Restrictive jewelry and clothing are removed immediately from the burn victim to prevent circumferential constriction of the torso and extremities. Examination of the fingers and interference with treatment may require removal of jewelry, but the primary reason is option 2. Scissors needs to be kept at the bedside of a client who has a Sengstaken-Blakemore tube. If the tube becomes dislodged and the client cannot breathe, the nurse cuts the tube to allow the balloons to deflate and restore a patent airway. A suction machine and oxygen are generally helpful airway adjuncts, but they do not apply to this situation. A laryngoscope is used to insert an endotracheal tube, but it does not apply to this question. A superficial thickness burn, such as sunburn, involves only the epidermal layer of the skin. The color ranges from pink to bright red and small painful blisters may form. Tanning and sun exposure can increase susceptibility to skin cancer and not all individuals use a sunscreen or consider tanning as having serious consequences. Moisturizing the skin helps decrease dryness that can aggravate pruritus. Soaps and hot water are also drying to the skin. Tepid water and a mild soap should be used and it is not necessary to take a bath daily. Oral intake should be increased to bring extra moisture to the skin, and only those perfumes/lotions with alcohol should be avoided. Staphylococcus aureus is the most common organism causing folliculitis, furuncles, and carbuncles. The red lesion noticeable after shaving is common in inflammation of the hair follicle. Hair loss occurring with tinea capitis is usually temporary but can be of extreme concern for a female. The other responses are incorrect for this disorder. Symptoms may resolve quickly after a few days, but the full course of prescribed medication for antifungals (7 to 10 days) should be used to prevent recurrence. The combination of moisture and the rubber boots contribute to fungal growth. Wearing clean cotton socks daily and changing them frequently decreases the moist environment of the feet. The other two options should not be problematic. Plantar warts occur at pressure parts on the soles of the feet, which prevent the wart from growing outward so they extend deeper and become painful. Increased pain, fever, drainage, or spread of blisters can indicate a secondary infection. The disease is contagious to people who have not had chickenpox. Secondary occurrences are rare. Antiviral medications, antipruritics, and pain medications are usually prescribed. Fluid shifts from the intravascular compartment to the interstitial compartment due to damage to the cells permeability, causing a drop in blood pressure and edema. Option 2 does occur in the beginning, but is not the reason for administering fluids. Notice the question asks about initially; options 3 and 4 would be appropriate rationales for decreasing fluid later on. An Ewald tube is a large-bore tube used to evacuate stomach contents rapidly following poisoning or overdose. Minnesota and Sengstaken-Blakemore tubes are used for clients with bleeding esophageal varices. A Miller-Abbott tube is a nasoenteric tube used to decompress the bowel with small bowel obstruction. The major etiological factor in basal cell carcinoma is solar radiation. An outdoor construction worker is more prone to constant sun exposure and for long periods of time. Chemicals (options 1 and 4) and radiation (option 2) are not causes. A waterproof or water-resistant sunscreen with SPF 15 or more should be used before every exposure to the sun. Senile lentigo occurs on UV light-exposed skin of older Caucasian adults and is benign. It is commonly called "liver spots." Option 2 is premalignant lentigo; option 3 is squamous cell carcinoma; and option 4 is commonly called benign lentigo. Shampooing alone is not enough to remove the eggs; manual removal with a comb is necessary. Also, NIX does not need to be repeated in 7 to 10 days, it is a one-time treatment. The stuffed animals and pillows must be washed but do not need to be discarded. Herpes zoster is believed to result from reactivation of a varicella virus that has remained in the sensory dorsal ganglia after a childhood infection of chickenpox. A client with previous reactions to insect bites may have a severe reaction to a large number of stings by hornets. Options 1, 2, and 4 are characteristic of insect bites and should be watched closely. Option 3 is extremely concerning and could mean an anaphylactic reaction has begun. The lesions of scabies are characteristic: small red-brown burrows sometimes covered with vesicles. The collection of lesions appears as a rash. The other responses do not have these classic characteristics. True urticaria lesions do not last longer than 24 hours. If a lesion lasts longer than that time, other differential diagnoses must be investigated. Treatment of superficial thickness or first-degree burns includes cleansing with a mild soap such as Phisohex, topical anesthetics as needed, and no dressings. Seborrheic keratosis appears as brown "stuck-on" spots over the trunk, may bleed when irritated by clothing or picking, are usually benign, and occur in the middle aged. Tuberculosis is highly contagious and spread by inhalation of airborne droplets. Airborne precautions would be initiated, requiring everyone to wear a special particulate respirator fit-tested mask. Individuals who have had tuberculosis in the past can be re-exposed and develop the active form of the disease again. The risk of aspiration with gastric lavage is of concern to the nurse. For this reason, observation of respiratory status, including respiratory rate and breath sounds, is of great concern. Other vital signs are also important as a measure of general condition but are not focused on detection of complications of this procedure. Urine output is of general concern, but peripheral edema is not a priority. Although option 4 is true, option 1 is the appropriate rationale for use of an antihistamine for most skin rashes. Option 2 is not therapeutically stated and option 3 avoids the client’s question. The rehabilitative stage of burn injury is to return the client to the highest level of health restoration, which includes physical therapy, occupational therapy, psychological, cultural and spiritual counseling if needed. By the time the client is ready for rehabilitation, the concerns for shock, electrolyte, and fluid imbalances should be lessened. Remember that according to the Rule of Nines, the anterior chest is 18 percent and both arms are 9 percent each, totaling 36 percent. Contact dermatitis is a type of dermatitis caused by a hypersensitivity response or chemical irritation. Tinea corporals are a fungal infection of the body called ringworm. The most common lesions are large, circular patches with raised, red borders of vesicles, papules, or pustules. Signs of infection may include fever, chills, erythema, tenderness, drainage, and malaise. A healthcare provider should be notified. Coal tar shampoo is a treatment option for psoriasis of the scalp. Folliculitis and cellulitis are bacterial infections requiring antibiotics. Pediculosis is head lice, which requires a shampoo such as Nix or Kwell. Clients with herpes zoster have impaired skin integrity and pruritis with scratching along with possible excoriation, which causes a high risk for secondary bacterial infection. Altered comfort would also be a diagnosis but is not one of the options. Most burns that occur at home are caused by hot water or steam. Lowering the temperature setting of the hot water heater is a first-line prevention measure, especially with children present. A contact dermatitis common to healthcare providers is latex glove allergies. All options could be correct but the addition in the stem of the question about the client's field of work should direct the learner to the correct option. Other common causes of contact dermatitis include chemicals, soaps and detergents, but most agencies use milder forms. The nurse should squeeze the collecting chamber to reestablish negative pressure and suction to the device. The nurse then wipes the port with alcohol before closing to reduce the risk of infection. The tubing should always be free of kinks to prevent obstruction. By altering the skin integument, all three concerns place the client at risk for infection by <i>Staphylococcus</i>, which is normally found on the skin. Psoriasis can also be triggered by a respiratory infection, particularly pharyngitis caused by <i>Streptococcus</i>. Pain is usually not a concern in psoriasis and will depend on the stage of a burn. Options 2 and 3 could be correct, but notice the stem asked for the priority diagnosis. Dietary restrictions have not been found to be clinically relevant in the severity or cause of acne. Stress should be placed however on healthy food preferences. A bulla measures > 0.5 cm. A papule is solid; a vesicle measures < 0.5 cm; and a pustule contains purulent exudates. The mole in option 1 meets the criteria of the "ABCD" rule: the size has increased in diameter over two months, the mole has two colors, the center is black, and the border is irregular. Herpes simplex virus 1 may reappear in times of reactivation. The infection is described as a vesicular lesion that occurs on the oral mucosa (lips, mouth), making option 3 incorrect. Option 4 is false because herpes lesions are painful and because the description is incorrect. The client with herpes zoster may experience impaired skin integrity and pruritis in which the client may frequently scratch the lesions, contributing to a secondary bacterial infection. Cool environments should be maintained because heat and scratching will make the pruritis worse (option 4). Options 1 and 2 are irrelevant to the client's case. The common wart, flat wart, and filiform wart are not painful, whereas the plantar wart is often painful. Vitiligo is a slowly progressive depigmentating condition of the skin caused by disappearance of melanocytes. Eczema is an inflammatory condition in which the skin appears erythemic, dry, and thickened. Psoriasis is a chronic inflammatory condition in which lesions appear whitish and scaly and commonly appear on the scalp, knees, and elbows. Contact dermatitis is an eruption of the skin related to contact with an irritating substance or allergen. Most burns occur at home caused by hot water or steam. All other aspects are important to general prevention but temperature setting of the water is a first-line prevention. In the emergent stage, the nurse determines the cause and extent of the burn and determines first aid measures that were used. Gender is not a factor in burn examination. A Penrose drain allows free flow of abdominal drainage out of the abdominal cavity and onto thick layers of gauze dressings that are placed around the drain. It is used when moderate to large amounts of drainage are expected, as with extensive abdominal surgeries. The nurse should monitor the skin for irritation and breakdown from contact with abdominal skin if dressing changes are not done on time or if an insufficient number of gauze dressings are used around the drain. The drain may be advanced over days for gradual removal. The surgeon does not need to be notified of moderate amounts of drainage because it is expected. The location of the rash helps identify the possible offending antigen. Age, gender, and recent travel are less helpful in identifying the etiology of the pruritic lesion. Psoriaris can often be brought on by a respiratory infection, particularly streptococcal pharyngitis. The other responses are insignificant findings as they relate to psoriasis. Psoriasis is characterized by the presence of silvery plaques, particularly on the extensor prominences, that bleed when scales are removed. The other disorders listed are not characterized in this way. Even though all these problems may cause itching, a classical symptom of scabies is pruritus with worsening at night. The mites tend to have increased movement at night, which accounts for the worsening symptoms at that time. Dietary restrictions were once believed to be necessary to decrease acne, but this has not been clinically relevant or supported in research. Stress and the use of moisturizers and oil-based cosmetics do seem to affect the severity of the disorder. Lindane (Kwell) can cause neurotoxicity in young children and nursing/pregnant women. This is not a concern with the other products listed. Plastic shoes or sandals increase moisture collection in the feet. This should be avoided as it increases the risk of recurrence. The other options describe helpful measures to prevent recurrence of <i>tinea pedis</i>. The consistent use of condoms helps protect from spreading herpes virus type 2 to other partners. The other options do not represent circumstances that provide any protection against sexually transmitted diseases. A wart is described as being a round, raised, firm lesion of the skin that may have ragged borders. Warts do not contain fluid and generally have the color of normal flesh (options 3 and 4). Generally only plantar warts on the feet are associated with pain. To improve folliculitis, the use of antibacterial soap daily along with good hand washing will control and prevent spread of the infection. Isolation is not needed. The site should also be allowed to air dry and should not be covered with a bandage. The head of bed is raised first because airway and breathing are the priority. Next, the tube is measured for accurate length of insertion. The tube is then advanced past the nasopharynx. The client is then asked to take sips of water to help with tube advancement into the stomach. Finally, the tube is taped when placement is assured. Good hygiene is recommended to help to prevent spreading the infection to other family members. Option 1 is false. Impetigo is contagious and antibiotic therapy is the recommended treatment (options 3 and 4). The epidermis protects the tissues from damage and prevents fluid loss of the body. The dermis regulates body temperature (options 2 and 3). Option 1 is false. The fastest and most cost-effective method to diagnose a fungal infection is using KOH preparation to reveal more clearly the spores and hyphae of each fungus. A macule is a nonpalpable flat lesion. All the other lesions listed are elevated. If needed, refer back to Table 10-1 (Primary Skin Lesions) in the textbook, for detailed descriptions. Satellite lesions are maculopapular areas outside an area of original infection and are characteristic of candidiasis. Satellite lesions are not characteristic of the other conditions listed. Herpes zoster presents with vesicular lesions that could become infected if the skin is not monitored carefully. This is the priority concern for the elderly client. There could be a possibility of injury and ineffective coping, however these are not the priority concerns. Risk for fluid volume deficit is irrelevant to the situation described. A systematic skin inspection should be done at least once a day with particular attention to the bony prominences. Weekly skin inspections are too infrequent to meet the needs of the client and evaluate how the ulcer is healing. The other interventions listed are appropriate to the care of a client with a pressure ulcer. Rehabilitation measures focus on the prevention of contractures and scars. The client is taught to continue ROM exercises to enhance mobility and to support the injured joints. Options 1, 3, and 4 should have been completed prior to the rehabilitative phase of burn management. First-line therapy consists of using topical retinoids or benzoyl peroxide. Antibiotics and accutane are used for moderate and severe cases. Corticosteroids are not to be used on the face because of absorption of the medication. All other lesions are benign, but lentigo melana (pre-melanoma) may develop into a true melanoma over time. For an intradermal injection, the needle enters the skin at a 10- to 15-degree angle and the medication forms a bleb under the epidermis. The other angles would permit the medication to be deposited too deeply into either subcutaneous or muscle tissue, depending on needle length and size of client. Reexposure to a bee sting may precipitate a more severe reaction and require emergency care. It would be inappropriate to give the client false information that reactions will decrease. Options 1, 3, and 4 should be included in client teaching. Sodium levels decrease and potassium levels increase secondary to massive fluid shifts into the interstitium and release of potassium from cells that are destroyed. The other responses are incorrect. Hot water can exacerbate symptoms of eczema and increase pruritus. Tepid water feels more comfortable than cool water. Strong or harsh soaps and perfumed products could be irritating to the skin and should not be used. Impetigo remains contagious for 48 hours after antibiotics are begun. The presence or absence of crusts does not address the issue of contagion. The characteristic appearance of pediculosis capitus (lice) is nits that adhere to the hair shaft about 1/4-inch from the scalp. They cannot be easily brushed off as dandruff. Scabies, eczema, and impetigo do not typically appear on the scalp and present as skin lesions elsewhere on the body. The fluid shift that occurs in burns leads to edema, so the burned extremity should always be elevated above the level of the heart. Eczema in a young child tends to be characterized by dry, scaly crusts that are well circumscribed. Pruritus is always present. About 60% of children with eczema have a family history of asthma or other allergy. Scabies is caused by contact with a mite; impetigo and cellulitis are bacterial infections. Sinusitis frequently precedes periorbital cellulitis. Facial cellulitis may be preceded by otitis media. A dog bite could cause cellulitis anywhere. Sun exposure causes a thermal injury. The only way to eliminate the infectious agent is to complete the prescribed course of antibiotics. Strict bed rest is not indicated, although the child initially may feel more comfortable resting with the extremity elevated. Fluid intake has no effect on the course of the infection, which is not contagious; therefore, visitors do not have to be limited. Several factors indicate the size and length of the needle to be used: the muscle, the type of solution, the amount of adipose tissue covering the muscle, and the age of the client. A smaller needle such as a 23- to 25-gauge needle 1-inch long is commonly used for the deltoid muscle. More viscous solutions require a larger gauge (e.g., 20 gauge). The other answers are less appropriate because of incorrect needle length or gauge. Lice is spread by sharing combs and hats. Close contact is required as the lice do not jump or fly. A teenager can and should be part of the treatment plan. If itching is avoided to prevent excoriation and secondary infection, scarring is unlikely. Improvement is often slow, and the problem may persist into adulthood. Food avoidance will not change the course of the disease. Handwashing is always the most important action that a nurse can take to prevent the spread of infection. Merely applying ointment or covering the site does not address the spread of infection, nor does isolation of a child at home. The nurse would teach the family the importance of good handwashing. Live nits can hatch up to 8 to 10 days later, so it is important to remove them from the environment. Soaking combs in a Lysol or anti-lice shampoo mixture will kill lice or nits (boiling water will not). Dry cleaning is not necessary because home washing and drying on hot settings will be sufficient to kill lice and nits. Use of commercial sprays is not recommended. Each member of the family should be examined so those infested can be treated. Sharing of haircare material spreads lice and should be avoided. The anticipated appearance of partial thickness burns is bright red skin with blisters of varying sizes. A superficial burn typically only has pink or red skin. A full thickness burn may be dark in color, from deep red to black. Permethrin is applied to cool dry skin after a bath, but only from the neck down. The child may dress after the lotion is applied. It should be washed off after 8 to 12 hours. A second application is often prescribed for 1 week later. A recent history of otitis media is often present in children with facial cellulitis. Sunburn would present as more diffuse and widespread redness. An insect or animal bite can be a cause of cellulitis, but in the case of cellulitis on the face the nurse would question a recent history of an ear infection first if a bite was not obvious. Dental caries are unrelated. Lice can only be passed by direct contact because lice do not fly. The usual mode of transmission is sharing of hats, combs, brushes, or hair ornaments. Being close to someone in a classroom, bus, or car does not presuppose direct contact with hair or nits that have been shed on hair. Keeping the skin well hydrated will prevent the need to scratch dry skin that can lead to excoriation and secondary infection. Eczema is not infectious, nor is it managed by dietary restrictions. Pruritus, not pain, is associated with eczema. Because he was in close proximity to the fire and tried to put it out, he is at risk of having inhaled smoke and therefore having a compromised airway. Other physiological signs will be of next highest priority, such as pain. Infection would be a third priority since it would not happen immediately, and psychosocial concerns are addressed once physiological needs have been met. The ventrogluteal site is in the gluteus medius muscle with the greater trochanter, the anterior-superior iliac spine, and the iliac crest as the landmarks. The vastus lateralis and the rectus femoris are located on the thigh, and the dorsogluteal is located on the buttocks, making the other options incorrect. The predictable rate of absorption makes IV morphine useful in treating severe pain. As part of the physiological stress response, blood is shunted away from the gastrointestinal tract, making oral absorption rates less predictable. The IV route will not prevent ileus and may actually have greater side effects because of rapid onset of action. The half life of the drug is not relevant to the question asked. Permethrin is the over-the-counter treatment of choice for head lice. Other choices are topical agents, but they would not be used for lice. Option 1 would be used for infection, while options 2 and 3 would be used to treat burns. Pediculosis capitus is head lice. The nits (eggs) are usually found at the nape of the neck or behind the ears. Head lice do not move away from the scalp to lay eggs, therefore, other choices are not appropriate. At birth, the infant's skin is thin with little subcutaneous fat. In addition, the infant has a greater proportion of body surface area relative to the amount of water present in the skin. Lanugo is shed within a few weeks of birth and has no relationship to heat loss. Sebaceous glands and apocrine glands are immature in the infant but are not related to heat loss or temperature regulation. Use of a mild soap such as Dove or Tone prevents the skin from excessive dryness in atopic dermatitis. Hot water is drying to the skin so should be avoided. Fabric softeners and many lotions contain perfumes that are irritating to the skin so should also be avoided Sulfamylon is a topical antibiotic that is used on burns to prevent bacteria from infecting the burn site. The other options are incorrect statements The saliva, ova, and feces of the scabies mite triggers an antigenic response that causes intense pruritus. Pain is not present nor is scarring. Antibiotics would only be added to the regimen if the itching leads to scratching and breaks in the skin with development of a bacterial infection. Scabicides are used to kill the mites causing scabies. By the teenage years, eczema presents as large patches of thickened dried (lichenified) skin. Areas of excoriation, crusts, and papules characterize eczema in infants and younger children. Bullae are not present in eczema The cause of