explanation: A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery. Hypotension, back pain, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention/evaluation (eg, notify health care provider, serial CBCs, abdominal CT). (Option 1) During a heart transplant, the donor heart is cut off from the autonomic nervous system (denervated), which alters the heart rate during rest and exercise after the transplant. The transplanted heart is expected to be tachycardic (eg, 90-110/min). (Option 3) Infective endocarditis is often associated with cardiac valve disease and requires long-term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills, joint pain, anorexia, and petechiae. (Option 4) Some clients notice swelling in the leg used for donor venous graft (interruption of blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms. Educational objective: Percutaneous coronary intervention via the femoral approach places the client at increased risk for retroperitoneal hemorrhage, which is exacerbated by anticoagulants. Back pain, hypotension, flank ecchymosis (Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention. Copyright © UWorld. All rights reserved. A client with sickle cell crisis reports severe generalized pain. Which intervention is a priority for correcting vasoocclusion? Administering high-flow IV fluids [72%] 1. 2. Applying oxygen via nasal cannula [17%] 3. Maintaining strict bed rest [3%] 4. Transfusing packed red blood cells [6%] Explanation: Sickle cell crisis occurs when inadequate oxygenation or hydration exacerbates sickling and causes red blood cells (RBCs) to clump together in the capillaries (vasoocclusion). Vasoocclusion causes severe ischemic pain, hypoxia, and possible organ dysfunction if left untreated. Adequate oxygenation and hydration may reverse the acute sickling response. In the sickled state, RBCs cannot carry enough oxygen from the lungs to the tissues, even with supplemental oxygen. The priority intervention is the administration of IV fluids to reduce blood viscosity and restore perfusion to the areas previously affected by vasoocclusion (Option 1). Only after IV rehydration reverses vasoocclusion can nonsickled RBCs effectively carry supplemental oxygen to the tissues (Option 2). (Option 3) Bed rest improves oxygen use and reduces energy consumption during sickle cell crisis but does not directly resolve vasoocclusion. (Option 4) Blood transfusions provide the client with nonsickled RBCs, increasing the oxygen-carrying capacity of the blood. However, this therapy is generally reserved for clients with sickle cell disease who do not respond to rehydration with IV fluids. Educational objective: Sickle cell crisis results from vasoocclusion of sickled red blood cells in the microcirculation, resulting in severe ischemic pain. The administration of IV fluids reduces blood viscosity and restores perfusion to the areas previously affected by vasoocclusion. Copyright © UWorld. All rights reserved. The charge nurse assists a student nurse preparing to apply knee-length compression stockings onto a client with chronic venous insufficiency. Which actions by the student nurse would cause the charge nurse to intervene? Select all that apply. Instructs client that stockings will be worn only at night 1. Measures circumference of both calves at the widest point 2. Rolls down any excess length at the top of the stocking 3. Selects a size larger to avoid friction against a leg laceration 4. Smoothes out any wrinkles or creases in the stocking 5. Explanation: Thromboembolic deterrent stockings (TED hose) are elastic stockings that provide graduated compression to the leg to promote venous return and reduce risk of venous thromboembolism. Correct sizing and application of TED hose are essential to effectively promote venous return. Stockings that are too large will not provide adequate compression, and stockings that are too tight or applied incorrectly may impair perfusion. When applying TED hose, the nurse should: • Select a size of knee-length stockings by measuring length from the heel to the popliteal area and circumference at the widest point of the calf (Option 2). • Ensure stockings are free of folds, rolls, or wrinkles; these may have a tourniquet-like effect, exacerbating venous stasis and impairing perfusion (Options 3 and 5). • Discrete wounds should be covered with occlusive dressings (eg, hydrocolloid) before TED hose application. (Option 1) Stockings should be worn continually and may be removed 1-3 times a day for vascular assessment. It is especially important to wear TED hose when the legs are in a dependent position while sitting or standing, usually during the day. (Option 4) Friction against nonintact skin (eg, stasis ulcers, lacerations) is alleviated by applying an occlusive dressing. Applying a size larger than recommended based on measurements will not provide adequate compression. Educational objective: Thromboembolic deterrent stockings (TED hose) promote venous return and reduce the risk of venous thromboembolism. TED hose are worn continually and should be properly sized, free of folds, rolls, or wrinkles. Copyright © UWorld. All rights reserved. Leadership & Management Concepts Organ donation Test Id: QId: 34616 () 14 of 75 The nurse is caring for a client who has been pronounced brain dead. The client is a registered organ donor. The client's family is voicing concerns about the possibility of disfigurement because they want to have an open casket funeral. How should the nurse respond? 