UWorld.exam.2.2020

The nurse is caring for a client with a central venous catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that the client has a temperature of 102 F (38.8 C). Which new prescription from the health care provider should the nurse implement first? 1. Administer ondansetron 4 mg IV push PRN for nausea or vomiting [3%] 2. Document the occurrence and notify the hospital's epidemiology team [1%] 3. Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV [13%] 4. Obtain blood cultures and discontinue the central venous catheter [81%] Central venous catheters (CVCs) are used in the treatment of clients who require long-term IV access or are prescribed hypertonic solutions (eg, total parenteral nutrition) or vesicant medications. CVCs can serve as a portal of entry for bacteria, which increases the risk of developing serious bloodstream infections. Nurses caring for clients with CVCs should report any new or worsening signs of infection (eg, fever, chills, erythema at the CVC site) to the health care provider because central line–related bloodstream infections (CRBSIs) require prompt treatment to prevent possible sepsis. In response to a possible CRBSI, the CVC should be removed as soon as possible to prevent continued exposure to the infection source. Blood cultures should be obtained before initiating antibiotic therapy, as antibiotics may contaminate the sample and prevent identification of the infectious organism (Option 4). (Options 1 and 2) Administering medications for comfort, completion of documentation, and facility-based report protocols should be done as soon as possible. However, to prevent progression to sepsis, treatment of a suspected CRBSI should not be delayed. (Option 3) Initiation of antibiotics is essential in treating infection and preventing its progression. However, the nurse should first draw blood cultures and remove the CVC, if possible. Educational objective: When caring for a client with signs of a central line–related bloodstream infection, the nurse should obtain blood cultures and remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management, documentation) should be done after initiating treatment of the infection. Additional Information contact: Pharmacological and Parenteral Therapies NCSBN Client Need 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%] 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. Additional Information Psychosocial Integrity NCSBN Client Need 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. Steps for indwelling urinary catheter insertion for the male client include:  Perform hand hygiene and open sterile catheterization kit (Option 3).  Apply sterile gloves and place sterile fenestrated drape with opening centered over penis (Option 2).  Maintaining sterility of gloves, 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.  Firmly grasp penis with nondominant hand, retracting foreskin if present. Nondominant hand is now considered contaminated and remains in this position for duration of procedure (Option 6).  Use dominant (sterile) hand to cleanse in a circular motion from the meatus to the glans with antiseptic solution using cotton balls or swab sticks. Use new cotton ball/swab stick with each swipe (Option 4).  Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5).  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, apply sterile gloves and place sterile fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse from meatus to glans using dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon. A client is in cardiac arrest, and resuscitation efforts are in progress when the client's spouse arrives. The client's spouse insists on coming into the room. How should the nurse respond? 1. Allow the spouse into the room and provide a chair [81%] 2. Call the chaplain to sit with the spouse outside the room [4%] 3. Have the unit secretary escort the spouse to the waiting room [10%] 4. Tell the spouse that the resuscitation is too graphic to be witnessed [3%] Allowing family to be present during resuscitative efforts and invasive procedures can help the family process and cope with the client's condition, alleviate fears and anxiety, and facilitate the grieving process if the expected outcome is poor. The nurse should permit the client's spouse to enter the room and provide a location to observe (out of the care team's way) and another nurse should explain the treatment measures that are occurring (Option 1). (Options 2 and 3) Chaplains and other interprofessional team members may be helpful in answering questions and providing resources for the client's spouse, but the spouse should not be barred from the client's room. (Option 4) The nurse should exercise the ethics of autonomy in allowing the client's spouse to form an independent judgment and decision on viewing resuscitative efforts. Educational objective: During resuscitative efforts and invasive procedures, the nurse should allow family members to be present if they desire. Allowing family members to be present helps with coping, alleviates fear and anxiety, and facilitates the grieving process in the case of a poor outcome. The charge nurse is responsible for making room assignments for multiple clients. Which pair of client assignments to a shared room is appropriate? 1. Client with blood loss anemia and client with intractable diarrhea [11%] 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%] 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%] 3. Explain the client's wishes to the client's child [79%] 4. Offer to call the hospital chaplain to provide support [4%] 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. 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%] 4. Peripheral arterial disease [75%] 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. 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%] 2. Stage2 [75%] 3. Stage 3 [12%] 4. Progress notes Stage 4 [1%] Shallow, open area with clean, dark pink wound bed about 1 cm in diameter noted on coccyx. Surrounding area is slightly hard and warm to touch with erythema. Foam dressing clean, dry, and intact. No drainage noted. Enterostomal consult made.________________, RN 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. 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%] 3. 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%] 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%] 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). Medication administration record Allergies: Penicillin Medications Time NPH insulin: 25 units subcutaneously, twice daily 0730, 2100 Regular insulin: Per sliding scale, subcutaneously AC and HS Sliding-Scale Blood Glucose Levels Regular Insulin Dose 150 mg/dL (8.3 mmol/L) 0 units 150-199 mg/dL (8.3-11.0 mmol/L) 4 units 200-249 mg/dL (11.1-13.8 mmol/L) 8 units 250-299 mg/dL (13.9-16.6 mmol/L) 10 units 300-350 mg/dL (16.7-19.4 mmol/L) 12 units 350 mg/dL (19.4 mmol/L) 16 units and notify the health care provider 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. 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. Additional Information Physiological Adaptation NCSBN Client Need 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. 1. Administer potassium replacement [74%] 2. Administer the dose of amiodarone [10%] 3. Attach cardiac defibrillator pads [5%] 4. Notify the health care provider [10%] Laboratory resultsSodium140 mEq/L (140 mmol/L)Potassium3.0 mEq/L (3.0 mmol/L)Magnesium1.8 mg/dL (0.9 mmol/L)Creatinine1.1 mg/dL (97 µmol/L) Medication administration record Allergies: None Medications Time Aspirin 81 mg PO daily 0900 Amiodarone 200 mg PO daily 0900 Potassium replacement protocol If serum potassium is: ≤3.2 mEq/L (3.2 mmol/L) Administer potassium chloride 40 mEq PO every 2 hours x 2 doses 3.3-3.8 mEq/L (3.3-3.8 mmol/L) Administer potassium chloride 40 mEq PO x 1 dose ≥3.9 mEq/L (3.9 mmol/L) No treatment Repeat serum potassium levels 2 hours after completion of potassium replacement. If creatinine 1.5 mg/dL (133 mol/L), do not � initiate protocol. Call health care provider for specific orders. 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. 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%] 2. Client 3 hours post coronary artery stent placement via femoral approach and reporting severe back pain [73%] 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%] 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. Additional Information Management of Care NCSBN Client Need There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage victims. Which client should the nurse send to the hospital first? 1. Client who has partial-thickness burns on both hands [4%] 2. Client who is screaming and has a left lower arm laceration [3%] 3. Client with a broken, protruding right tibia and gray, pulseless foot [73%] 4. Client with a gaping head wound and Glasgow Coma Scale score of 3 [19%]