cellulitis is a bacterial infection, often preceded by trauma. Colds and flu illness are viral infections and are not related to cellulitis; thus further teaching is needed about the cause. The child should complete all medication ordered and is not contagious so company is allowed. If further swelling occurs, it could indicate the infection is not responding to the antibiotics. Topical steroids are readily absorbed through the skin; therefore, they should be applied sparingly over affected areas only. They are applied three to four times daily as ordered over clean dry skin. Pulling the ear pinna down and back straightens the ear canal, allowing the drops to enter the ear. Not touching the dropper to the ear is a point of aseptic concern but has slightly lesser priority than correct instillation procedure. The infant should remain on the side for approximately 5 to 10 minutes after instillation and then placed on the back. It is unnecessary to wear gloves. Eczema is also called allergic dermatitis. It is not contagious. Scabies is caused by the mite and is highly contagious. Pediculosis capitis is an infestation with lice and can spread. Impetigo is an infection caused by staphylococci and streptococci and can also be spread on contact. Burns that are circumferential are always considered major because they can cause edema that restricts blood flow to an extremity. Therefore, it is important to check pedal pulses in this child. Pedal pulses should always be monitored, but the nurse would be more alert to the possibility of impaired circulation in a child with a circumferential burn. Amoxicillin is given only by the oral route. Because of this, the nurse cannot give the dose and must question the order. There is no problem with the dosage or the frequency. Candida infections are a common side effect of antibiotic therapy due to alteration of the normal bacterial flora by the antibiotic agent. The white patches in the mouth do not represent allergic reaction, herpes simplex infection, or mumps. The nurse must emphasize the importance of completing the full course of antibiotic therapy, even though symptoms may have resolved before the antibiotic is finished. The nurse must observe the post-tonsillectomy client for signs of excessive bleeding or hemorrhage from the operative site. In the posterior pharynx, the bleeding can be concealed by the child swallowing the blood. Applying heat to the neck, warm liquids, or giving a straw would be contraindicated, as this could cause bleeding. The common cold is a viral infection. It is self-limiting, with symptoms lasting about 4 to 10 days. Therefore, emphasis is on symptom management. Antibiotics are not indicated for a viral infection. Nutrition and injury prevention are general concerns for a child, but do not relate to the question. Turning up the volume loudly is a behavioral indicator suggesting hearing impairment. The other options are behaviors that are not consistent with or indicative of hearing impairment. Development of parent–infant attachment is important in promoting developmental progress. Parents are encouraged to talk, sing, and interact with their baby to learn about their infant’s response, and to provide appropriate stimulation at 1 month of age. The other options are incorrect statements to the parents. Purulent exudate and crusting are characteristics of conjunctivitis. Conjunctivitis associated with foreign body can cause severe eye pain. Serous drainage and periorbital edema are not associated with conjunctivitis. The essential parts of a drug that must be present in order to implement the order are name of the drug, date and time the order was written, dosage, route, frequency, and signature of the person writing the order. Nurses may not independently administer a medication without all of the essential parts or determine a route based upon the client’s condition. Administering Tylenol without a medical order constitutes practicing medicine without a license. In hospitalized clients, an order must be present for any medication to be given. The infected area should be cleansed with a disposable tissue after a single use. Handwashing is important to prevent the spread of infection. Items that come in contact with the infected eye are considered contaminated. Saline nose drops will loosen secretions and crusting. The bulb syringe is necessary because infants cannot blow their own noses. The other options are incorrect nursing actions for this purpose. The procedure for instilling eye ointment begins with washing hands and applying clean gloves. After ensuring the medication is at room temperature and removing any discharge from the eye, the lower lid is pulled down to make a sac and the ointment is applied there. The tip of the tube should never touch the eye surface, and the tip is held parallel to the eye so as to prevent injury if the child should move suddenly. The nurse observes increased swallowing rather than decreased swallowing when there is bleeding following tonsillectomy. The child may also spit out red blood from the mouth at this time. Tachycardia and hypotension are late signs of significant blood loss, and these would be consistent with active uncontrolled bleeding. The child would not exhibit hypertension or bradycardia. Age and developmental level affect the pain response of a child. Infants are less able to communicate their feelings than an older child and usually demonstrate restlessness and crying behaviors. Adolescents are able to describe their pain sensations. Children do not generally recover from painful procedures more quickly than adults (option 2). Children do not have higher pain thresholds than adults (option 4) and do require opioid analgesics (option 3). Uncooperative pediatric clients may need to be gently restrained long enough to accomplish the examination or procedure that is necessary. Parents may be able to assist with this effectively. A 2-year-old will not listen to explanations (option 1) and is not likely to respond to pleas for acting maturely (option 3). The exam should not be postponed until the next yearly exam (option 2). One of the greatest fears of preschoolers is fear of mutilation. Options 2 and 3 (immobilization and premature death) are not developmentally appropriate concerns of a preschooler. Unfamiliar caregivers (option 4) could be a concern for any child, but is less so than the fear of mutilation for a child of this age. The tympanic method is preferred. It is quick, accurate, and convenient. Oral temperature can be obtained on a cooperative child age 3 and older. A rectal temperature is obtained as a last resort, when other methods are not possible. Crusting of dried exudate is common with bacterial conjunctivitis. The parents will need to know how to administer the eye drops or ointment. Washing the hands frequently will reduce the spread of the infection, which is hand-to-eye and spreads easily to other children. The use of antihistamines and topical anesthetics is not indicated in the management of bacterial conjunctivitis. Increased fussiness and elevated temperature are expected symptoms of viral pharyngitis in infants. A cough may occur because of local irritation. Symptoms of ear infection can occur because of secondary infection and should be reported to the health care provider. A nurse can take a telephone order from a physician. When the nurse documents the order, “telephone order” and the physician’s name must be written on the order and the physician must cosign the order, usually within 24 hours. The other answers are incorrect. Option 1 is a false statement, option 3 fails to note that it is a telephone order, and option 4 is unnecessary. Eliminating contact or sharing of items with the infected person can reduce the potential spread of infection to other family members. Medication should be used as specifically ordered (option 4). Medication should not be saved for use during future illness (option 2). The dropper should not be inserted “as far as possible” due to risk of injury to the infant. Rheumatic fever can follow an infection of certain strains of group-A beta-hemolytic streptococci. Otitis media is an ear infection that can be caused by many organisms, but is not the priority concern related to a strep infection. Diabetes insipidus and nephrotic syndrome are pituitary and renal disorders, respectively, but are not related to sequelae of strep infection. Pulling the pinna down and back straightens the auditory canal of an infant, permitting the instillation of eardrops. Pulling the pinna up and back is the proper method for straightening the canal of an adult client. The other options are incorrect. A normal tympanic membrane is pearly gray and mobile when a puff of air is applied to it using an attachment on an otoscope. A red, bulging non-mobile tympanic membrane would be typical with otitis media, a common ear infection in young children. The child is no longer considered contagious after completing 24 hours of antibiotic therapy. Until 24 hours of antibiotic therapy, the child would be contagious. Exposure to secondhand smoke increases incidence of otitis media so this should be avoided to reduce the risk of future episodes of otitis media. Preventing the infant from falling asleep with a pacifier will also help because saliva from sucking cannot accumulate and enter the Eustachian tube. Infants who feed in the supine position have an increased risk of otitis media. Medications such as a nasal decongestant would have side effects and should be avoided unless specifically needed. Warm compresses will not prevent future infection. Although strabismus is associated with a positive family history in many cases, the mode of inheritance is unknown. The pathophysiology is misalignment of the eyes causing the brain to stop receiving the signal of the affected eye. Without treatment, including patching, corrective lenses, and muscular exercises, the damage will become permanent. The child should be positioned where pressure to the nostrils can be applied and upright to avoid excessive amounts of blood swallowed. Hyperextending the head opens the airway and increases the risk of aspiration. Positioning the client in Trendelenburg position also increases the risk for aspiration by allowing blood to accumulate in the nasopharynx. Early identification and treatment of visual impairment can prevent significant vision loss in children at risk. For this reason, screening should be started at birth. Symptoms of decreased visual acuity are squinting to focus, excessive tearing of the eyes, and rubbing of the eye. Gloves are removed first because they would be most contaminated. The mask would be removed next, followed by the gown. Eye protection is removed last, followed by washing the hands. Blood levels of two metabolically produced substances, urea and creatinine, are routinely used to evaluate renal function. Both are normally eliminated by the kidneys and are measured as serum BUN and creatinine. The color and odor of the urine are general observations (option 2). Sugar and acetone in urine are found in diabetes mellitus with ketoacidosis (option 3). Serum hemoglobin (option 4) is a measure of the red blood cell count but does not reflect kidney function. To encourage the child to use the weaker, deviating eye and in an attempt to strengthen the muscles of the affected eye, the unaffected eye is patched. Strabismus (or cross-eyes) affects the appearance and visual acuity of the child. This can affect parental relationships. It is not a painful disease and there is no risk for infection. The circulation to the eye is normal. Narrow-angle glaucoma develops abruptly and manifests with acute face and eye pain and is a medical emergency. Halo vision, dull eye pain, and impaired night vision are symptoms commonly associated with open-angle glaucoma. A cloudy-appearing lens is symptomatic of cataract development. As the cataract matures, the red reflex is lost. A sense of a curtain falling over the visual field is associated with detached retina. Eye pain and double vision are not associated with cataracts. The foreign body should not be removed or manipulated. It should be immobilized if possible and the eye covered to protect from further injury. A paper cup can be used in place of an eye patch. Patching both eyes is an appropriate intervention to prevent ocular movement but follows immobilization of the foreign body. Irrigation with water is an intervention for chemical burns to the eyes. Carbonic anhydrase inhibitors are used to decrease intraocular pressure following blunt trauma. Conductive hearing loss results from changes that occur in the external or middle ear. Hearing aids, assistive listening devices (i.e., "pocket talkers"), and reconstructive surgeries can improve or correct hearing loss. Exposure to high levels of noise on an intermittent or constant basis damages the hair cells of the Organ of Corti, resulting in sensorineural hearing loss. Weber and Rinne tests are used to differentiate conductive hearing loss from sensorineural. Tympanocentesis is the aspiration of fluid/pus from the middle ear to identify the causative organism of acute otitis media. Transillumination of the sinuses is a diagnostic tool used to examine for sinusitis. The diagnosis of Meniere's disease is confirmed by electronystagmography, a series of tests to evaluate vestibular-ocular reflexes. A higher incidence of acute otitis media is noted in infants who are bottle-fed in a horizontal position and who live in homes with smokers. The full 10- to 12-day course of antibiotic therapy must be administered. There is no relationship between the ingestion of fruit juices and acute otitis media. Atrophic macular degeneration causes loss of central vision. Magnification devices and enhanced lighting help to promote safety. Peripheral vision remains intact. Although laser photocoagulation is effective for exudative macular degeneration, there is no treatment for the atrophic form. Since macular degeneration is not an infectious process, antibiotic therapy is not indicated. Pilocarpine (Pilocar) is a miotic and the most commonly prescribed drug for glaucoma. Scopolamine (Hycoscine) and atropine are anticholinergics; epinephrine is an adrenergic agonist. All three are mydriatrics. The pupil dilation caused by mydriatrics is contraindicated in glaucoma. Before making a decision about how to infuse the antibiotic, the nurse should check compatibility of the antibiotic with the continuous IV solution. If the drug and the infusion were compatible, they would run together through the same line. If the drug and infusion were incompatible, the nurse would stop the infusion during the period of antibiotic administration and flush the line carefully before and after the antibiotic. It is always inadvisable to start a second IV site unless absolutely necessary. Increasing the IV flow rate constitutes changing a medical order and does not address the issue of compatibility. These symptoms, along with dysphagia, foul-smelling breath, and pain when drinking hot or acidic fluids, are common signs of laryngeal cancer. Chronic sinusitis can produce foul breath and pain or burning in the throat. GERD and CAD may produce epigastric and/or chest pain, but hoarseness and change of voice do not occur. All of the nursing actions listed are appropriate for the client following nasal packing for epistaxis; however, the risk of aspiration is high, and monitoring respiratory function essential. Notice the question asks for the priority intervention. Closed or narrow-angle glaucoma has an abrupt onset and is characterized by severe pain of sudden onset. The pain usually lasts longer than 20 minutes with closed-angle glaucoma. Eye pain that comes and goes quickly can be indicative of allergies. Open-angle glaucoma occurs gradually with no initial manifestations. Pain is not associated with cataracts or retinal detachment. Meniere's disease is associated with vertigo that may last for hours as well as fluctuating hearing loss, nausea, and vomiting. The disorder is unilateral, but because hearing is bilateral, the client often does not realize the extent of the hearing loss. Option 3 is indicative of swimmer's ear, and option 4 is indicative of acute otitis media. Without a lens, the eye cannot accommodate. Since it is difficult to judge distance and climb stairs when the eyes cannot accommodate, for safety reasons the client should have assistance when climbing stairs. Retinal detachment is painless, but eventually floaters and visual loss will be manifested, especially if hemorrhage has occurred. Subconjunctival hemorrhage is a manifestation of blunt trauma to the eye. Halo vision is characteristic of glaucoma. Cholesteatomas are benign, slow-growing tumors of the middle ear that are filled with epithelial cell debris. Untreated cholesteatomas may enlarge to fill the middle ear, destroy the ossicles, and cause profound hearing loss. Option 1 (endolymph) is indicative of Meniere's disease. Options 3 and 4 are distracters. Age-related macular degeneration is the leading cause of loss of vision in clients over 50 years of age. Blunt trauma, exposure to toxins, and allergies are not known causes of macular degeneration. Transillumination of the sinuses in a non-invasive technique used to detect fluid in the maxillary and frontal sinuses. The Weber test differentiates conductive hearing loss from sensorineural hearing loss. Fluorescein staining helps identify corneal abrasions and caloric testing is used to evaluate nystagmus in Meniere's disease. Since the amount of blood lost in a nosebleed can be frightening to clients, anxiety is a priority nursing concern. Blood draining into the nasopharynx poses a risk of aspiration. Risk for infection and pain are appropriate nursing concerns related to nasal packing but are not the priorities. Impaired verbal communication is unlikely. The correct action should be to withhold the medication and call the physician. Nurses cannot independently change the route of a medication. Oral medications should not be administered to clients who are vomiting, which could interfere with the ability to absorb the medication and possibly initiate further vomiting. The nurse should not just omit the dose without notifying the physician of the client’s change in condition. The two major risk factors for laryngeal cancer are prolonged smoking along with concomitant use of alcohol. Although the majority of cases occur in men ages 50 to 75, advancing age does not significantly increase risk. Injury to the larynx and chronic sinusitis are not risk factors. The client with sensorineural hearing loss experiences social isolation and depression and may appear withdrawn. Amplification devices such as hearing aids are helpful for clients with conductive hearing loss but only amplify noxious sounds for the client with sensorineural hearing loss. Antibiotics are not helpful for sensorineural hearing loss, and tympanoplasty is used to correct damage to structures in the middle ear. The best method to improve communication with the client is to face him directly when speaking. Hearing-impaired clients often consciously or unconsciously lip-read to enhance perception. The other options are ineffective and may frustrate or demean the client. Leukoplakia are white, patchy, precancerous lesions; erythroplakia are red, velvety, precancerous patches. Both can be found on the laryngeal mucosa. Biopsies of both types of lesions aids in diagnosing and staging laryngeal cancer. Gonioscopy and tonometry are tests used for glaucoma. Caloric testing is associated with Meniere's disease and central nervous system (CNS) disorders. Ear pain is the primary symptom of otitis media and, in children, may be evidenced by the child's pulling on the ear. Secondary symptoms of otitis media include fever, nausea and vomiting, dizziness, and hearing impairment. Notice the question asks for the primary symptom. Tympanostomy (ventilation) tubes allow air into the middle ear. While in place, it is important to avoid getting water into the ear canal, which could potentially enter the middle ear. The other activities are not risks to the pediatric client with tympanostomy tubes. Presbycusis is the most common form of sensorineural hearing loss in older adults. Meniere's disease in an inner ear disorder that affects primarily middle-aged adults. Otalgia is an earache; otitis externa is infection in the external auditory canal and can occur in clients of any age. Bending over to pick up objects from the floor is contraindicated because it increases intraocular pressure. Activities such as walking on level surfaces, lying on the nonoperative side, and performing simple isometric exercises are not harmful. Amplification is of no help with sensorineural hearing loss and serves only to increase the intensity of distorted sounds. The other options are incorrect. These are the classic symptoms of Meniere's disease. Nystagmus occurs with acute attacks. Headache, double vision, pain, and purulent drainage are not reported. The nurse who prepares the medication must be the nurse to give the medication. It would be prudent for the second nurse to assist the second client so that the first nurse may continue medication administration. Option 2 is incorrect. Option 3 is acceptable but requires destruction of the original medication, which is an added expense. Option 4 is appropriate but does not resolve the issue of the preoperative client. Anticholinergics and antiemetics are used to control symptoms associated with Meniere's disease. Diuretics are used between acute attacks to reduce the volume of endolymph and prevent attacks. Glucocorticoids, beta blockers, and analgesics are not commonly used. Constricting the pupil stimulates the ciliary muscles to pull on the trabecular meshwork surrounding the Canal of Schlemm. This increases the flow of aqueous humor and decreases intraocular pressure. The immediate priority for clients with chemical burns is flushing the affected eye with copious amounts of normal saline or water. Evaluation of visual acuity is an appropriate intervention after flushing. Analgesics, with the exception of topical anesthesia, are not indicated. Antibiotics may be administered after the initial actions have been taken. Clients with retinal detachment frequently report flashing lights and loss of vision commonly described as a curtain being drawn across the eye. Retinal detachment is painless, does not cause increase lacrimation (unless associated with trauma), and does not affect ocular movement. Remember drugs that end in -olol are beta blockers. Beta blockers, when administered as ophthalmic preparations, can produce systemic effects such as bradycardia, hypotension, and bronchospasm. Beta blockers act as central nervous system (CNS) depressants and are used to treat anxiety. Symptoms of acute sinusitis include facial pain, purulent nasal discharge, fever, and headache. Transillumination is a diagnostic tool used to detect fluid in the maxillary or frontal sinuses. Fluid in the sinuses indicates infection. Transillumination is not used to diagnose the other conditions. Although all of the options are appropriate, providing the client with an opportunity to express feelings of anger or fear is the priority. Clients with laryngeal cancer requiring total laryngectomy need permission to grieve for their anticipated losses before mobilizing coping strategies to deal with the surgery and follow-up care. Atrophic or "dry" macular degeneration results from atrophy and degeneration of the outer layer of the retina. In exudative or "wet" macular degeneration, blood leaks into the subretinal space and gradually scar tissue forms. The resulting loss of vision occurs rapidly and is more profound. Exudative macular degeneration accounts for 90 percent of all cases of legal blindness. The trauma resulting from nose picking is a common cause of anterior epistaxis because of damage to Kiesselbach's area, a highly vascular area in the anterior septum. Blood dyscrasias, hypertension, and diabetes are causes of posterior epistaxis. Options 1 and 2 are incorrect. Option 4 is the definition of pneumatic retinopexy. Scleral buckling as described in option 3 is used in conjunction with laser photocoagulation or cryothermy. Medications should not be left at the bedside, with certain exceptions that are ordered in advance (e.g., nitroglycerin and cough syrup). The other answers are not prudent nursing actions because they either fail to ensure that the medication is taken (option 1), waste the nurse’s time (option 2), or invade the client’s privacy unnecessarily (option 3). Blunt trauma does not cause loss of intraocular contents, and no foreign body is present. Constriction of the pupil with miotics is not indicated. Intraocular pressure may increase as a result of the trauma and is prevented by the use of carbonic anhydrase inhibitors. Proper positioning is important after eye surgery to avoid complications. The client should avoid bending, straining, and strenuous activity in order to reduce intraocular pressure in the affected eye. Presbycusis is a term to describe degenerative changes from aging and is associated with loss of the hair cells in the Organ of Corti leading to sensorineural hearing loss. Air and bone conduction are terms applying to conductive hearing loss. The term "central" is not commonly used when referring to hearing loss. Low-sodium diets and diuretics help reduce the volume of endolymph and prevent recurrence. Salted cashews are the high-sodium food in this list. Ninety percent of nosebleeds arise from the anterior portion of the nose known as Kiesselbach's area. Pinching the area for 5 to 10 minutes aids in hemostasis. Nasal packing and cauterization are subsequent treatments if bleeding doesn't subside. The application of warm compresses is contraindicated. Laryngeal cancer spreads by direct invasion into surrounding tissues and by metastasis. The most common site of metastasis is the lungs. Metastasis to other sites such as the brain, breast, and uterus is rare. Intranasal steroids are commonly used to treat sinusitis to reduce inflammation. Nasal oxygen by cannula (which dries the mucous membranes), the use of diuretics, and restriction of oral fluids are contraindicated. Open-angle glaucoma is characterized by halo and blurred vision. The abrupt onset of severe eye pain, a fixed, partially dilated pupil, and increases in intraocular pressure are indicative of closed-angle glaucoma. The normal intraocular pressure ranges from 12 to 20 mmHg. Floaters in the visual field are found with detached retina. A child's Eustachian tubes are shorter and straighter than those of an adult. The other responses are incorrect. The development of cataracts causes scattering of the light entering the eye, resulting in glare. Sunglasses will reduce glare. Night vision declines in clients with cataracts and would be discouraged. Pilocarpine eye drops and carbonic anhydrase inhibitors are used to treat glaucoma. 