1. "If the family is not in complete agreement about organ donation, we won't be able to proceed." [9%] "Once the body is dressed, there is no evidence of organ removal. An open casket will be fine." [69%] 2. 3. "Some organ procurement leaves evidence on the body. You may want to consider a closed casket." [9%] 4. "Your family member consented to be an organ donor. You should really honor this wish." [12%] Explanation: Friends and family of deceased clients often have questions about, and may even be suspicious of, the organ donation process, especially during their time of loss and grieving. Organ procurement does not leave obvious evidence on the client's body when the body is dressed. Special precautions and techniques are used by the surgical team and funeral home personnel (eg, morticians) to maintain the integrity and outward appearance of the body (Option 2). Funeral arrangements are not delayed by organ donation and the family will not incur any costs related to procurement. An organ transplant coordinator should be consulted by the nurse to address the family's specific questions related to donation. (Option 1) Consent is not needed from the family if the client is already registered to be an organ donor. (Option 3) Organ procurement does not leave obvious evidence once a body is clothed and prepared for viewing. A closed casket is not necessary. (Option 4) Family members should be advised of the donor's wishes and have their questions answered as to how procurement will proceed. However, the nurse should never try to invoke guilt when communicating with clients or families. Educational objective: A deceased client who is registered as an organ donor does not need familial consent for organ procurement to proceed. Organ donation does not delay or interfere with funeral arrangements or leave obvious evidence on the body; deceased clients can still be displayed according to their wishes, including open casket funeral services. Copyright © UWorld. All rights reserved. The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks unlicensed assistive personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used. Unordered Options • Advance catheter to tubing bifurcation and inflate balloon • Perform hand hygiene and apply sterile gloves • Place fenestrated drape with shiny side down • Use dominant hand to cleanse meatus with cotton balls or swab sticks • Use dominant hand to insert catheter until urine return is observed • Use nondominant hand to grasp penis below glans Your Response/ Correct Response • Perform hand hygiene and apply sterile gloves • Place fenestrated drape with shiny side down • Use nondominant hand to grasp penis below glans • Use dominant hand to cleanse meatus with cotton balls or swab sticks • Use dominant hand to insert catheter until urine return is observed • Advance catheter to tubing bifurcation and inflate balloon Explanation: Steps for indwelling urinary catheter insertion for the male client include: 1. Perform hand hygiene, open sterile catheterization kit, and apply sterile gloves from kit (Option 2). 2. Maintaining sterility of gloves, place sterile fenestrated drape with opening centered over penis (Option 3). 3. Arrange remaining kit supplies on sterile field. Remove protective covering from catheter, lubricate catheter tip, and pour antiseptic solution over cotton balls or swab sticks. 4. Firmly grasp penis with nondominant hand, retracting foreskin if present (Option 6). Nondominant hand is now considered contaminated and remains in this position for duration of procedure. 5. Use dominant (sterile) hand to cleanse meatus with antiseptic solution using cotton balls or swab sticks (Option 4). Use new cotton ball or swab stick with each swipe. 6. Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5). 7. Advance to bifurcation of catheter tubing. Hold in place and inflate balloon (Option 1). Urine return in catheter tubing may be from urethra and does not indicate that balloon tip is fully inside bladder. Because male urethra varies in length, balloon should not be inflated until catheter is fully advanced. Educational objective: To insert an indwelling urinary catheter in a male client, perform hand hygiene and apply sterile gloves, place fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse meatus using dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon. Copyright © UWorld. All rights reserved. Four pediatric clients are brought to the emergency department at the same time. Which client should be seen first? 1. Child who is unable to eat or drink without vomiting [13%] Child with a recently placed tympanostomy tube that has fallen out [5%] 2. Child with bruising behind the ears after a football injury [68%] 3. 