4 The priority nursing intervention is directed toward maintaining contact of the retina with the choroid and positioning the client so the area of detachment falls against the choroid. Both eyes are patched to limit ocular movement. Retinal detachment is generally painless. Darkening the room is not necessary. Increasing difficulty with central vision and distortion of vision in one eye are common manifestations of macular degeneration. Peripheral vision is usually not impaired. The symptoms are not characteristic of glaucoma or cataracts. Subconjunctival hemorrhage occurs with ocular trauma. A result of 20/120 means that this client can read at a distance of 20 feet what another individual with normal vision can read at a distance of 120 feet. This means that the client is nearsighted in that eye. The other responses are incorrect. Cyclopentolate is a mydriatic and a cycloplegic medication that is used to dilate the pupil and paralyze the ciliary muscles before an eye exam. Carbachol and latanoprost are miotics that constrict the pupil and are used to treat glaucoma. Glycerin is an osmotic diuretic used to treat acute angle-closure glaucoma. It is important to share with the client that lifelong medication therapy is needed to preserve vision. The statement in option 2 is correct also but is not as critical as option 3, since the client has just been diagnosed. Options 1 and 4 are false statements. A cloudy-appearing lens is characteristic of cataract development. Early symptoms of cataract formation include blurred vision and a loss of ability to see colors. A sense of a curtain falling across the field of vision characterizes detached retina. Eye pain and double vision are not symptoms associated with cataracts. A client who is legally blind has either visual acuity no better than 20/200 in the better eye with optimal correction, or has a visual field of 20 degrees rather than 180 degrees. It is essential to determine that the tympanic membrane is intact before completing an otic irrigation. No more than 50 to 70 mL of solution should be drawn up at one time, and the fluid should be at body temperature. The client may be positioned wherever it is comfortable, and needs only a receptacle to hold the drainage, and a waterproof pad to protect clothing. Ear pain is a primary or classic symptom associated with otitis media. Secondary manifestations could include dizziness, vertigo, and diminished hearing in the affected ear. Following ear surgery, clients should avoid activities that could result in increased pressure in the middle ear. These include blowing the nose, sneezing, coughing, or doing any activities that involve holding the breath or bearing down. Talking is an acceptable activity. One gram is equal to 1,000 mg. Use the following formula as one way to set up the problem: Cross-multiply 95 by <i>x</i> and 1,000 by 1 to yield 95<i>x</i> = 1,000. Divide 1000 by 95 to yield 10.52 or 10.5 mL. Otosclerosis is characterized by Schwartz's sign, a tympanic membrane that is reddish or pinkish-orange because of increased vascularity. It would not be pearly white or pale (options 2 and 4), nor would it have a bruised appearance (option 3). The client with Meniere's disease should limit intake of salty foods that could cause an increase in endolymphatic fluid in the inner ear. The other foods listed pose no problem. The nurse should evaluate the client's vision first to provide a baseline, and then treat the injury. Irrigation is often used to remove foreign bodies from the eye, followed by application of an eye patch. Following eye surgery, the head of bed should be elevated 30 to 45 degrees and the client should lie on back or unaffected side to reduce intraocular pressure. Small pillows may be used at the sides of the head to immobilize the head when lying on the back. Glaucoma is characterized by a gradual loss of vision that is irreversible, because of the effects of increased intraocular pressure on the optic neurons. Compliance with medication therapy is important to preserve the current level of vision, although vision that is lost cannot be regained. The client with a detached retina should have activity restricted with eyes patched to reduce eye movement and prevent worsening of the detachment. The client may be prepared for surgery quickly, and thus may be placed on NPO status rather than clear liquids. The nurse should orient the client to the room for safety, using both words and a physical walking tour for best effect. Options 2 and 4 are helpful, but do not ensure client safety. Leaving doors partially closed (option 1) is hazardous because the client could inadvertently walk into the door during ambulation. Pathways should be free of obstacles. The nurse places the base of the tuning fork on the client's mastoid bone to perform the Rinne test. When the sound is no longer heard, it is quickly repositioned in front of the client's ear, and hearing is again examined. The tuning fork may be placed at the top of the forehead or the vertex of the skull in the midline to perform the Weber test. The bridge of the nose is not used as a reference point for examining hearing. The client should avoid the use of aerosol sprays, cosmetics, or other hair or facial products near the hearing aid. The aid should not get excessively wet. The hearing aid should be turned off when not in use, and should be maintained on the lowest setting that is comfortable and effective. A stapedectomy is a common surgical procedure used to treat the hearing loss that is associated with otosclerosis. It is not performed for the other conditions listed. The following is one way to set up the calculation: Cross-multiply 2.5 by <i>x</i> and 1.25 by 1 to yield 2.5<i>x</i> = 1.25. Divide 1.25 by 2.5 to yield 0.5 tablet. Presbycusis is an age-related decline in hearing. Otosclerosis is a familial disorder characterized by hearing loss. Meniere's disease is a disorder of the inner ear that results in vertigo. Otalgia is an earache. Meniere's disease is characterized by bouts of vertigo, which place the client at risk for falls and injury. The client may have manifestations of the other nursing concerns as well, but the highest priority is on preventing injury. Angle-closure glaucoma can manifest abruptly as acute onset of eye and facial pain. It is considered a medical emergency because it signals a rapid rise in intraocular pressure. Halo vision and difficulty seeing at night are symptoms commonly associated with open-angle glaucoma. Itching of the eyes is an unrelated item. A Snellen eye chart, as shown in the photograph, is used to test distance vision. The client reads aloud the smallest line of print that can be seen. Each line is coded to interpret the visual acuity for that line. Normal vision is 20/20. A Rosenbaum chart is used to test near vision; an Ishihara chart is used to test color vision. The nurse performs peripheral vision testing by facing the client and bringing an object into both their visual fields from the side. A clouding of the lens occurs with cataract development. The red reflex becomes absent or is lost as the cataract gets worse or "matures." Double-vision and intermittent aching eye pain do not occur. Option 3 describes findings with macular degeneration. The foreign body should not be removed or manipulated. It should be kept immobilized if possible with an item such as a plastic cup, which will not put pressure on the eye. Eye patching is desirable (option 3), but a flat patch could cause further eye injury. Eye irrigation is done when the client suffers chemical burns to the eye (option 1). Examination of vision (option 2) while the glass is still imbedded could cause further harm by encouraging eye movement. Presbycusis is characterized by sensorineural hearing loss. Weber and Rinne tests are used to differentiate conductive from sensorineural hearing loss. Caloric testing evaluates ocular-vestibular reflexes. Tympanocentesis is the aspiration of fluid/pus from the middle ear to identify the causative organism of acute otitis media. CT scanning is not used. Atrophic macular degeneration results in loss of central vision. Thus, the priority is to obtain magnification devices, other aids, and provide enhanced lighting to promote safety. Antiviral medication is not a form of therapy. Surgical therapy is not an option for the atrophic (dry) form of macular degeneration. Peripheral vision loss rarely occurs with macular degeneration. Open-angle glaucoma is characterized by halo and blurred vision. The presence of floaters or the sensations of a curtain or veil over the visual field are found with detached retina. A burning sensation in the eyes is not part of the clinical picture. The priority nursing intervention is one that maintains contact of the retina with the choroid by positioning the client so the detached area falls against the choroid. It is unnecessary to darken the client's immediate environment. A preoperative medication may be ordered, but has lesser priority than maintaining proper position of the head to protect the eye. Both eyes, not just the affected eye, are patched to minimize eye movement. The following is one way to set up the calculation: Cross-multiply 2.0 by <i>x</i> and 0.5 by 1 to yield 2<i>x</i> = 0.5. Divide 0.5 by 2 to yield 0.25 mL. Visual difficulty caused by distortions and impairment of central vision is common with macular degeneration. Peripheral vision in most cases is normal. The symptoms are not characteristic of glaucoma, cataracts, or detached retina. Communication with a hearing impaired client is enhanced by facing the client while speaking, because they often consciously or unconsciously lip-read to better interpret the spoken word. The other options are inappropriate and ineffective. A child diagnosed with thalassemia who will receive multiple transfusions throughout life will need chelation therapy for excessive iron stores. An iron supplement would be inappropriate in this child. Rectal temperatures can traumatize the fragile rectal mucosa, leading to bleeding, and should be avoided. The vital signs will need to be measured on a regular basis. An intravenous start kit is appropriate as the child will need plasma and blood products. A bedpan will be needed if the child is on bed rest. Urinary catheters are avoided if possible. All of the injuries require nursing care; however, the child with the head injury has a potentially life-threatening injury. RBCs sickle under conditions where low oxygen concentrations exist; therefore, administering oxygen will prevent additional sickling. The oxygen has no effect on the oxygen-carrying capacity of RBCs. It will not have an effect on development of respiratory complications. It will not decrease the potential for infection. Iron preparations should be taken through a straw in order to prevent staining the teeth. While it is best to give toddlers choices in the hospital setting, the other options are not appropriate as iron is best absorbed on an empty stomach. In an acute care setting such as a hospital and with a potentially life-threatening disease such as DIC, the family may need help with coping with the stress they are feeling. This stress often interferes with communication. A patient response by the nurse with repetition of information will allow the family to absorb the information. The other options are not helpful Factor VIII concentrate is a blood product. Fluid volume overload is an unlikely concern, as the factor will be given in a comparatively small volume of fluid. There is no greater a chance of emboli formation with administration of factor than with any other IV preparation. Concern as to contracting AIDS from administration of a blood product is a long-term concern related to multiple administrations. It is not a concern during the actual administration of the factor. There are 3 common problems seen in sickle cell anemia. First there is the anemia crisis. This is a continuous problem for the sickle cell patient. Sequestration crisis occurs primarily in children under 6 and in older children and adults who have functioning spleens. The crisis is a pooling of the blood causing circulatory collapse. The third crisis is the vaso-occlusive crisis. The following is one way to set up the calculation: Cross-multiply 325 by <i>x</i> and multiply 650 by 1 to yield 325<i>x</i> = 650. Divide 650 by 325 to yield 2 tablets. Anemia does occur easily in infancy, and infants have limited stores of iron. The first solid food offered to infants is often cereal, which is an excellent source of iron. All infants do not require iron supplements; it is preferable that the iron comes from dietary intake. Alterations in platelet function necessitate treating a break in the skin’s integrity as you would an arterial stick—apply pressure for 5 minutes or more. The goal of treatment is to apply pressure long enough that the defective clotting mechanism will have time to form a clot. Steri-strips would not close the wound adequately, and restricting arm movement will not assist in the initial formation of a clot. It is not possible for parents of a hemophiliac to prevent a bleeding episode, no matter how careful they are. The nurse should reinforce this information along with methods for decreasing the chance of an injury that will lead to a bleeding episode. The other statements all indicate an appropriate understanding of hemophilia. Sickle cell anemia is an autosomal recessive condition. Therefore, if both parents have the trait, each pregnancy carries a 25% (1 in 4) risk that the child will have the disease. Many infants with nutritional anemia rely primarily on the milk/formula for dietary intake and refuse solid foods. When the milk/formula is limited, the child will be more willing to take solid foods. Cow’s milk is a poor source of iron. Peanuts and unsweetened chocolates are sources of iron but are not appropriate for this child’s diet. Blood transfusions are utilized in order to maintain normal hemoglobin (HGB) levels. There is an excess of iron secondary to repeated transfusions, and, thus, iron supplements will not be necessary. The other therapies are inappropriate for the child with thalassemia major. Appropriate oxygenation is not possible when there is significant loss of blood volume. Replacing the blood volume is critical to saving the child’s life, and it is imperative that replacement occurs prior to any of the listed nursing actions. Folic acid potentiates the removal of iron from ferritin, which makes it further available for heme production. The synthesis of albumin, blood proteins, fibrinogen, and hemoglobin is dependent upon the presence of proteins. None of the others are involved in building red blood cells (RBCs). The nurse would elevate the leg above the level of the heart to reduce bleeding. Aspirin or aspirin-like products such as ibuprofen interfere with the clotting mechanisms. During active bleeds, the joint should be immobilized. Warm soaks would promote bleeding; ice packs should be used instead. Such positioning indicates the likelihood of abdominal pain. Nausea or constipation does not generally cause a child to self-position as described. Fear related to the hospitalization would be common in a child this age. However, if this were the case, it is more likely the child would seek refuge in the arms of one of her parents. The nurse must have a relationship with the client that involves providing care. The relationship is usually a component of employment. Options 2 and 4 are false. Option 3 is a true statement, but is not the one that applies to this case. SARS is a highly contagious viral respiratory illness that is spread by close person-to-person contact. SARS is transmitted by airborne respiratory droplets and by touching surfaces and objects contaminated with infectious droplets. Instituting infection control measures would be the first priority of the nurse. This action would protect both health care workers and other clients in the emergency department. Then all other interventions can be safely implemented. Since the dose is 2 grams and each vial contains 1 gram, the nurse needs to use two vials. The nurse then adds 10 mL of sterile water to each vial of powder based on the direction to “add 10 mL of sterile water per 1 gram of medication.” Once both vials are reconstituted, the concentration of each solution is 1 gram/10 mL. The nurse then must draw up the contents of both vials, making the total volume 20 mL. Such lab results indicate severe anemia. Fatigue results when the oxygen-carrying capacity of RBCs is impaired and cellular hypoxia is present. Fatigue can be diminished and oxygen depletion limited when the client’s energy is conserved. There will be an increased oxygen requirement and increased fatigue with increased mobility. Increasing general hydration without transfusing RBCs will not positively affect the anemic state. Skin integrity is not a high priority at this point. Although improving nutrition is appropriate, the response would not be immediate. The priority activity would be conserving energy and reducing cardiac stress. Chelation therapy works to rid the body of excess iron storage that results from the frequent transfusions required to maintain adequate hemoglobin. Chelation will have no effect upon hypoxia or bleeding. Sickling of RBCs does not occur with thalassemia. A vaso-occlusive crisis is a very painful experience and proactive examination and pain control are imperative. Although oxygen will help in pain control by preventing more sickling, high concentrations are not needed. Acid-base balance is not routinely disrupted in a vaso-occlusive crisis. Factor VIII replacement therapy is utilized with hemophilia. Bed rest without immobilizing and elevating the affected area is inappropriate to stop the bleeding. If coagulants are needed, they would be applied topically, not orally. Gentian violet will have no effect upon the bleeding. Warm compresses will increase the blood flow, making it harder to stop the bleeding. As the child’s safety is the first concern, walking to the office would not be safe at this time. Sitting immediately will decrease the chance of falling. The urgent safety requirements take precedence over physical examination. The information given does not indicate the need for ammonia at this time to prevent fainting. A change in the stools to a black, tarry color is an expected side effect of the medication and a sign that the medication is working properly. It is not a symptom of the anemia, a sign that the dose is high, or an indication that the child is experiencing bleeding. Children with sickle-cell anemia develop sickling of the red cells when exposed to low oxygen tension; this means that the cells become crescent-shaped. Polycythemia is not a finding with sickle-cell anemia (option 1). Hematopoiesis is the formation of new cells, which occurs at a rapid rate in children with sickle-cell anemia due to the rapid destruction of RBCs; however, this process is not visible under the laboratory microscope. Children with sickle-cell anemia have adequate iron stores, so the cells are not pale in color (option 4). All of the other activities hold a risk of bleeding, whether it is from physical contact or stress on joints and muscles. Swimming is considered ideal for clients with hemophilia as it provides necessary activity with minimal risk for bleeding and injuries. Children with iron-deficiency anemia are more susceptible to infection related to microcytosis and limited bone marrow function. The information in the other options is incorrect and does not address the connection between the conditions of anemia and infection. A child with hemoglobin and hematocrit levels this low would already have a heart that is under stress. A sudden increase in blood volume can cause congestive heart failure. All of these data collections are appropriate, but pulse rate is the priority data collection. The following is one way to set up the calculation: Cross-multiply 0.125 by <i>x</i> and 0.25 by 1 to yield 0.125<i>x</i> = 0.25. Divide 0.25 by 0.125 to yield 2.0 mL. The child with sickle-cell anemia does not need more iron supplements than the regular child. The cause of the child’s anemia is fragile red blood cells, which are broken down more rapidly than the normal cell. Children with sickle-cell anemia must guard against low oxygen tension in the air. For that reason, they should not fly in unpressurized planes. Because infections increase the basal metabolic rate (BMR) and oxygen requirements, infections often precipitate a crisis. During a sickling crisis, the child will need hydration therapy and pain management to break the sickling cycle. The PTT is used to monitor heparin therapy, as it is an indicator of the clot formation pathways. Bilirubin levels are elevated with liver disease or excessive RBC damage. A client with DIC will likely need to have platelets and hemoglobin and hematocrit monitored, but they are not indicators of effectiveness of heparin therapy. Cerebral tissue hypoxia is commonly associated with dizziness. The greatest potential risk to the client with dizziness is injury, especially with changes in position. Planning for periods of rest and consuming energy are important with someone with anemia because of his or her fatigue level, but most important is safety. Major complications of multiple myeloma include bone pain, hypercalcemia, renal failure, anemia, and impaired immune responses that are a result of bone marrow involvement and the systemic effects of substances secreted by the malignant plasma cells. Myelodysplastic syndromes often progress to acute myelogenous leukemia. They are often refractory to treatment and are associated with a poor prognosis. They are not hereditary and are often referred to as pre-leukemia. Bone marrow biopsy and aspirate is the only definitive diagnosis of AML. The presence of Auer rods is diagnostic for AML. The presence of leukemic cells in the spinal fluid is more common in acute lymphocytic leukemia (ALL). Uric acid and lactic dehydrogenase levels may be elevated in AML, but this is not diagnostic for the disease. Option 1 contains foods high in protein, folic acid, iron, and Vitamin B<sub>12 </sub>that are needed for erythropoiesis. Options 2 and 4 contain lesser amounts. IM administration is recommended over intravenous infusion because of the potential for anaphylaxis. The gluteal muscle is the best route for administration since the muscle is large and highly vascular. The Z-track method is preferable to prevent tattooing of the skin and tissue necrosis caused by infiltration into the subcutaneous tissue. Platelet aggregation forms a platelet plug at the site of bleeding, but fibrin reinforces the platelet plug. The absence of clotting factors impairs the coagulation response and the capacity to form a stable clot. Pernicious anemia is caused by the body’s inability to absorb Vitamin B<sub>12</sub>. This is caused by a lack of intrinsic factor in the gastric juices. The Schilling test helps diagnose pernicious anemia by determining the client’s ability to absorb Vitamin B<sub>12</sub>. The following is one way to set up the calculation: Cross-multiply 40 by <i>x</i> and 120 by 1 to yield 40<i>x</i> = 120. Divide 120 by 40 to yield 3.0 mL. Pain from sickle-cell crisis is primarily related to obstructed capillary blood flow causing ischemia and possible tissue infarction. While dehydration often causes increased viscosity, the primary cause of pain is vaso-occlusion of the blood vessels from sickled red blood cells. The client with neutropenia is unable to mount an inflammatory response. Fever is usually the first sign of infection. Options 1, 2, and 4 are all true, but they explain why the neutropenic client is at greater risk for infection. Cerebral tissue hypoxia is commonly associated with dizziness. Recognition of cerebral hypoxia is critical since the body will attempt to shunt oxygenated blood to vital organs. Approximately 95 percent of clients with CML are Philadelphia chromosome-positive. This represents a translocation of the long arms of chromosomes 9 and 22. The risk for hemorrhage is of greatest risk since a large-bore needle is used to perform the biopsy and aspiration. Many of these clients often have an altered clotting capability. While the risk of infection is also a consideration, the procedure is performed under sterile conditions, so infection is less of a concern than hemorrhage. Organ meats such as liver are a good source of iron as well as green, leafy vegetables and egg yolks. Whole grain breads also contain iron, however not in as high a quantity as organ meats. Options 1, 2, and 4 relate to the white blood cells. A platelet count below 20,000 increases the client’s risk for severe bleeding because of reduced platelets to assist in the clotting cascade to form a clot. Leukemia is a result of erratic production of white blood cells by the bone marrow, which replace normal marrow components. It can arise from both a lymphatic and a myelocytic etiology. White blood cells are often immature and incapable of performing their expected function(s). Sickle-cell trait is generally a mild condition that produces few if any manifestations. These clients are considered carriers of the disease and require genetic counseling to determine presence of the hemoglobin S. Certain stressors result in a sickle-cell crisis. All of the medications in the first option can affect platelet aggregation and should be avoided in a client with bleeding tendencies. A thorough review of all medications taken at home should be done whenever clients are issued new medications. The following is one way to set up the calculation: Cross-multiply 10 by <i>x</i> and 40 by 1 to yield 10<i>x</i> = 40. Divide 40 by 10 to yield 4 tablets. Hemophilia is a group of hereditary clotting factor disorders characterized by prolonged coagulation time that results in prolonged and sometime excessive bleeding. It is an X-linked recessive characteristic transmitted by female carriers, displayed almost exclusively in males, often resulting in spontaneous bleeding into the joints resulting in hemarthrosis with joint deformity and potential disability. Option 3 is a specific form of hemophilia, von Willebrand’s Disease. Option 4 is pernicious anemia. Findings in pernicious anemia include a smooth, red, beefy tongue; altered sensations such as numbness or tingling in the extremities; and difficulty identifying one’s position in space, which may progress to difficulty with balance and spinal cord damage. Palpitation is a significant change in the condition of the client and may be indicative of progressing anemia. If palpitations occur, the client should report the symptom to the physician. Options 1, 2, and 3 are all positive responses to client teaching. Lytic bone lesions are the most common cause of pain in multiple myeloma. Although the marrow may be involved, this is not a common cause of pain. Neural infiltrations and intestinal obstructions are not common in multiple myeloma. Chronic leukemia progresses over a period of years rather than weeks. It occurs primarily between ages of 50 to 70. Hemoglobin S in sickle-cell anemia causes the red blood cells to elongate, become rigid, and assume a crescent, sickle shape, causing the cells to clump together and obstruct capillary blood flow in small vessels, causing ischemia, decreased organ perfusion, and possible tissue infarction. Increased calcium excretion in the urine from the diuretics decreases calcium levels. All other measures increase calcium. Vitamin B<sub>12</sub> deficiency anemia causes the production of abnormally large red blood cells. This deficiency causes the red blood cell to be irregular and oval, rather than the biconcave shape of a normal red blood cell. This shape predisposes the cells to a shorter lifespan. In this type of anemia, there is an increase in the MCV (option 1) and a decrease in the hemoglobin (option 2). Option 4 is characteristic of iron-deficiency anemia. Hypoxia stimulates the release of the hormone erythropoietin from the kidney and increases bone marrow production of RBCs. The hemoglobin does not increase in size with hypoxia. Reticulocytes mature in 24 to 48 hours, and their maturation is not influenced by hypoxia. Lysis of red blood cells causes retention of iron and other substances including bilirubin to accumulate in plasma. The accumulation of bilirubin causes jaundice. Although hepatitis infection may also be the reason for jaundice, the hemolytic anemia present most likely caused the jaundice to occur. Use the following formula to calculate the rate of IV solutions: Set up the problem as follows: Multiply 40 by 60 to yield 2,400 and divide 2,400 by 60 (or cancel out the 60s) to yield 40 drops/minute. The reticulocyte (immature RBC) count is an indicator that new red blood cells are being produced by the bone marrow. An increase in the reticulocyte count in an anemic client indicates that the bone marrow is responding to the decrease in RBCs. The hematocrit count measures the percent of RBCs in the total blood volume. Hemoglobin is not directly linked to bone marrow activity. Serum ferritin levels reflect available iron stores. Iron-deficiency anemia is manifested clinically by glossitis, or inflammation of the tongue. After pallor, this is the second most frequent manifestation of this type of anemia. Cheilitis, or inflammation of the lips, is another finding in this type of anemia. Achlorhydria, or the absence of free hydrochloric acid, is a manifestation of a depressed parietal cell function and is associated with Vitamin B<sub>12</sub> deficiency anemia. Cheilosis is cracking of the lips at the angles of the mouth. An acidic environment (such as in the presence of vitamin C) enhances the absorption of iron. Administering the medication with meals binds the iron with food and interferes with its absorption. The client on an oral iron preparation should be taught to expect stools to turn black because of the excessive iron that is eliminated. All the other choices should be included in the teaching plan. The health care practitioner may change the iron preparation prescribed to the client if gastrointestinal symptoms become intolerable. Liver and muscle meats are excellent sources of iron. The other foods are also beneficial for the dietary management of anemia, but option 4 is specifically an excellent source of iron. When administering an iron preparation intramuscularly, it should be given deep in the muscle. The site should be in the upper outer quadrant of the buttocks utilizing the Z tract technique. No more than 2 mL of the solution should be administered and the length of the needle should be 2 to 3 inches. The area should not be massaged after the injection. Resection of the distal ileum results in the impaired absorption of Vitamin B<sub>12</sub>. The other cause of Vitamin B<sub>12</sub> deficiency is the loss of intrinsic factor-secreting surfaces that are normally secreted by parietal cells. The Schilling test involves the administration of radioactive Vitamin B<sub>12</sub>. Increased absorption of Vitamin B<sub>12</sub> when intrinsic factor is given parenterally is indicative of pernicious anemia. Individuals who are chronically undernourished including the elderly, alcoholics, substance abusers, and those with high metabolic requirements and on total parenteral nutrition are also at risk for folic acid deficiency anemia. Alcoholics are particularly at risk because alcohol interferes with folate metabolism. The differentiating symptom of vitamin B<sub>12</sub> and Folic acid deficiency anemia is the absence of neurologic symptoms such as numbness and altered proprioception in folic acid deficiency anemia. The gastrointestinal symptoms of cheilosis, glossitis, and diarrhea are present in both forms of nutritional anemia although usually more severe in folic acid deficiency anemia. The problem can be set up using the following formula: Multiply 500 by <i>x</i> and multiply 45 by 5 to yield 500<i>x</i> = 225. Divide 225 by 500 to yield 0.45 mL. Sickle-cell disease is an autosomal recessive genetic disorder where the individual is homozygous for the abnormal hemoglobin. If both parents have sickle-cell traits, there is a 25 percent chance that each pregnancy will produce a child with the disease. Clients with sickle-cell disease have scarred spleen resulting in decreased ability to fight off infection. The individual with sickle-cell disease must seek early treatment of infections. Pneumonia is one of the most common infections affecting individuals with sickle-cell disease. Option 4 is inaccurate in that vigorous physical activity should be avoided. The client in sickle-cell crisis will have pain related to ischemic tissue injury resulting from obstruction of blood flow. The other diagnoses, although important, are of lesser priority than the nursing diagnosis of pain. Clients with sickle-cell disease express 80 to 90 percent of HbS. Clients with sickle-cell trait usually express less than 40 percent of HbS. The hematocrit of clients with sickle-cell disease is usually decreased between 20 to 30 percent. Clients with sickle-cell trait may also develop sickle cell crisis, although their symptoms are often milder since only about 30 percent of their hemoglobin is abnormal. The other options are rational lifestyle adjustments the client makes in order to deal with the disease. An observation for the client in sickle-cell crisis that indicates a positive outcome includes stable vital signs, an oral intake of 3,000 mL/day, and verbalization of pain control. Maintaining an adequate intake is essential to maintain blood flow, decrease pain, and prevent renal damage. Clients with polycythemia experience satiety and fullness resulting from hepatomegaly and splenomegaly. Frequent, small meal servings will help maintain adequate nutrition. Foods rich in iron are not appropriate since there is an increase in erythrocytes in this condition. Spicy foods will increase the gastrointestinal symptoms, which also include dyspepsia and increased gastric secretions. Clients with thrombocytopenia have decreased platelet counts below 150,000/uL. The usual presenting manifestation of this condition is the appearance of petechiae, purpura, and ecchymoses. The other laboratory values will not explain the petechiae or support the presence of a hemostatic disorder. Clients with aplastic anemia usually experience pancytopenia (decreased erythrocytes, leukocytes, and platelets). The client with this type of hypoplastic anemia should therefore have a room where reverse isolation can be instituted. The client with aplastic anemia is susceptible to infection as well as hemorrhage. Respiratory isolation requiring negative airflow (option 2) is not necessary in the care of clients with aplastic anemia. In DIC, there is abnormal initiation and formation of blood clots. As clots are formed, more end products of fibrinogen and fibrin are also formed. These are called fibrin degradation products or fibrin split products. Although the PT and PTT are prolonged and the platelet count is reduced in DIC, that could also be a result of other coagulation disturbances. First calculate the daily dose of the medication by dividing the number of mg (1,380) by the client’s weight in kg (13.8) to yield a single dose of 100 mg/kg. Because there are three doses ordered during a 24-hour period, multiply 100 by 3 to yield 300 mg/kg/day. Since the dose range is 100 to 200 mg/kg/day, the nurse should question the order for the excessively high dose as a safe nursing action. Initially there is an enhanced coagulation mechanism with resulting increase in fibrin and platelet deposition in arterioles and capillaries in DIC. This results in thrombosis. Although it remains controversial in DIC, the use of heparin is aimed at preventing the formation of further thrombotic clots that further complicates the bleeding disorder. Clients with DIC should be protected from injury that will result in bleeding. The use of an oral swab has the least potential of causing tissue injury to the oral cavity during the performance of oral care. Mouthwashes with alcohol base should be avoided as they may cause discomfort and because they tend to dry the mucous membranes. A soft-bristled toothbrush should be used although a swab or toothette is the best option. Hydrogen peroxide is not a good choice of mouthwash solution in clients with stomatitis because it tends to dry the oral mucosa and further aggravates the discomfort. All the three options are acceptable mouthwash solutions to use and may also include diphenhydramine (Benadryl) or Maalox. Harvested bone marrow is infused into the recipient intravenously. The transplantation is usually preceded by chemotherapy and radiation therapy. During this period and up to when the client’s response to the transplantation has been successful, nursing interventions should focus on prevention of infection. Histological isolation of Reed-Sternberg cells in lymph node biopsy examination is a diagnostic feature of Hodgkin's lymphoma. Philadelphia chromosome is attributed to chronic myelogenous leukemia. A nontender and moveable cervical node may suggest the presence of malignancy and even lymphoma. Palpable nodes do not confirm the diagnosis of a malignancy. Biopsy and histological examination will aid in interpreting the significance of enlarged nodes. This is the usual presentation of Wilms’ tumor (nephroblastoma), and palpating the area may cause the tumor to spread. Since Wilms’ tumor is a cancer of the kidney, it is important to monitor growth and development, kidney function, and blood pressure, which may be elevated due to increased renin production. There is no evidence of abuse or rationale for performing a neuro check. This tumor occurs in 1 in 10,000 live births. It arises out of embryonic neural crest cells and, therefore, is usually found in the adrenals or retroperitoneal sympathetic chain. Symptoms are vague and depend on location. Acute lymphocytic leukemia (ALL) is staged at diagnosis to determine treatment. The goal is remission, which is usually accomplished using chemotherapy. The most common reported symptoms of brain tumors in children are headache, especially upon awakening, and vomiting that is unrelated to eating. Both are related to increased intracranial pressure. Irritability and ataxia may also be present; however, presenting symptoms are often vague. Fever is not a symptom of a brain tumor. Papilledema may be noted, but red reflex is not indicative of brain tumors. First calculate the total daily dose by dividing 240 mg by 18 kg to yield a single dose of 14.44 mg/kg. Multiply the single dose by 4 doses (every 6 hours) to yield a daily total dose of 57.76 mg/kg/day. Since this exceeds the safe total daily dose of 40 mg/kg/day, the nurse should question the order. Bone tumors usually occur in otherwise healthy children. Given the interruption of normalcy and the developmental tasks of the adolescent, body image disturbance can occur when a limb is lost. Neutropenia is a reduced white blood count, which increases the risk for infection. Only live vaccines are contraindicated in children who are immunocompromised. Contact sports would be a problem with thrombocytopenia, and spicy foods would increase discomfort if an alteration in mucous membranes occurred. Thrombocytopenia refers to a decrease in platelets. Preventing falls and bruises would be appropriate for an individual with platelet deficiencies. Fresh flowers may contain molds and fungus that can lead to infection and would be a concern for a child with neutropenia. Providing foods high in iron would be appropriate to restore red blood cells. Limiting contact with the child could affect his or her body image and self-esteem. Contact is acceptable as long as the individual is not infectious. Healthy children are often a source of infectious organisms. Children in hospitals may carry a number of infectious organisms. Hospitalized neutropenic children should be protected from exposure to other children whenever possible. Toys from home would not carry a high risk. Hand washing before contact with the child is the important intervention. Limiting physical contact with peers would decrease exposure to infectious organisms. Telephone contacts allow for the peer support the child needs. All of these examinations look at possible postoperative complications. Since the child is left with only one kidney, failure of that kidney due to inadequate blood flow, infection, or any other cause could be fatal. Preparation helps individuals handle stressful situations. If the child had not been prepared for hair loss, it could be more anxiety-provoking for the child. Hair loss cannot be prevented. Vomiting is a symptom of increased intracranial pressure. Bulging fontanels would not be present in a school-age child. Drainage from the ear or nose might indicate a basilar skull fracture, not a brain tumor. Some brain tumors display the symptom of diabetes insipidus, not diabetes mellitus, thus the symptom would be dilute urine rather than elevated blood glucose. Nausea and vomiting, anorexia, mouth sores, constipation, and pain are early and common side effects of chemotherapy. Bone marrow suppression reaches its peak 7 to 10 days after induction. Sleep disturbance may be related but is not directly caused by chemotherapy. Peripheral tissue perfusion is not related to the question. Self-care during external radiation therapy includes loose-fitting clothes, gentle washing with mild soap, avoiding sun exposure, and avoiding scratching and other irritation. Any lubricant must be water-soluble, not oil-based, such as petrolatum jelly. Hematuria is an adverse effect of the commonly used cancer medication cyclophosphamide (Cytoxan) and should be reported. Fluids are usually encouraged prior to administration, and the bladder is emptied frequently to prevent hematuria. Measuring intake and output should be done routinely on all clients and is not specific to managing this complication. The dose can be administered as ordered. The order for 1/2 of a 10 mg tab means that the child is receiving 5 mg per dose. If there are 3 doses per day, then the total daily dose is 15 mg, which is within the safe dosage range. A private room assignment is indicated for children with chemotherapy-related neutropenia. Careful hand washing is also an essential element to reduce the risk of infection. Because the neutropenia is mild at this time, the client does not require neutropenic precautions and does not require full protective isolation. However, neutropenic precautions could be instituted later if the client’s neutrophil count continues to decline. Nursing care must be supportive of body image adjustment. The child would be encouraged to sit in a chair and ambulate on crutches while waiting for the permanent prosthesis. The stump dressing is a continuous ace bandage, which supports the stump shape in preparation for the prosthesis. The client’s goal should be stated in terms of behaviors of the child that demonstrate the problem is solved. Option 1 is a nursing action, not a goal. Absence of nausea does not guarantee adequate intake. Equal intake and output indicates fluid balance but does not indicate adequate nutrition. Only the caloric intake adequately addresses the outcome needed by this client. A vesicant drug can cause significant tissue damage if the IV line infiltrates. By checking for blood return throughout the administration, the nurse can stop the infusion at any time a blood return does not occur. A positive pressure infusion pump, maintaining the infusion site below the level of the heart, or rapid drug delivery does not guarantee that the infusion does not extravasate. Studies have shown that simply rinsing the mouth with water decreases the onset of stomatitis in chemotherapy patients. Alcohol-based mouthwash would be avoided as it is drying to the oral mucous membranes. A stiff toothbrush may cause the gums to bleed. Should oral lesions be present, acidic foods and liquids will increase discomfort. Drinking through a straw and pain management will provide comfort for the child, as will using swabs for mouth care. The stages of grief and bereavement include denial, anger, bargaining, depression, and acceptance. The anger expressed may often be displaced and directed toward persons who have a role in the loss. Nurses and other health care personnel must be aware of this in order to help the family cope with the impending loss. The low red blood cell count will limit the ability of the blood to carry enough oxygen to meet tissue needs, making risk for impaired gas exchange the correct diagnosis. There is no indication that the child is at risk for injury. The high WBC count does not indicate an infection is present but is an indication of the disease process. Since the WBCs are immature, they would be unable to fight an infection appropriately. The deficiencies are not related to inadequate nutritional intake. The volume of blood is adequate; rather, it is the cell count that is abnormal. Stomatitis may cause the child to refuse fluids and foods. Hydration status would be an appropriate examination to monitor the child’s condition. Vitamin C intake would be important in healing the mucous membranes but not as important as hydration. The condition of the teeth and hand washing techniques are not involved in stomatitis. The chemotherapy agent poses a risk to all individuals, including the child who was to have received the drug. Removal of individuals