4. Child with increased pain at skeletal pin insertion sites on the leg [11%] Explanation: Bruising behind the ear (eg, Battle sign) following head trauma may indicate a basilar skull fracture (Option 3). Because of their close proximity to the brainstem, basilar skull fractures pose a risk of serious intracranial injury, which is the most common cause of traumatic death in children. Other signs include blood behind the tympanic membrane, periorbital hematomas (ie, raccoon eyes), and cerebrospinal fluid leakage from the nose or ears. This client requires cervical spine immobilization, close neurologic monitoring, and support of airway, breathing, and circulation. (Option 1) Vomiting with oral intake may indicate infection (viral or bacterial). Most serious abdominal processes (eg, obstruction, intussusception, appendicitis) also have abdominal pain. This client may require IV fluids and antiemetics but is not a priority. (Option 2) Tympanostomy tubes placed for recurrent otitis media may fall out of the ear canal. This child should be evaluated for the presence of infection and the need for possible tube reinsertion, but this is a common occurrence and can wait to be addressed. (Option 4) Increasing pain at skeletal pin sites after surgical fracture repair may indicate infection or displacement of the pins. Pin displacement may compromise blood flow to the leg. The nurse should assess the neurovascular status of the limb, but this does not take priority over a basilar skull fracture. Educational objective: A client with signs of basilar skull fracture (eg, periorbital hematomas, bruising behind the ear, leakage of cerebrospinal fluid) requires immediate cervical spine immobilization, neurologic assessment, and airway, breathing, and circulation support. Copyright © UWorld. All rights reserved. A client with a history of a seizure disorder has a seizure while sitting in a chair. Which nursing interventions are appropriate during the seizure activity? Select all that apply. 1. Administer oxygen as needed if client becomes cyanotic Insert a flexible nasopharyngeal airway for airway protection 2. Move the client from the chair to the floor to prevent a fall 3. Record the duration of seizure activity for documentation 4. Restrain the client's arms and legs to prevent injury 5. Explanation: During seizure activity, the priority is client safety. Nursing interventions include: • Assist seated or standing clients to lie down, while protecting the head, and position on the side to maintain a patent airwayand prevent aspiration (Option 3). • Loosen restrictive clothing and clear the area near the client (eg, furniture corners, sharp or hard objects) to prevent injury. • Administer oxygen as needed in response to signs of hypoxia (eg, cyanosis, pallor) (Option 1). • Record and document the time and duration of the seizure (Option 4). (Option 2) Although clients may require oxygen if they are symptomatic (decreased oxygen saturation level), artificial airways or other objects are never inserted into the mouth or nose during a seizure due to risk of trauma. A nasopharyngeal airway would not prevent the tongue from obstructing the airway during a seizure. When seizure activity has stopped, suctioning and/or insertion of an oral airway may be necessary if the client's airway is obstructed. (Option 5) The client should never be restrained during a seizure. Strong muscle contractions occur during seizures; therefore, if the client is restrained, injury could occur. Educational objective: During seizure activity, the priority nursing interventions are to assist the client to safely lie down (if seated or standing), position on the side to maintain a patent airway, loosen restrictive clothing, provide oxygen as needed, and remove objects from the immediate area. The nurse also documents the time and duration of seizure activity. Copyright © UWorld. All rights reserved. Leadership & Management Concepts Confidentiality Test Id: QId: 34938 () 18 of 75 The nurses on a medical-surgical unit maintain a shared social media page. Which social media posts written by nurses breach client confidentiality? Select all that apply. "I'm going to private-message everyone a cute story about our sweet client with dementia." 1. "It breaks my heart that our paraplegic client was so neglected by her husband." 2. "So proud of how well our nurses worked together yesterday, despite how busy we were!" 3. "The client in room 5 is positive for influenza, so please remember your flu vaccines!" 4. "Wash your hands well if you had room 4 this week! Cultures are now positive for Clostridium difficile." 5. Explanation: Nurses are ethically and legally obligated to prevent breaches of confidentiality when using social media. Nurses should protect client confidentiality and safeguard any protected health information (PHI) learned during care. PHI may include the client's name, diagnosis, history, examination results, or treatment and may be discussed only in a private setting with staff members who are directly involved in the client's care. When used responsibly, social media can be a valuable tool for networking with colleagues, sharing professional information, and supporting peers (Option 3). However, careless use of social media that reveals client PHI, even unintentionally, can prompt disciplinary action from employers and regulatory boards. (Option 1) Sharing information in private messages or using social media privacy settings does not protect client confidentiality. Once PHI has been shared through social media, it can be copied or shared again by others and can always be retrieved, even after deletion. (Options 2, 4, and 5) Sharing PHI while referring to a client by a diagnosis, nickname, or room number does not protect the client's confidentiality. Even if a client or group of clients is referred to in a general way without using names, nonspecific information can still reveal clients' identities to a third party. Educational objective: The nurse is responsible for protecting client confidentiality and preventing inappropriate sharing of protected health information (PHI). Sharing a client's PHI on social media breaches confidentiality, even if the client's name is not identified or sharing is in a private message.