from the area reduces the risk of inadvertent exposure. Care is taken to avoid inhalation of the fumes, but the procedure would involve activities to avoid aeration of the chemical not speed in cleanup. Disposable cleanup materials are included in a spill kit. Using multiple chemotherapeutic agents with different modes of action allows for the greatest amount of cell destruction. Using multiple drugs does not prevent renal damage, reduce nausea, or allow for efficient use of nursing time. Convert 2.6 grams to 2600 mg. Since a single dose is only 120 mg, the client could theoretically receive this dose 21 times (2600 divided by 120 = 21.66) within a 24-hour period without exceeding the top of the dosage range. However, since the medication is ordered only every 4 to 6 hours, the nurse can legally administer the medication only 6 times maximum (every 4 hours). The access device illustrated is a tunneled central venous access device. The tunneled device can last for years, and once implanted, does not require puncturing the skin for access. There is no maximum dose of morphine. Increasing the dose in small increments is appropriate to control the pain. Addiction is not an issue as the child is terminal. Stopping the infusion will put the child into withdrawal, which could be fatal. The physician is not misusing a narcotic. Because of the danger of radiation, the child will be alone in the therapy room. Staff or parents cannot stay with the child. A 3-year-old is not old enough to use mental imaging when frightened. A favorite stuffed toy can provide comfort as can the calming voice of the parent over the intercom system in the room. Assessing this child will give baseline data to plan and evaluate care. Activity intolerance will be likely, so rest is important. This child is also too young to make choices about planning schedules and is likely to choose favorite foods that do not meet his or her nutritional needs. The caregiver should be educated in planning activities and making food choices that include soft, nonspicy foods that are high in iron and protein. Using antiemetics regularly will help to manage nausea and vomiting. Foods that have strong odors will increase nausea and vomiting. Only small amounts of fluids should be offered. During periods of illness, children often regress to a "safer" period and regressive behaviors should be allowed if they comfort the child. One of the side effects of cyclophosphamide is hemorrhagic cystitis, not anaphylaxis. Appropriate interventions include using mesna to counteract the irritating nature of Cytoxan, forcing fluids, and having the client empty the bladder frequently. As the immature white blood cells crowd the marrow, the ability for the marrow to perform the proliferation of red blood cells and platelets is also inhibited leading to a potential for infection, occult blood, and hemorrhage. While the client may also experience constipation, nausea, vomiting, anxiety, or depression, the potential for hemorrhage is most important. Hypercalcemia produces a generalized slowing of functions through neuromuscular depression, i.e., constipation, increased urination, hyporeflexia, and confusion. Gallium nitrate can impair renal function as evidenced by elevated urea and creatinine levels. Hypotension, extravasation, and hyperglycemia are not side effects of gallium nitrate. Although all the interventions help to decrease serum calcium, ambulating the client is the action that will most likely encourage calcium to return to the bone. SARS is a highly contagious viral respiratory illness that is spread by close person-to-person contact. SARS is transmitted by airborne respiratory droplets and by touching surfaces and objects contaminated with infectious droplets. Personal protective equipment would include protective gowns, gloves, N95 respirators, and eye protection. Airborne precautions would also include placing the client in a private room with negative air pressure flow. The correct answer is option 2. Airborne and contact precautions would provide the necessary protection outlined above. Options 1 and 3 are incorrect. Droplet precautions would not protect the nurse who touches contaminated items. Droplet precautions do not provide a negative air pressure room. Option 4 is incorrect. Contact precautions alone would not provide adequate protection from airborne particles. The following formula illustrates one way to set up the problem: Multiply 95 by <i>x</i> and multiply 1180 by 1 to yield 95<i>x</i> = 1180. Divide 1180 by 95 to yield 12.421 or 12.4 mL after rounding down to the nearest tenth. A lymph node biopsy is the only definitive means of establishing the diagnosis of Hodgkin’s disease. The presence of the Reed-Sternberg cell is ascertained through this biopsy. Options 1, 3, and 4 are not necessarily true. Preventing contact with contagious visitors decreases the client’s risk of infection. The use of aspirin or aspirin products as well as injections should be avoided in clients with thrombocytopenia. The client’s temperature should be monitored every 4 hours for signs and symptoms of infection, not necessarily the respirations. Vasospasm creates the logjam, which impedes blood flow that leads to clots, infarction, and pain. The repeated sickling and unsickling causes the weakened cell membrane and hemolysis. A clot can form (option 2) but is usually not in the deep vessels, but in the microcirculation. Option 4 is incorrect because vasodilation does not occur. Since hemophilia A is carried on the X-chromosome, all of the female children will be carriers. The disease will not affect a male child, unless he marries a woman who is also a carrier. During decreased oxygen tension in the plasma, the hemoglobin S causes the red blood cells to elongate, become rigid, and assume a crescent, sickled shape, causing the cells to clump together and obstruct capillary blood flow, causing ischemia and possible tissue infarction. Adequate iron stores are required to allow the oxygen molecule to attach to the red blood cell. Small hemoglobin molecules insufficient in iron and oxygen are released into the circulation, resulting in the signs and symptoms of fatigue and shortness of breath. In severe neutropenia, there is a decrease of mature white blood cells, which significantly decreases the inflammatory response. Therefore, fever may be the first sign of infection in these clients. Auer rods may be present in the cytoplasm of the myeloblasts in AML. A standard diagnostic criterion for AML is that over 30 percent of hematopoietic cells must be myeloblasts. Gastric secretion analysis in the client with pernicious anemia reveals an absence of free hydrochloric acid in a pH maintained at 3.5. Leukostasis occurs as the leukemic blast cells accumulate and invade the vessel walls, causing rupture and bleeding. Patients with extremely high circulating blasts (WBC > 50,000/mm<sub>3</sub>) are at increased risk for leukostasis. One half of a 60 mg tablet is 30 mg. Because the dose is ordered twice a day, the total daily dose is 30 multiplied by 2, or 60 mg. Tissue requires a certain degree of oxygenation to prevent feeling fatigued. When inadequate oxygenation is available due to the pathophysiology of the disease, a supply-and-demand imbalance occurs. Iron-deficiency anemia results in less iron available and less oxygen to adhere to the hemoglobin molecule. Relentless proliferation of lymphocytes invade and compromise the function of various organs, especially the bone marrow. Most clients with Hodgkin’s disease exhibit signs of immune deficiency early in the disease. Immunosuppressive therapy makes the client even more susceptible to infection and hemorrhage because of a compromised bone marrow function. Leukocyte proliferation is characteristic of lymphomas. Multiple myeloma is a neoplastic proliferation of the plasma cells. Antacids coat the stomach and intestinal lining, thereby inhibiting the absorption of iron supplements. Vitamin C increases absorption. Birth control pills and aspirin products have no effect on absorption. The greatest risk affecting a client with hemophilia is the potential for hemorrhage. Although activity intolerance may also be a problem, in these clients it is caused by the injury potential, not a decrease in functioning hemoglobin. Option 1 is appropriate for a client with pernicious anemia and option 3 for a client with leukemia. After a lymphangiogram, veins of the lower extremities, dorsal skin of the feet, and urine may have a blue-green discoloration from dye excretion for 2 to 5 days. The best response to the client’s question is one that provides accurate information as well as reassures the client. Thrombocytopenia is a decrease in circulating platelets leading to a prolonged bleeding time and disruption of the primary homeostatic plug. While a Vitamin K deficiency can lead to a prolonged prothrombin time, the patient does not exhibit petechiae and ecchymosis. Iron supplements are better absorbed if taken before meals; however, the side effect of nausea may be experienced if taken on an empty stomach. Taking with meals may hinder absorption, so orange juice or other foods containing Vitamin C may be taken with the medicine to help with absorption. ITP is an autoimmune disorder in which the body destroys platelets. In order to decrease the immune response, corticosteroids are usually administered. Platelet transfusions may be given in acute bleeding, however the body will actively destroy these as well. Although COPD can be an underlying etiology for the formation of secondary polycythemia, it is the chronic tissue hypoxia from the COPD that is the underlying cause of the condition. Not all patients with COPD develop the condition. Correct administration technique is to use a 90-degree angle (insulin syringes have a short 1/2-inch needle), avoiding aspiration before injection (to avoid tissue complications over time), and avoiding massaging the area after injection (which would enhance quicker absorption of the dose). Approximately 67% of all cancer occurs in people over age 65, necessitating early screening and detection. The incidence of cancer increases with age, making it a significant factor in the development of cancer. Benign neoplasms are localized, encapsulated growths. They are not malignant, and they do not metastasize. They are harmful only if they interfere with vital functions such as circulation. Malignant neoplasms have a high mortality rate unless therapeutic interventions are performed. The client's question is a normal, expected response. Administering antiemetics before chemotherapy helps reduce the severity of nausea. Waiting until the client is experiencing nausea demonstrates lack of planning. Cool foods and liquids are better tolerated and are less irritating than warm foods and liquids. Small, frequent meals are more easily tolerated and may reduce the incidence of nausea and vomiting. The client is a risk to others as long as the radiation implant is present. Therefore, certain precautions to protect others must be taken. The client should have a private room, and visitors should maintain a distance of 6 feet and limit visits to 10 to 30 minutes. The client may not need isolation for the entire period of hospitalization, rather just for the time the implant is in place. Washing the hair daily will promote further hair loss. Hair washing should be limited to 2 to 3 times per week. Options 2, 3, and 4 are correct actions taken by the client. The client with a low WBC count is at high risk for infection. The grandchild recently exposed to varicella could be contagious at this point. The nephew with HIV, unless currently infected with another communicable disease, does not pose a risk. There is no indication that the husband has tuberculosis. The pregnant daughter does not pose a risk. The American Cancer Society recommends a breast examination by a health care provider every 3 years for ages 20 to 39, then yearly from age 40 and older. Breast self-examinations should be performed monthly. Mammograms are recommended yearly beginning at age 40. Extravasation of the chemotherapeutic agent, especially if the agent is a vesicant, is a major complication of intravenous administration of chemotherapy. <i>Never</i> test vein patency with the medication. Making the client comfortable is important, but assuring vein patency is the highest priority. There is no indication to administer acetaminophen. The client with a low platelet count (thrombocytopenia) is at risk for bleeding. Aspirin further interferes with platelet functioning (option 1). Monitoring for fever (option 2) is necessary for low WBC count, and managing fatigue (option 3) is necessary for anemia. Flossing is contraindicated in the client with low platelet count (option 4). Damage to the mucous membranes, especially oral mucous membranes (stomatitis), leads to painful ulcerations of the mouth, interfering with the client’s desire to eat. The mucous membranes and mouth may be dry (xerostomia) as a side effect of the chemotherapy. Pale skin may be a sign of anemia, and ecchymosis may be indicative of a low platelet count. Thus, the problem should be set up as follows: Multiply 500 by 10 to yield 5000 and divide it by 60 to obtain a flow rate of 83.33 gtts/min, which rounds down to 83 drops/minute. The immunosuppressed client is at high risk for infection. A private room, maintaining aseptic technique, and limiting visitors will reduce exposure and risk. Fresh fruits and vegetables may harbor bacteria; serve cooked foods only. The client with a decreased platelet count should be counseled to avoid using razors. Unexplained, rapid weight loss may be the first symptom associated with cancer, and immediate evaluation is required. Options 2, 3, and 4 are risk factors associated with cancer, and education and screening are important to reduce the risk of cancer. Options 1, 2, and 3 are noncontrollable or nonmodifiable risk factors. Diet is the only listed risk factor that is controllable. Assisting the client to develop a diet plan low in fat and high in fiber will help reduce the risk of some types of cancer. Lotion, deodorant, and powders should not be applied to the radiation site during the treatment period to avoid further irritation to the skin. Options 1, 2, and 4 are correct actions. Long-handle forceps should be used to pick up the implant. Lead containers are necessary to prevent exposure to radiation. Direct handling of the implant causes exposure to radiation; no one should directly touch the implant. Gloves and biohazard bags do not offer protection from radiation. Infection control personnel have no role in the disposal of the implant, which should be returned to the radiation therapy department after properly being placed in the lead container. The conditioning phase depresses bone marrow function, and infection is the major cause of death for clients with leukemia. Options 1, 2, and 3 are appropriate concerns for clients receiving chemotherapy and radiation, but the risk for infection is the highest priority during this phase. The American Cancer Society recommends a digital rectal examination and PSA yearly for males beginning at age 50. Options 2 and 3 are only partly correct, and option 4 is incorrect. Denial is a protective mechanism, and during this time, the client needs a supportive environment. Allowing the client to express feelings will enable an effective adaptation to this change. Option 1 is not therapeutic. Wound care must be done in order to prevent complications (option 3), and the client is obviously not psychologically ready to participate in self-care (option 4). Options 1, 3, and 4 are common side effects of chemotherapy. Even though they do require intervention, ecchymotic areas may be a sign of decreased platelet count, making the risk of hemorrhage the priority. External radiation poses no risk of radiation exposure to contacts, even during intimate physical contact. Clients are encouraged to maintain their usual activities, as long as they are tolerated (option 3). There is no increase in risk of infection to the client with cancer during intimate physical contact unless that person has a current infection (then contact should be avoided until infection is treated). First convert the child’s weight to kg by dividing 44 by 2.2 to yield a weight of 20 kg. Then calculate the daily dose of the medication by dividing the number of mg (500) by the client’s weight in kg (20) to yield a single dose of 25 mg/kg. Because there are four doses (every 6 hours) ordered during a 24-hour period, multiply 25 by 4 to yield a total daily dose of 100 mg/kg/day. Bone marrow is usually harvested from the iliac crest (option 1), frozen, then stored until treatment. The marrow is administered intravenously through a central line. Options 3 and 4 are incorrect. Even though anemia (option 1) and hemorrhage (option 2) also result from bone marrow suppression, immunosuppression leading to an inability to fight infection is the priority to prevent complications potentially leading to death. Weight loss (option 4) may occur as a result of anorexia and can be managed. For cancers in females, by order of occurrence, breast cancer ranks first, followed by lung and colorectal cancers. Options 2, 3, and 4 are incorrect. Stomatitis is inflammation of the oral mucosa, a common side effect of chemotherapy. Management includes teaching the client to use a soft toothbrush, rinse mouth with plain water or saline, and avoid irritants such as mouthwashes, peroxide, and hot liquids (options 2, 3, and 4). Profound malnutrition can result from loss of appetite related to nausea and vomiting, and the concurrent stress of the body fighting cancer. Options 1, 3, and 4 do not completely address the issue of altered nutrition. Dietary habits that reduce the risk of cancer include consuming cruciferous vegetables such as cauliflower, broccoli, and cabbage (option 3) and high-fiber foods (option 4); avoiding nitrates in prepared meats (option 1); and limiting intake of red meats. Pineapple and other tropical fruits offer no special protection against cancer (option 2). The client receiving a bone marrow transplant must first undergo an immunosuppressive phase before receiving donor marrow. This places the client at extreme high risk for infection. Options 1, 3, and 4 are potential complications but are not immediately life threatening. In the elderly and immunocompromised client, even a slight elevation of temperature may indicate an infection and must be investigated and treated immediately. Options 1, 2, and 4 are appropriate actions to be taken by the family. A white coating on the tongue may indicate thrush (<i>Candida</i>). Infections should be identified and treated immediately to avoid complications. The client may experience a very dry mouth (xerostomia), but it is not a serious complication (option 1). Dental floss should be avoided if the client has thrombocytopenia secondary to bone marrow suppression (option 3). Mouthwash should be avoided to reduce irritation to the mouth (option 4); however, options 3 and 4 do not relate to follow-up care. Superior vena cava syndrome is usually caused by the growth of a lung or mediastinal tumor, not by metastasis (option 1). The tumor obstructs the flow of blood to the right atrium, leading to facial and arm edema. Superior vena cava syndrome occurs as a late-stage manifestation (option 3), and option 4 is incorrect. Since the infusion pump delivers fluid in mL/hour, the nurse needs to calculate the equivalent hourly rate when infusing the 100 mL over 90 minutes. The problem can be set up as follows to cancel out the labels and end up with mL/hour: Multiply 1000 by 60 to yield 6000 and divide it by 90 (90 x 1) to obtain an equivalent hourly flow rate of 66.66 or 66.7 mL/hr. This answer also makes common sense because if the medication were infusing over 90 minutes, then two thirds of it would infuse in 1 hour; 66.7 mL is two thirds of 100 mL. One of the most common side effects of gentamicin is nephrotoxicity. The nurse can monitor kidney function by monitoring intake and output. White blood cells are one component of the general nonspecific immune response. They are among the first responders stimulated by a pathogenic organism. A white cell differential can often determine if the illness is of bacterial, viral, or allergic origin. Oral polio virus vaccine contains a live virus, which could cause an infection in a child who is immune-depressed as a result of taking steroids. Care of the immunocompromised child focuses on preventing infection. The nursing implementations related to reaching this goal might include limiting contact with a large number of people, but that would not be the goal of the nursing care plan. Allergies are confirmed by a RAST test. RAST is a radioallergosorbent test that detects IgE antibodies that are part of the allergic response. Urticaria is itching and is symptomatic of allergies and other diseases, and an increase in eosinophils is diagnostic of allergies. The acronym TORCH stands for toxoplasmosis, other (syphilis, hepatitis), rubella, cytomegalovirus, and herpes simplex virus. It is a study of common viruses that cause significant fetal damage. Neonates with sepsis may display either hypothermia or hyperthermia, but hypothermia is more common. The other symptoms are not associated with sepsis. Families need to know that casual contact cannot spread HIV. However, basic infection control practices must be maintained to prevent exposure through body fluids. Growth and development milestones and immunization schedules are routine elements of teaching, and are therefore not as high a priority for this client as infection control. Lab studies and results are ongoing and are therefore also lesser priority. The prodromal period refers to the period of time between the initial symptoms and the presence of the full-blown disease. The rash would not be apparent during this time. All the other statements are correct. Cloth items hold in dust. Only essential items should be stored in the child’s bedroom, and those should be in drawers or closets. Stuffed animals retain dust and should be removed from the bedroom. Cotton curtains would be preferred over blinds because cotton curtains can be washed frequently. Both the mattress and the bed should be enclosed in special plastic covers to eliminate a source of dust. First convert the child’s weight to kg by dividing 55 by 2.2 to yield a weight of 25 kg. Then calculate the daily dose of the medication by dividing the number of mg (250) by the client’s weight in kg (25) to yield a single dose of 10 mg/kg. Because there are 3 doses (every 8 hours) ordered during a 24-hour period, multiply 10 by 3 to yield a total daily dose of 30 mg/kg/day. Prick tests determine allergens. Should the child have an allergy, epinephrine might be needed to counteract anaphylaxis. Corticosteroids such as prednisone are helpful in minimizing allergic response, but would not be effective in the management of anaphylaxis. In addition, pretreatment with prednisone would make test results invalid. Naloxone reverses the effects of opioid analgesics, and cromolyn sodium is useful in managing asthma. Every time a child enters the health care system, the immunization status should be checked. Some children have uncertain history of immunization due to parental noncompliance or special circumstances, such as being refugees. Infants receive passive immunity, which lasts 3 to 4 months, through the placenta or breast milk. Active immunity lasts long term and is acquired by exposure to disease or immunizations. The immunocompromised child would be the one at greatest risk for acquiring an infectious organism. The other children would be at less risk for acquiring the gastrointestinal infection. Eosinophils are the type of white blood cell that is associated with allergic reactions. Hemoglobin is present in red blood cells (RBCs), and RBCs carry oxygen to tissues. Leukocytes fight infection. TORCH is the acronym for a set of microbes that includes toxoplasmosis; other (syphilis, hepatitis); rubella; cytomegalovirus; and herpes simplex. If an infant has one of the viruses, the virus could be shed for up to 1 year. The baby may be asymptomatic at birth, but the disease may show up later. The disease is congenital—present at birth but not genetic. Since the baby may shed the virus, which in turn would affect an embryo, a pregnant woman should avoid contact with the baby. The earlier in pregnancy the embryo is exposed, the greater the risk of fetal loss or damage. The HIV virus is spread by contact with blood and body fluids. Clean gloves should be worn when changing the diapers as bare hands would expose the workers to body fluids. It is not necessary to store the infant’s items separately from those of others, since the virus is not transmitted on objects. It is also not necessary, and in fact is excessive, to wear isolation gowns, and it is unnecessary to minimize contact when the infant has a fever. The incubation period is the time between exposure and outbreak of the disease. It is often a period when the child can be contagious without others being aware of the possible exposure. Koplik’s spots are associated with measles (rubeola) and appear on the buccal mucosa 2 days before and after the onset of the rash. An elevated basophil count is associated with a chronic infection, inflammatory reactions, or stress. It is not associated specifically with allergy, viral infection, or bacterial infection. Since the infusion pump delivers fluid in mL/hour, the nurse must calculate the equivalent hourly rate when infusing the 400 mL over 90 minutes. The problem can be set up as follows to cancel out the labels and end up with mL/hour: Multiply 400 by 60 to yield 24,000 and divide it by 90 (90 x 1) to obtain an equivalent hourly flow rate of 266.66 or 267 mL/hr. A scratch test tests many allergens at once. It is of low sensitivity, but many allergens can be tested at once and the results can be obtained in 30 minutes. Caladryl will reduce itching and discomfort and therefore diminish scratching and skin breakdown. Acetylsalicylic acid should not be given to young children with a viral disease because of the relationship to Reye's syndrome. Immunizing the sibling and isolation will have no effect on skin eruptions. The child will need to be tested at approximate 3-month intervals until the child is 18 months to 2 years. CD4+ counts are used to assess a young child’s immune status and risk for disease progressions. The p24 antigen test needs to be repeated if positive. The ELISA is used with children over 18 months. Carpet, bedding, fabrics, pets, dust, and cigarette smoking can cause allergic reactions. Even with aggressive treatment, prognosis is poor. Current developments in bone marrow transplantation are hopeful. Because of possible genetic involvement, parents may feel some guilt. The child’s immunizations should be kept up-to-date. Live vaccines should be avoided for the child and family. The family will need information on how to protect themselves and how to administer the prophylactic drugs as well as their side effects. The child can safely attend school with proper education of the school personnel. Bone marrow aspirations are usually performed under local anesthesia unless the child is too small to cooperate and hold still. The other statements are correct and do not require further follow-up or teaching. Emotional support for families of HIV+ clients can be challenging. Families who have already dealt with the problems associated with the disease process are most likely to be receptive to the discussion and able to offer emotional support. Active acquired immunity occurs when the body produces antibodies or develops immune lymphocytes against specific antigens (chicken pox). Breastfeeding a child would offer passively acquired immunity; immune globulins offer passively acquired artificial immunity; immunizations offer actively acquired artificial immunity. A client with AIDS will usually have a low CD4 count and a high viral load. What is desired is to have a high CD4 count and a low viral load (which should normally be zero). The white blood count will usually show neutropenia. The problem can be set up using ratio and proportion as follows: Multiply 80 by <i>x</i> and multiply 200 by 5 to yield 80<i>x</i> = 1000. Divide 1000 by 80 to yield 12.5 mL. The ELISA test may be negative upon initial testing and positive at the time of seroconversion, which takes 6 to 12 weeks after infection. This time period when the antibodies are negative is called the seroconversion window and virally infected individuals may have negative antibody tests. Type I hypersensitivity reactions are caused by widespread antigen-antibody reactions such as anaphylaxis. These responses are usually immediate and lead to an antigen-antibody complex that causes the release of histamine. Option 4 is an explanation of what occurs with a blood transfusion reaction. Option 3 is an explanation of a type IV delayed hypersensitivity. Option 1 is false. Recognition of self as foreign is the definition of any autoimmune disease. Further explanation may be needed to explain that the immune system usually recognizes self and identifies what is foreign, targets foreign cells, and destroys them. You should have recognized this as serum sickness, a reaction a week after ingestion of a drug. Serum sickness is a type III hypersensitivity reaction where formation of IgG or IgM antibody-antigen complexes occurs in the blood. Symptoms of HIV infection are vague and nonspecific. Characteristic manifestations of HIV disease resulting from opportunistic infections and neoplasm make treatment difficult. Invasion may be from sexual contact as well as blood contact. HIV is not always predictable because the virus can lie dormant for many years. There are really no carrier states in HIV. Only fluids containing blood or blood cells have been identified as a mode of transmission for HIV. Collecting blood, especially in a mobile unit (where the population is more diverse) is a risk for any health care worker. Appropriate gloving is essential. Counseling may require touch, which isn’t a form of transmission; perspiration has not been identified as a form of contact; and the ELISA test requires contact with saliva. Because laryngeal spasms and bronchial constriction can occur with anaphylaxis, assessing the client’s airway is top priority. The nurse should maintain and establish a patent airway first. Remember the ABCs (airway, breathing, and circulation); cardiac output would come next followed by risk for injury and finally anxiety. A client with AIDS will have exacerbations and remissions with opportunistic infections, therefore symptoms may vary. With a diagnosis of AIDS, an ELISA test would remain positive for antibodies. WBC of 1,700 shows neutropenia, which does not indicate improvement. The CD4 cell count between 200 and 500 is in the “suppressed immune state” but certainly above the 200 mark that is indicative of severe depression of the immune system. Eosinophils are usually elevated in an allergic response. The WBC in option 2 is barely above normal. The monocytes are normal in option 3 and the elevated neutrophils indicate an acute infection (option 4). The mother is already alarmed enough, and the nurse needs to be careful with wording of the response. Option 2 is correct and is not alarming so that the mother may be able to focus on a different perspective besides cancer. Before making a decision about how to infuse the antibiotic, the nurse should check compatibility of the antibiotic with the continuous IV solution. If the drug and the infusion were compatible, they would be run at the same time. If the drug and infusion were incompatible, the nurse would stop the infusion during the period of antibiotic administration and flush the line carefully before and after the antibiotic. It is often inadvisable to start a second IV site unless absolutely necessary. The other answers are incorrect. This type of contact dermatitis is commonly a delayed reaction and a type IV hypersensitivity. This reaction is cell-mediated rather than antibody-mediated and delayed 24 to 48 hours. Remember the Rh must also match besides the type of blood (A in this case). Rh matching is not just for mothers and infants to prevent erythroblastosis fetalis. Clients with a history of allergies to fruit such as bananas or kiwi tend to have latex allergies. The degree of moistness of the skin might need to be assessed but will not determine a latex allergy. Although drug allergies should be asked about, this information does not help in determining a latex allergy. Option 4 is also important information for an assessment, but the focus of the question for a latex allergy would be if there were any problems after the surgery similar to the one being exhibited now. A barking cough, wheezing, and stridor are clinical manifestations of the bronchoconstriction and edema that accompanies anaphylaxis. The blood pressure is usually low (hypotension) and the pulse fast (tachycardia). The T helper cells are the primary target for the parasite to infect in order to replicate. The virus destroys the T-cells and along with this destruction, memory cells can also be destroyed, hence opportunistic infections are more prevalent. The police officer and nurse on the telemetry unit should be using standard precautions including gloves anytime body secretions are encountered. Although either of these may encounter blood accidentally, the percentage is low. A school nurse should not be coming into contact with body secretions that would increase the risk factor. A sexually active teenager, especially if the act is unprotected, is at highest risk. The stages of HIV are varied, but most clients begin with flulike symptoms that occur days to weeks after contracting the virus. Following this is a long asymptomatic period; however the virus is still present. It is unclear why or when a client moves from being asymptomatic to AIDS. To answer this question correctly, you must understand that transfusion reactions (in this case from mother to child since the Rh was incompatible) is a type II hypersensitivity reaction. The maternal antibodies that were developed with a first child who may have been Rh+ are passed to the infant and cause hemolysis of fetal red blood cells (not white blood cells). The child may suffer from anemia (option 3), but this is not the primary cause of the problem. The spleen is vital in storing blood and in the breakdown of red blood cells, but it is not essential for life. The liver and bone marrow assume its function when it is removed, and most clients do well even though it is removed. Common manifestations are fever, chills, low back pain, hypotension, tachycardia, nausea, and vomiting. Urticaria and red-colored urine are often seen. A mask is necessary for anyone within 3 feet of a client with an infection spread by particle droplets. There is not enough information in the question to support the use of any other equipment. Alarms sound on electronic infusion devices when the infusion is complete, there is an occlusion, air is in the line, the battery is low, or the cassette is improperly loaded. The other answers are incorrect reasons for an alarm. Edema and bronchoconstriction are the clinical manifestations involving the respiratory system in anaphylaxis and usually produce diminished lung sounds, wheezing, and stridor (which does not require a stethoscope). TB skin tests are read 72 hours after administration and a true positive reading should show redness and be raised (greater than 5 mm). Clients may react within several hours to 24 hours of receiving the injection and then show a negative finding at 72 hours. A TB skin reaction at 72 hours is a type IV delayed hypersensitivity reaction and can indicate exposure or active disease. Acute tissue rejection is common and usually occurs between 4 days and 3 months after transplant. The manifestations are caused by the inflammatory process. The key word in this stem is <i>first</i>. All of the options are correct, and the nurse should perform all of them, but in the proper sequence. The transfusion should be stopped because of the signs of a transfusion reaction. The physician then needs to be called, and the vital signs and client should be monitored every 5 minutes. Sending the bag to the laboratory is the last step. When the viral load (number of circulating HIV particles per milliliter) is high and the CD4 count is low, the client is most at risk. This would explain why the opportunistic infections are recurring—the immune system is extremely compromised. A zero viral load is expected in normal individuals. A moderate or low viral load may be seen in clients who have received medication for AIDS. Although options 2, 3, and 4 are sometimes the case, the flulike symptoms are rather vague. Most individuals do not rush to a physician with flulike symptoms unless they are not getting any better. Sexual activity if one partner is positive for HIV can be resumed as long as protection is always used. Option 1 is inappropriate and option 2 is incorrect. Option 3 may need to occur but seems to be an answer that avoids the client’s concern at this time. Consenting sexual partners should be tested to determine that each is HIV-negative if unprotected sex is preferred. No known proof exists that saliva is a route for transmission. HIV-1 is the most common form in the United States, HIV-2 is in Africa, and AIDS is still a major threat to certain populations in the United States. Killer T cells bind with cell-surface antigen or virus-infected or foreign cells. Killer T cells destroy the antigen by combining with it and then either destroying its cell membrane or releasing cytotoxic substances into the cell. After exposure to a known antigen such as hepatitis, temporary immunity is recommended in the form of immune globulins. If the nurse had received the hepatitis B vaccine (Heptavax), he or she should have artificial active immunity. Remember, natural immunity comes in the form of antibodies from having the disease or from mothers who breastfeed. All catheters should be flushed with syringes with barrels of 10 mL or larger. The smaller the barrel size, the greater the pressure that comes from the tip. Smaller syringes could damage the catheter. All other activities are done correctly. An Arthus reaction is a type III hypersensitivity reaction that causes acute, localized edema and tissue inflammation (usually of the skin). It usually occurs at the site of an injection of an antigen in a client previously sensitized. Hay fever is an atopic type I reaction that is local instead of systemic. Transplant rejection is a type IV; transfusion reaction is a type II, and serum sickness is a type III. Graft-versus-host disease is most common with bone marrow transplants. When immunocompetent graft cells recognize host tissue as foreign, a cell-mediated immune response occurs. CD4 or T helper cells are those that play a key role in controlling the immune response by stimulating proliferation of other T cells, amplifying the cytotoxic activity of killer T cells, activating B cells to proliferate and differentiate, and interacting directly with B cells to promote antibody production. In category A of the CDC classification, individuals who have been infected may not demonstrate antibodies on an ELISA test or Western blot. This time period when antibodies are negative, but infection has occurred, is called the “seroconversion window.” The danger here is that the individual does not know he or she is HIV-positive and may infect others. AIDS dementia complex involves cognitive, behavioral, and motor deficits and is a common central nervous system complication of untreated HIV. Along with the above symptoms, apathy, confusion, hallucinations, personality changes, unsteady gait, leg tremors, impaired handwriting, and mental slowing will occur. Antibodies that the mother has will be passed on to the infant. This form of immunity is natural versus artificial. Remember the difference between passive (temporary immunity) and active (long term). Words such as indefinite (option 1) and all (option 2) should be red flags that these are incorrect. Allergic rhinitis is a type I or IgE-mediated hypersensitivity where an allergen interacts with IgE that is bound to mast cells and basophils. A radio allergy sorbent test (RAST) will determine the presence of IgE. Any local reaction (type I hypersensitivity) to an injected allergen should place the nurse or health care provider on guard for a possible anaphylactic reaction. The client should be closely monitored. The itching and edema are common local reactions. If itching occurs all over, especially on the palms and scalp, a systemic effect is likely. If dyspnea occurs, a systemic anaphylactic reaction is occurring and precaution should be taken to manage the airway. A wheal and flare reaction usually doesn’t occur for several hours or days and is a local reaction, sometimes expected. Reactions such as these may be genetic and knowing whether other members of a family have similar reactions is useful in determining a cause. The use of OTC medications and home medications may be helpful, but if this reaction has not occurred before, it is less likely to be from those sources. Option 3 would not offer any assistance at this time. Groshong catheters have a three-way, pressure-sensitive valve that restricts air from entering the venous system and prevents backflow of blood; therefore, the catheter should not be clamped and the client does not need to perform the Valsalva maneuver. The catheter is designed so that only saline is used to flush. The other answers are incorrect actions for catheter maintenance. Airway is always first (ABCs) when determining priority in an emergency situation such as this. All of the other options are accurate and should be implemented, but with the symptom of difficulty breathing, laryngeal edema is a priority concern. Although a change in occupation may be wise, the beekeeper can practice cautious steps and preventative measures to protect self. A MedicAlert bracelet is highly suggestive and epinephrine (EpiPen) should be with the client always. Use of corticosteroids as a maintenance dose is not recommended because of the vast majority of side effects. Decongestant nasal sprays have a rebound effect, which causes congestion and swelling of the mucous membranes with long-term use. Although temporary relief may be obtained, continued chronic use of the sprays may be needed due to this engorgement of the vessels and increased congestion. This client may need to consult an allergist or physician. This question draws on your knowledge of pharmacology. As you study and you find a question such as this that you miss, go back and look up the classification of this drug and agents such as oxymetazoline (Afrin) or phenylephrine (Neo-Synephrine) and reread about it. This is an example of graft-versus-host disease (GvHD), which is a complication of bone marrow transplants. When immunocompetent graft cells recognize host tissue as foreign, a cell-mediated immune response is initiated. The skin, liver, and gastrointestinal tract are often targets. This client has a Category C2, which is an AIDS-indicator condition (pneumonia) and a CD4 count between 200 and 499. Category A: PGL is persistent generalized lymphadenopathy and would not be accompanied by the pneumonia. Category B has several conditions that may occur but <i>Pneumocystis carinii</i> pneumonia is not one of these. Wheals, erythema, and itching are common after a skin prick test, which is conducted by placing a drop of a specific allergen to the skin and pricking the skin at the site of the drop. A response should occur in 15 to 20 minutes. Dyspnea would indicate an anaphylactic reaction and usually hypotension occurs. A rash usually doesn’t occur over the entire body. Mental status changes ranging from restlessness to confusion is one of the most frequent “atypical” signs of infection in older adults. Fever, erythema, edema, and leukocytosis may be present in varying degrees; however, these presentations are considered typical responses. Coexisting chronic conditions along with the use of prescribed medications may cause typical responses to be minimized or absent altogether in the elderly client. Any client who presents with unexplained weight loss and persistent nonspecific complaints of fatigue and nausea should be evaluated with regard to HIV status. Testing measures are not always conclusive and it is not apparent from the client's statement exactly what specific tests were administered. Low-grade fever does not correlate directly with the presence of HIV. Vitamin supplements could be considered to be supportive and protective. A history of blood transfusion may prove to warrant further assessment, but it is not the highest priority at the present time. Type 1 hypersensitivity involves humorally mediated antigen-antibody reactions. Food allergies and medications can provide a localized as well as systemic response. Clients who have a history of multiple allergies usually have high IgE levels that are a characteristic measure of this type of reaction. The other hypersensitivity reactions do not apply to this characteristic presentation. Antinuclear antibodies indicate the presence of an autoimmune disorder. They are not considered specific for systemic lupus, because many other autoimmune disorders have significant numbers of these antibodies. This reported titer is suggestive of the presence of ANA antibodies, and therefore it is an abnormal response. Although it is not necessary to flush peripheral capped access devices with heparinized normal saline (100 or 10 units per 1 mL of normal saline), central venous access devices that are not Groshong catheters are flushed per agency protocols with heparinized normal saline. When medications are administered, the access device is first flushed with normal saline, then with heparinized normal saline. Heparin is incompatible with many medications, and for this reason, normal saline is used prior to the administration of heparinized saline that maintains patency of the catheter. The other answers are incorrect procedure. Clients with a past medical history of anaphylaxis should have epinephrine readily available for emergencies because it is the drug of choice for treatment. Tylenol and ASA will not mediate the chemical response to prevent anaphylaxis. Benadryl, although an antihistamine, may not be effective enough to prevent a full-blown anaphylactic response. Plaquenil is an antimalarial agent used in the treatment of rheumatoid arthritis. This medication can cause retinal toxicity, and therefore the client should be closely monitored for this possibility with specified visual exams. Gastric irritation, fluid retention, pulse elevations, and drowsiness are not routinely seen with this type of medication. Anticholinesterase medications are aimed at symptom management. These medications should be taken prior to eating to help the client chew and swallow and to minimize gastric upset. Taking this medication at night may not provide symptom relief, and since absorption is variable, the client may not be assured of receiving the correct dose. The medication does not have to be taken with milk in order to minimize gastric upset. Taking the medication on a full stomach (which would constitute after eating) would not allow for the primary effect of aiding with swallowing and chewing that is needed in clients who have this disease process. Raynaud's phenomenon is one of the most common findings associated with systemic sclerosis. Conjunctivitis, photophobia, and splenomegaly can all be seen in clients who experience the effects of systemic lupus erythematosus. The client’s understanding is demonstrated by acknowledging the fact that sun exposure should be limited to times other than 10:00 a.m. to 3:00 p.m. (when the sun is at its highest intensity). Tanning bed exposure can be considered to be an ultraviolet light trigger and could exacerbate dermatologic presentations. Initial use of SPF 15 sunscreen (or higher value) is indicated, as is the reapplication of sunscreen during exposure periods. Clients should avoid exposure to potential infection. Regardless of isolation precautions, the basic action by the nurse to prevent infection is hand washing. All of the other options should also be followed but hand washing establishes the first line of defense and is therefore of highest importance. CDC case definition of AIDS for adults states that the two factors described in the question are diagnostic of progression to AIDS. Seroconversion and positive HIV status has already occurred. The latent period is considered to be one in which the individual is asymptomatic. A client diagnosed with an autoimmune disease is faced with a lifetime of chronic illness and yet may not appear acutely ill because of the episodic nature of remissions and exacerbations. The nurse promotes a therapeutic relationship by allowing the client to ventilate feelings. It is inappropriate to minimize any changes that a client may experience that are unnoticeable to others as they may be quite unsettling to the individual. It is not the role of the nurse to speculate how a disease process will progress. Suggesting that the client use any “available remedy” may lead the client to potential harm or medical quackery. Pain and pain control are the most important elements of care for a client who has rheumatoid arthritis. Interventions aimed at pain management will allow the client to function at a more optimal level. While the other diagnoses are important, pain management remains the critical factor. Raynaud’s phenomenon is a common presentation in clients who have scleroderma. It is characterized as a vasospastic disease of the periphery that causes color changes ranging from pallor to reactive hyperemia. Joint swelling, effusion, and symmetric polyarthritis can be seen in other autoimmune processes such as systemic lupus erythematosus and rheumatoid arthritis. One of the complications of IV therapy is air embolism—introduction of air into the vein. Air embolism can be prevented by using luer lock devices on all attachments. The other responses are unrelated to this connection. One of the most critical problems with regard to antiretroviral therapy is the emergence of antiretroviral resistance as the HIV virus continues to mutate. Combination therapies have been proven to be more effective in treating disease progression. Antiretroviral therapies, in proper dosage, do not cause specific organ toxicity, although they can cause myelosuppression. Vaccines are administered to the client to promote the development of specific antibodies to afford protection. This is an example of active artificial immunity. Active natural immunity implies the development of antibodies in response to a client who had an actual active infection. Passive natural immunity implies the maternal and or placental transfer of antibodies. Passive artificial immunity implies the specific injection of an immune serum. The client should be monitored for myasthenic crisis, which is often a result of missed or undermedication. The other options (gastrointestinal symptoms, vertigo, and bradycardia) are associated with cholinergic crisis. Cholinergic crisis is usually the result of overmedication. Both complications are viewed as acute in nature and may require airway assistance. The nurse must be acutely aware of the potential for clients with MG to have these types of complications. Airborne precautions should be instituted for all clients being admitted with a diagnosis of tuberculosis. Specific CDC guidelines may also be instituted to prevent TB transmission in health care facilities. Standard precautions should be maintained for all clients in the hospital setting. Contact and droplet precautions do not apply to this disease process. Scattered area rugs are a potential safety hazard for an individual who has long-standing RA because of possible joint deformities and contractures that could increase risk of falls. All of the other assessment findings are considered to be supportive of this client with RA because they enhance mobility, safety, and medication compliance. The spleen is not usually palpated in an individual with normal immune function. Splenic enlargement (splenomegaly) is associated with a deviation from normal and bears further investigation. Deep palpation is not indicated when splenic congestion is noted as it may cause the spleen to rupture. Dehydration and allergic reaction are not consistent with enlargement of the spleen. While breastfeeding does convey passive acquired immunity to the infant, it by no means offers complete protection against any and all infectious processes. Immunizations with antigens (vaccines) will provide the infant with active artificial immunity and is more long lasting. In addition, the infant can and will receive "booster" doses to maintain immunity status. The length of time or duration of breastfeeding is not the sole determinant of an infant’s passive immunity. The richest source of immunoglobulins is actually provided to the infant during the transfer of colostrum, which is the precursor to actual breast milk. The thymus gland is located in the superior mediastinum. In the child, the gland is usually quite large. As the individual ages, the gland shrinks in size. Initially, the thymus gland is responsible for T-lymphocyte differentiation and maturation. The gland becomes a source of connective tissue, lymphocytes, and fibers in the older client. The MPS helps to trigger or promote an immune response by capturing, processing, and presenting the antigen to the lymphocyte. The MPS contains monocytes and macrophages that participate in forming a bound antigen complex and presenting it to circulating lymphocytes to elicit an immune response. While the MPS is a critical factor in the immune response, it does not complete the immune response, but rather serves as a pathway for the response to start and progress. The MPS operates using the process of phagocytosis, whereby it engulfs the antigen. CD4 cells are indicative of a client’s HIV status. As the disease progresses, the T-helper cells decrease in number and lose their ability to function effectively, leading to an overaggressive immune response. B-lymphocytes indicate the status of humoral immunity and are not directly associated with HIV infection. NK cells and T-cytotoxic cells are not directly related to HIV infection and as such are not considered to be reliable indicators of HIV status. The device that provides the most accurate infusion rate is the electronic infusion pump. The other devices are less accurate and less controllable. Transfusion and Goodpasture’s are examples of type II cytotoxic hypersensitivity reactions and are involved with the activation of complement. Lupus is an example of a type III hypersensitivity reaction which involves IgG and IgM with the activation of complement. While Megace is used as a palliative treatment for clients with advanced cancers, this is not the rationale for its use with AIDS. In AIDS clients, it provides appetite enhancement. Side effects of Megace can include nausea and constipation. Hyponatremia is a common finding seen in clients with AIDS. The incidence of opportunistic infections may contribute to this decrease in sodium. Hypernatremia, hyperkalemia, and hypocalcemia are not usually seen in clients who have AIDS. With a diagnosis of neutropenia, the primary concern is to protect the client who is immunosuppressed from developing further infections. The immunosuppressed client should not be exposed to potential infection in a semiprivate room (option 1). Use of Standard Precautions will prevent transmission of the virus (option 3). Contact precautions are unnecessary (option 4). Celery juice, honey, and fresh fruit are considered to be “noneffective” dietary foods for clients with arthritis. Salmon is high in omega-3 fatty acids. Omega-3 fatty acids have proven to be of benefit in clients with heart disease and rheumatoid arthritis by reducing inflammation. Client identification of help from family support indicates that coping strategies have been instituted and have allowed the client to adapt to the disease process. Refusal to discuss other matters does not reflect successful coping strategies or open communication. Scheduling requests relates to personal preference and time management, not coping. An opportunistic infection is one in which an individual develops a disease from an organism that does not cause disease in healthy individuals. This occurs with compromised immunity. Antibiotics may affect the outcome of the culture. Fever will continue to be present until the bacteria are eliminated, making obtaining a culture a priority. The erythromycin products are the best for treating mycoplasmal pneumonia or walking pneumonia. Vermox is used for helminthic infections; Aralen hydrochloride is used for protozoal infections; and Chloromycetin is used for spirochetal infections. A pathogen is any organism capable of causing disease. Pathogenicity refers to the ability of the organism to cause pathologic changes. 0.45% sodium chloride (1/2 normal saline) is a hypotonic solution that draws fluid from the vascular compartment into the cells. Normal saline and lactated Ringer’s are isotonic solutions, while 5% dextrose in normal saline is a hypertonic solution until the glucose is metabolized, then it is isotonic. The virus makes a DNA copy of its own RNA using the reverse transcriptase enzyme and the DNA copy is inserted into the genetic material of the infected cell. Influenza virus is transmitted through respiratory droplets. Herpes virus is transmitted by direct contact and HIV through blood and body fluids. Cytomegalovirus is an opportunistic infection. Epidemiological studies indicate Chlamydia as the most prevalent sexually transmitted disease in the United States. Endotoxins are often not destroyed even by autoclaving. Options 1, 2, and 4 are descriptions of endotoxins. Rickettsia are parasites of ticks, fleas, and lice. Influenza is an example of transmission by respiratory droplets; encephalitis is transmitted by mosquitoes; and lice and scabies are transmitted by direct contact. Infection occurs in a predictable sequence requiring virulence, movement from a reservoir, and entry into a susceptible host. The capsule contributes to the invasiveness of pathogenic bacteria. Encapsulated bacteria are protected from phagocytosis unless coated with anticapsular antibody. Eosinophilia is present with allergies and infestation with parasites. Neutrophils are elevated with acute infections and bacterial organisms. Options 2 and 3 are irrelevant. Epidemiology is the study of how various states of health are distributed in the population. Herpes is a virus and is spread through direct contact. An antifungal would not be useful; bed rest and temperature measurement are usually not necessary. The Groshong catheter is designed with a three-way, pressure-sensitive valve that restricts air from entering the venous system and prevents backflow of blood. The other options do not have this protection. Acyclovir is the antiviral drug of choice for treating herpesvirus. Penicillin products are used for a wide variety of bacterial infections. Rifadin is used for TB and Virazole is an antiviral agent. Neutrophil counts are often decreased in viral infections and elevated in bacterial infections. Neutropenia can occur because of chemotherapy and immunosuppression. With recovery, his neutrophil count should be returning to normal. Abdominal distention is caused from infestation of worms. Blood in sputum often results from migration of worms through alveoli. Mycoplasma pneumonia has similar side effects as bacterial pneumonia (cough, fatigue, rales, and temperature). Spirochetes cause fever, neck stiffness, and lymphadenopathy; rickettsial infections cause headaches, nausea, vomiting, and muscle aches. Prions are associated with degenerative encephalopathies. While similar to viruses, they lack nucleic acid and lesions are usually limited to a single organ. With bacterial infection there is an increased need for neutrophils. When the percentage of immature neutrophils (bands) increases at a greater rate than mature neutrophils (segs), it is an indication that the infection is severe or prolonged. This is often referred to as a shift to the left. Lyme disease is a spirochetal infection. Examples of rickettsial infections are typhus and Rocky Mountain spotted fever. Cytokines serve as mediators of inflammation, while leukocidin, adherens, and coagulase enhance bacterial resistance to body defenses. Most antifungal agents act by inhibiting biosynthesis of ergosterol. A surface peptide found in chlamydia is similar to one in heart myosin and may trigger T-cells to attack both chlamydia and the heart. Fungizone and Mycostatin are both antifungal agents. Mycostatin is most commonly used for topical application, while Fungizone is used systemically. Infiltration is leakage of fluids into the surrounding tissues, resulting in edema around the insertion site, blanching, and coolness of skin around the site. The other options would not have these manifestations. Chlamydia is a bacteria and responds to bacteriostatic agents that interfere with protein synthesis. Neuropathies are usually associated with spirochetal infections along with lymphadenopathy, fever, and stiff neck. Skin rash is associated with rickettsial infections; an unproductive cough and fever could be many infections including protozoal. Toxic shock is usually associated with staphylococcal infections. Pneumocystis pneumonia is a protozoal infection that often affects immunocompromised clients with human immunodeficiency (HIV). It is characterized by a dry, unproductive cough and results from aggregation of parasites and cellular debris. Administration of immune globulins can provide passive short-term immunity to the disease if administered within 7 days of exposure. Hepatitis A is transmitted through food feces and is usually not chronic. Epstein-Barr virus is the causative agent for mononucleosis. Varicella zoster results from reactivation of a latent virus in sensory cells of the dorsal root ganglion. Activation tends to follow the nerve path. Influenza has been associated with Guillain-Barré syndrome, which causes progressive paralysis. The bacteria produces a neurotoxin that blocks release of acetylcholine at the neuromuscular junction. Klebsiella is a Gram-negative rod. Aminoglycosides are used effectively against Gram-negative bacteria by binding to ribosomes and preventing protein synthesis. The enzyme urease produced by the bacteria raises the pH of the stomach, allowing the bacteria to survive. Urea in the stomach is converted to ammonia, which is cytotoxic to gastric mucosa. Continuing the infusion at that site would only increase the phlebitis. The IV is discontinued and restarted at a new site. Applying a warm compress to an area of phlebitis dilates the vessel, improving circulation, and reduces the resistance to blood flow from within the vein reducing the pain. The other options are incorrect. Scarlet fever, rheumatic fever, and glomerulonephritis can all result from streptococcal bacteria. Tuberculosis is caused by M. tuberculosis; PID by Neisseria gonorrhoeae; and toxic shock by staphylococcus. While the PPD skin test can detect previous exposure to the tuberculosis bacillus, it does not necessarily establish the presence of active infection. Treatment for tuberculosis often requires months of antimicrobial therapy and compliance must be encouraged. Tetracyclines and chloramphenicol are identical in mechanism of action and organisms against which they are effective. Chloramphenicol is reserved for serious infection because it may cause bone marrow suppression. Mycoplasma pneumoniae is an atypical form of pneumonia, occurs often in children, and is transmitted by droplets. Signs and symptoms are similar to bacterial pneumonia and the virulence is no worse. The proximity of the anus to the urethra in female clients increases the risk for infection from bacteria normally found in the colon, such as <i>E.coli</i>. Prion disease is similar to viruses. <i>Staphylococcus</i> is responsible for many infections such as sepsis, cellulites, and toxic shock syndrome; <i>Treponema</i> causes spirochetal infections. Urease breaks down urea in the stomach, producing ammonia that increases the pH to allow survival of <i>Helicobacter pylori</i>. Amebic infection can be carried via the blood to other organs, with the liver as the most common site, causing liver abscess. Both forms of hepatitis may result in jaundice, fever, and elevated liver enzymes, but the incubation period for hepatitis B is greater than that for hepatitis A. Clients with antibiotic-resistant microorganisms must be isolated with transmission-based precautions. The organism is transmitted via close person-to-person direct contact and by touching contaminated surfaces and objects. Standard precautions are used with all clients, regardless of medical diagnosis. Reverse isolation is instituted for immunocompromised clients. This organism is not transmitted via droplet nuclei. Tourniquets are made of latex. A blood pressure cuff can be used as an alternative method of vein distention. A new tourniquet may not resolve the latex issue. The other responses do not address the latex issue. Both gonorrhea and chlamydia may be asymptomatic, with the bacteria invading reproductive organs prior to detection. Toxoplasmosis is spread through contact with cat feces. Ticks carry the threat of Lyme disease or rickettsial infections. Protozoal infections can be found all over the world. <i>M. avium-intracellulare</i> is a mycobacterial infection (an opportunistic infection) that has been identified in those who are HIV-positive or have AIDS. The convalescent stage occurs when the infection is contained and symptoms are diminished. The acute stage is when all symptoms are present; prodromal is the presence of initial symptoms; resolution is elimination of an organism. Mycoplasma have no cell wall membrane and therefore are not sensitive to penicillin, which works by interfering with cell wall synthesis. The viral replication cycle can range from minutes to days. Some viruses remain latent for long periods of time without replicating. The nurse’s responsibility involves early recognition of side effects from a drug. Therefore, the nurse would monitor the child for symptoms of ototoxicity. Diluting the dose and slowing the infusion would not diminish the total dose of drug and would not prevent ototoxicity. The nurse cannot decrease a dose independently. Reducing the dose will decrease the blood levels and may lead to bacterial resistance. Tepid baths allow heat to be removed from the body. Aspirins are avoided because of the risk of Reye’s Syndrome. The child should have only light clothing to allow heat to escape. Antibiotics are not usually ordered for this viral infection. Immunoglobulin titers are low in children with SCID, with or without an infection. The low titer levels are what prevent the child from fighting an infection. The other options do not address this concept. Epinephrine 1:1000 is the drug of choice for an acute anaphylaxis reaction. A child may have allergies yet unknown at the time of immunizations. Albuterol is a bronchodilator that opens the airway, but epinephrine is the drug of choice during anaphylaxis. Toxoids and immunoglobulins are other classes of drugs that affect the immune system, but they do not treat anaphylaxis. The nurse would refrain from advancing the catheter if mild resistance is noted. The other data are normal. The IV should be inserted bevel side up. The client should not experience pain, and a backflow is normal on insertion, indicating that the vein has been pierced. Children with mumps are uncomfortable but rarely very ill. Give nonaspirin analgesics and antipyretics to control fever and pain. Swallowing and chewing may be painful, so give fluids and soft foods. Be alert to signs of complications such as headache, stiff neck, vomiting, and photophobia which may indicate meningeal irritation. Antibiotics are not prescribed. Koplik’s spots are unique lesions found in the mouth of the individual with rubeola. Altered temperature, jaundice, and respiratory distress are all symptoms of sepsis in infants. Respiratory function is the highest priority. Body fluid-contaminated liquids can be absorbed through the eye mucosa. The other activities do not expose the woman to blood and body fluid. The first infection often seen in these children is oral candidiasis (thrush). That, along with the low white blood cell count, would be a warning symptom. A 2-year-old is unlikely to have survived this long undiagnosed. Maintaining an open airway is always the highest priority. With anaphylactic shock, the airway may constrict, mucous membranes swell, and air trapping occurs. Babies are born with nonspecific immunity. Active immunity and specific immune response are developed over time with exposure to an organism. Immunizations are inactivated substances or weakened organisms given to promote the development of immunity. The family will need to know how to protect themselves from the virus. Hand washing is the first line of protection. However, family coping skills will best be enhanced by the nurse demonstrating acceptance of the child. This along with child and family education will help the family deal with this disease. TORCH is an acronym for toxoplasmosis, other (which includes hepatitis and syphilis), rubella, cytomegalovirus, and herpes simplex. These infections are caused by bacteria, viruses, and other organisms. Transmission is by blood or body fluid contact. It is not an inherited disorder. Equipment is not shared in the nursery, but the virus can be spread only if the contact involves blood or body fluid. The first step is to gather equipment. The nurse then selects a vein and cleanses the site. The nurse applies a tourniquet and inserts the catheter. Finally, the nurse attaches the primed tubing and regulates the drip rate. Additional steps are to release the tourniquet, continue to monitor the site, apply a dressing, and document the procedure. Hyposensitization injections carry the risk of allergic reaction including anaphylaxis. They should only be given in a controlled environment with emergency drugs and equipment on hand. The upper respiratory symptoms may be early prodromal symptoms of chicken pox. The incubation period of chicken pox is 14 to 21 days. Cool fluids will help decrease the swelling of the glands around the mouth and neck. Acidic foods are too caustic and difficult to swallow. Soothing the skin with an oatmeal-based substance will decrease the itching and redness. Overdressing the child will increase perspiration and thereby increase the itching. Although drinking adequate fluids is helpful, it does not directly affect the itching. Both live and silk flowers will have increased dust levels associated with them. The other activities are appropriate. Cromolyn sodium is an aerosol taken daily to prevent an attack. All of the other answers are incorrect. Knowledge of the cardiovascular disease risk factors and associated symptoms can assist in determining the origin of chest pain, and can direct the nurse to prioritize and implement appropriate care. Diabetes, smoking, and hypertension are known modifiable and nonmodifiable risk factors to cardiac disease. Chest pain that occurs during activity could indicate cardiac ischemia, due to the increased oxygen demand. Associated symptoms of nausea and diaphoresis are known warning signs of cardiac ischemia. Chest pain that increases with breathing, especially taking a deep breath, is most likely pleuritic pain, and travel out of the country is an unrelated factor. Current BLS guidelines include establishing responsiveness as the first step to avoid performing CPR unnecessarily. With the use of AEDs and the benefit of early defibrillation, requesting to get the AED or defibrillator equipment is initiated early in the BLS sequence. Opening the airway, rescue breathing, and determining circulation follow the recommended sequence. The rate of rescue breathing for a child is 20 breaths/min, compared with 12 breaths/min for an adult. The jaw-thrust maneuver is used when there is suspicion of a neck injury. Diving into shallow water is a known cause of spinal cord injuries. Despite the unconsciousness of the client and the inability to check for spinal injury, a neck injury is to be suspected in this client. In all other scenarios, the head tilt/chin lift is appropriate to open the airway. The LPN is responsible for all medications and fluid administered, even if asked to hang the fluid by a supervising nurse. For that reason a prudent LPN would verify that the fluid type, the IV flow rate, and additional fluid has been ordered for this client to avoid errors. The bent arms will displace the downward force and make the chest compressions less effective. Bouncing movements decrease effectiveness of resuscitation, and most likely will cause injuries. Using the heel of one hand is appropriate for CPR in the child. Proper positioning of the airway is essential for rescue breathing, and might not be established with the first attempt. BLS guidelines recommend a second attempt to open the airway. A good seal over the mouth and nose is necessary to ensure ventilations are being delivered to the client. These two interventions must be established before any other steps are taken to ventilate the client. The rate of rescue breathing for an adult client is 12/min, or 1 every 5 seconds. Once breathing and circulation return, the recommended position if no injury is the “recovery” position. It has been found to be optimal to keep the airway open, and also will reduce the risk of aspiration if the client has an emesis. BLS guidelines indicate that when not confident that signs of circulation are present, if no pulse is felt, or if there is a pulse rate less than 60/min with poor signs of perfusion, begin chest compressions. Since the child was eating, you must determine if foreign body airway occlusion (FBAO) has occurred. This can be accomplished by the tongue/jaw lift and visualization of the mouth. Opening the airway and attempting rescue breathing would aid in identifying if FBAO is present. Blind finger sweeps are not done. The nurse would not check a brachial pulse on a 5-year-old, and an external defibrillator is not the core issue when there is FBAO. The most common cause of sudden cardiac arrest is an abnormal heart rhythm called ventricular fibrillation. Therefore, delivering a shock via the AED can restore normal cardiac rhythm. An AED warrants use immediately when it becomes available. The child is old enough to apply the adult guidelines, which are 1 1/2–2 inches for effective chest compressions. BLS guidelines for AED use is to perform three analyses and, if no shock is indicated and there is still no sign of circulation, perform CPR for 1 minute before checking circulation and cycling the AED to analyze the rhythm again. An alternate position with the obese client is using the chest thrusts while the individual is in a standing or sitting position. Methergine provides long-sustained contraction of the uterus. It is commonly used to treat late postpartum hemorrhage (subinvolution). Oxytocin (option 2) and prostaglandin are more frequently used to treat early postpartum hemorrhage caused by uterine atony. When blood products are used (option 4), they are generally ordered for early postpartum hemorrhage. Increased fluid intake (option 3) is a general, helpful measure for any client who has lost body fluid volume, but it is not a specific therapy. Most electric shock injuries in adults occur at work, as is possible in this scenario. Removing the electrical source that this client is on or near and providing scene safety prior to approaching the victim are the first steps in this sequence. Then follow the BLS guidelines for EMS activation, CPR, and AED use. Individuals with partial obstruction can still breathe and cough. They are to be encouraged to continue this. FBAO interventions are to be used only with severe or complete airway obstruction. Methergine has a side effect of raising the blood pressure. A woman with hypertension or pregnancy-induced hypertension would not be a good candidate for use of Methergine. An alternative would be necessary. The client in option 1 has a normal blood pressure, which is not a contraindication. A pulse of 60 (option 2) or respiratory rate of 12 (option 4) are not contraindications to use of Methergine. Naloxone is the antidote to the opioid analgesics that are used with epidural analgesia. If respiratory depression occurs, this medication needs to be readily available for use. Meperidine is an opioid analgesic but is not used for epidural analgesia. Betamethasone is a glucocorticoid used to enhance fetal lung maturity before premature delivery. Carboprost is an abortifacient. Contractions lasting longer than 90 seconds indicate uterine hyperstimulation, which is a reason to stop the oxytocin infusion. The increase in blood pressure is not of concern. Early decelerations of fetal heart rate do not indicate fetal distress; rather, they are a reassuring sign. Squeezing eyes shut during contractions could have variable meanings, including coping with the contraction, and needs to be correlated with other client data for proper interpretation. The danger of preeclampsia is that it can progress to eclampsia, characterized by seizure activity. Magnesium sulfate is given to prevent seizures. It is not given to stabilize BP, although it can cause a transient decline in BP. It is not given to regulate magnesium level or uterine contractions. An indirect Coombs’ test assesses for the presence of Rh antibodies in the maternal blood. Direct Coombs’ test and bilirubin tests are conducted on the newborn. Hemoglobin is not a determinant for the administration of RhoGAM. Option 1 is the only goal that is client-focused, specific, and measurable. Options 2 and 4 are client-focused but vague. Option 3 focuses on the nursing action of teaching. Terbutaline, a beta-adrenergic agent, has many maternal and fetal side effects, including tachycardia, cardiac arryhthmias, and pulmonary edema. In addition to taking routine vital signs, the nurse should observe for signs of pulmonary edema. The frequency of fetal heart tones and oral temperature measurement depends on the intensity and length of the drug therapy as well as surrounding circumstances. Deep-tendon reflex examination is not indicated. Corticosteroids such as betamethasone have been shown to enhance fetal lung maturity and prevent respiratory distress. Betamethasone does not stop labor or cervical changes. A side effect is increased risk of infection. The best explanation is the one that explains the use of phytonadione. The medication is given to supply vitamin K, which the newborn cannot produce in the early days of life because of lack of intestinal flora needed to synthesize it. Although phytonadione does treat hemorrhagic disease of the newborn, its use in the healthy infant is prophylactic. The medication is not water soluble, nor is it a multivitamin. The nurse would give the ophthalmic dose by applying a 0.5- to 1-cm ribbon of ointment into each lower conjunctival sac. The dose can be delayed up to an hour after birth, but not 2 hours. The eyes are not cleansed or irrigated after the dose, and a new tube is used for each newborn. German measles is also termed rubella. Pregnant women are tested at their first prenatal visit for immunity to rubella. If the client is found to be nonimmune, immunization will be given after delivery, before discharge. The rubella vaccine is prepared with a live virus; therefore, it is not appropriate to administer during pregnancy. Clients are counseled to avoid pregnancy for 3 months after immunization. This client statement indicates that she does not understand the fundamental indications for treatment of this potential blood incompatibility. If an Rh-negative client is carrying an Rh-positive infant, the potential for mixing of fetal blood into the maternal system could occur at midpregnancy and again at delivery of the placenta. If the infant is found to be Rh-positive, the client will be given RhoGAM within 72 hours of delivery to block any antigen-antibody formation. Aerosol medications are delivered via a liquid mist, which delivers medication to the lower respiratory tract. Postural drainage would be done if indicated. The droplets need to be small, not large. Drugs are always administered during pregnancy after evaluating both the benefit to the mother and the risks to the fetus. The neonate intestinal tract is sterile at birth. Colonization of bacteria in the gut necessary for Vitamin K synthesis takes approximately a week to occur. The other options listed contain incorrect rationales. Magnesium sulfate is a CNS depressant; therefore, disappearance of the patellar or knee-jerk reflex would indicate serious CNS depression. The other options do not indicate adverse effects of the medication. The client with tuberculosis can spread the infection by breathing and requires a private room and airborne precautions. Options 1, 2, and 3 are aspects of standard precautions that would be implemented with any client, regardless of medical diagnosis. The antidote for magnesium sulfate is calcium gluconate. The other drugs listed are not. Excretion of magnesium sulfate is primarily accomplished through the renal system. Critical examinations prior to administration of the drug would be focused on the body’s ability to excrete the medication and the status of the CNS. Both examinations should be within normal limits, or the prescribing health care provider should be notified. Magnesium sulfate is an anticonvulsant medication given to pregnant women with preeclampsia to diminish the risk of convulsions. The drug is a CNS depressant and therefore acts to reduce CNS activity. CNS activity should not be absent. Epidural medications cause vasodilatation, which can lead to hypotension. This is the primary risk factor the nurse needs to monitor after placement. Other considerations can be regarded once the client’s ABCs are stable. The most critical incident that could occur in a client receiving magnesium sulfate is toxic CNS depression, which could affect respiratory and cardiac function. Therefore, the antidote should be available at the bedside. The nurse should observe patellar reflexes to detect excessive dosing. It is also important to keep the room quiet. It is not necessary to prepare for precipitous birth (option 2) or severely limit fluid intake (option 1). This client is suffering from anxiety. The correct answer is an anxiolytic. Option 1 is a sedative-hypnotic, which would not be prescribed. The client is not suffering from psychosis or hallucinations, so option 3 is inappropriate. Option 4 is inappropriate for the signs and symptoms described. The medication normally works within 30 minutes to 1 hour after administration, making option 2 correct. Option 1 is incorrect because the client should not be watching stimulating shows on television before trying to fall asleep. Option 3 is incorrect because the medication will not work instantly. Option 4 is incorrect because the client should not take a sedative and then stay active for 30 minutes to 1 hour after taking medication. In order to safely monitor clozapine, a weekly blood test is mandatory. If the client does not have the hematologic exam, the medication is not given for the following week. This is to monitor for agranulocytosis, the drug’s major adverse effect. A full physical exam (option 1) and urinalysis (option 3) are unnecessary. Follow-up visits (option 3) are done periodically but may not be needed weekly with the physician. Sertraline is an antidepressant of the SSRI type. These agents work within 1 to 4 weeks. Option 1 is an insufficient amount of time, while options 3 and 4 are excessive as well as similar. With an MAOI such as phenelzine, the client must eliminate foods that contain tyramine. Intake of tyramine-containing foods could lead to severe hypertension and other complications. All of the other considerations are not major teaching considerations for MAOIs. Transmission-based precautions are required for all antibiotic-resistant microorganisms regardless of their mode of transmission. The other options indicate the need for medical and surgical asepsis in the care of the client but not the use of transmission-based precautions. These symptoms are the commonly seen symptoms of withdrawal from alcohol or other CNS depressants. Option 2 is incorrect because there would usually not be complaints of disorientation or insomnia with flulike symptoms. Individuals do not usually have withdrawal symptoms from antipsychotic medications (option 3), nor are these the signs of lithium carbonate discontinuation (option 4). In the correct response, the nurse acknowledges the client’s feelings and asks the client to discuss the feelings and thoughts. In options 1, 2, and 4, the nurse is not acknowledging the client’s feelings or thoughts. An open and trusting nurse–client relationship helps support the client in decisions related to medication therapy. The most serious side effect of carbamazepine is agranulocytosis (low WBC count). Neuroleptic malignant syndrome is not common with carbamazepine, nor is there a need for weekly monitoring for low platelet count (option 3) or anemia (option 4) while taking carbamazepine. Akathisia is an inability to sit. This is the most common extrapyramidal side effect of haloperidol. The side effect described in option 1 would include dry mouth, urinary hesitance, constipation, mydriasis, tachycardia, and diminished lacrimation. Option 2, gustatory hallucination, is tasting something that is not present, while option 4 is a painful twisting and turning of the head and neck. Trazadone is an atypical antidepressant that is used more for insomnia than for depression. Abuse potential is minimal, so option 4 is incorrect. Option 1, for safety reasons, is not a good practice when taking trazodone as a sleep aid, and option 2 is incorrect because taking more fluids will not increase the effectiveness of the medication. The client needs to make an agreement with the nurse to remain safe or report to the nurse if not feeling safe. Option 4 does not keep the client safe for 24 hours, only during meals. The agreement in option 1 is too vague and does not give specific responsibility either to the nurse or to the client. The promise in option 2 is also vague and does not make the client accountable to the health care professionals. Flumazenil is the only drug available that acts as an antagonist to the benzodiazepines. Options 1 and 2 are benzodiazepines themselves, while option 3 is a selective serotonin reuptake inhibitor (SSRI) type of antidepressant. Dry mouth occurs from the anticholinergic effects seen with fluphenazine. Options 1 and 2 are incorrect because orthostatic hypotension is not a major side effect of fluphenazine. Confusion (option 4) is not a side effect of this agent. Option 1 is the accurate response to the situation. Option 2 is incorrect because imipramine is very slow to become effective—2 to 6 weeks, not 5 days—and as the client begins to “feel better,” it is not appropriate to make major changes, especially after a suicide attempt. Options 3 and 4 are not true, but gradual change and monitoring for changes in mood and behavior are still very critical for this client. With thioridazine, the anticholinergic side effects of dry mouth, constipation, urinary retention, and blurred vision are usually high. Dry mouth is not associated with extrapyramidal side effects (option 2) or neuroleptic malignant syndrome (option 4). There is usually a weight gain, not a weight loss, as a side effect of thioridazine (option 3). Scarlet fever is transmitted by particle droplets larger than 5 microns. Scarlet fever is not transmitted through sexual intercourse or the blood or by consuming contaminated food. Marijuana has been used for individuals with AIDS to increase their appetite. Marijuana does not increase organization and motivation (option 2), reduce stress (option 3), or have antibacterial properties (option 4). Although options 1, 2, and 4 are all appropriate nursing interventions, the need for physical safety is the primary nursing priority for this client at this time. The others can be addressed once physical safety is established. Risperidone has very few side effects; they include orthostatic hypotension (option 4) and insomnia, agitation, headache, anxiety, and rhinitis. Options 1, 2, and 3 are incorrect conclusions about the causes of the client’s dizziness. The principle of remaining abstinent is one of the three most important goals of treatment for alcoholism. It is also critical when taking disulfiram in order to avoid adverse effects from the interaction of the medication and alcohol. The other two goals of treatment are amelioration of concurrent psychiatric conditions and long-term prevention of relapse. Options 1, 2, and 4 are important components, but without option 3, the others could not occur, and they do not directly correlate with disulfiram therapy. Risk of hypokalemia is worsened by the concurrent use of a potassium-wasting diuretic (Lasix) and a beta-agonist (albuterol) medication. Furthermore, the risk of cardiac glycoside toxicity is worse in the presence of hypokalemia. Hyperkalemia (option 1), hypernatremia (option 2), and hypocalcemia (option 3) are not concerns with this drug regimen. Concurrent use of an MAOI and a beta-agonist may lead to hypertensive crisis. The beta-agonist may lead to tachycardia (option 3), but since no specific agent is listed, the nurse should consider the potential interaction of the MAOI and the beta-agonist first. Hypotension (option 1) and bradycardia (option 4) are not of concern with this combination of medications. Epinephrine is a beta-adrenergic agent used to dilate bronchial airways. It can cause an increased blood glucose level, which is especially an issue for a client with diabetes mellitus. Diabetic clients should be instructed to monitor blood glucose levels because an adjustment in maintenance doses of hypoglycemic agents may be indicated. Options 2, 3, and 4 are unrelated to effects of the medication on diabetic clients. The client should wait at least 1 minute between inhalations. Dosages should be taken exactly as prescribed (option 1). The OTC products should not be added without consulting the physician (option 3). Inhaler equipment should be rinsed and dried daily to keep it clean (option 4). Nervousness and tremors may be experienced when medication is newly administered and frequently decrease over time. Clients should not terminate medication use without consulting the prescriber (option 2). Caffeine would exacerbate the problem (option 3). The symptoms are likely related to the medication and not to the disease process (option 4). Taking the medication with food can decrease GI symptoms. Sustained-release forms should not be crushed or chewed because doing so irritates the gastric mucosa and changes the absorption of the medication (option 1). Medications should be taken as prescribed without omissions or doubled doses (option 2). Medications should be taken at all times, not just when symptomatic (option 3). Prophylaxis is the goal, not acute treatment. Methicillin-resistant <i>Staphylococcus aureus</i> requires transmission-based contact precautions. Eye protection would be worn to protect the mucous membranes of the eyes when splatters of body fluids or excretions are possible. A gown would be worn when the nurse is in direct contact with the client. Contact precautions require gloves. N95 respirators are needed when caring for the client with tuberculosis, so it is inappropriate for this scenario. Restlessness is a sign of theophylline toxicity but often is a first indicator of hypoxia. The first and best action is to monitor for hypoxia. After ruling it out, the other actions should be taken: monitoring for other signs and symptoms of toxicity, obtaining an order for the blood level, and explaining toxicity to the client. Beclovent is an inhaled corticosteroid that is thought to decrease inflammation and dilate the airway. The exact mechanism of action is unknown. Beclovent, as is true of any other corticosteroid, does suppress the immune response, but this is not the rationale for administration of the medication (option 3). Inhaled corticosteroids are thought to <i>increase</i> responsiveness of bronchial smooth muscle to beta-agonist drugs (option 4). Cromolyn is a nonsteroidal agent that stabilizes mast cells so bronchoconstrictive and inflammatory substances are not released when stimulated with an allergen. It is used to treat inflammation of the airway. It does not cause bronchoconstriction (option 4) and is not a bronchodilator (option 1) or expectorant (option 3). Side effects of cromolyn include dry mouth, irritated throat, cough, unpleasant taste, and headaches. Side effects do not include vomiting (option 1) or tachycardia (option 3). Moist mucous membranes (option 2) is a normal finding. Leukotrienes are released when a client is exposed to an allergen. Leukotrienes cause inflammation, bronchoconstriction, and mucus production. Leukotriene modifiers such as montelukast block the action of leukotrienes and therefore decrease mucous secretion and reduce inflammation, which prevents bronchoconstriction. Liver function tests should be monitored with leukotriene modifiers because of the potential for liver dysfunction with this type of medication. Renal studies are unnecessary (option 1) in relation to this medication. Fluid intake should be increased (option 3), unless contraindicated by another condition, in order to thin secretions and assist in their mobilization. The medication should be taken 1 hour before or 2 hours after meals (option 4). Second-generation antihistamines cause less sedation than first-generation medications, so the client experiences less drowsiness. They are selective for peripheral H<sub>1</sub> histamine receptors and do not cross the blood–brain barrier. Nausea (option 1), anxiety (option 2), and euphoria (option 4) are unrelated as comparison points between first- and second-generation antihistamines. The effects of first-generation antihistamines are increased with alcohol, tricyclic antidepressants, antianxiety agents, antipsychotic agents, opioid analgesics, sedative hypnotics, and monoamine oxidase inhibitors. Nicotine (option 2), caffeine (option 3), and CNS stimulants (option 4) would not have an additive effect. The proper application of nasal spray decongestants is with the client sitting and squeezing the bottle once, holding a finger over the other nostril, and inhaling. Administering more than one squeeze application (options 1 and 4) would increase the dose. The applicator should be rinsed after each use to prevent contamination (option 3). Avoidance of eating or drinking for 30 minutes after medication administration allows the medication time to work. Nasal spray decongestants should not be taken for longer than 3 days because they can cause rebound congestion (option 1). Fluid intake should be increased to 2 to 3 L/day to liquefy secretions, not decreased (option 2). Smoking should be avoided because it increases secretions and decreases ciliary action (option 4). An infection with vancomycin-resistant <i>enterococci</i> requires transmission-based contact precautions. Since the nurse will be irrigating the wound and splatters of body fluids or exudates are possible, eye protection and surgical mask should be worn to protect the mucous membranes of the eyes, nose, and mouth. A gown would be worn when the nurse is in direct contact with the client. Contact precautions require gloves. It is important to teach clients side effects of medications. The side effects of expectorants include nausea, vomiting, gastric irritation, and rash. If a cough lasts longer than a week (option 2), it should be reported to the physician. The client should avoid eating or drinking for 30 minutes after medication administration to allow the medication to work (option 3). The medication should be taken as directed, and doses should not be doubled (option 4). All of the symptoms listed are potential side effects of opioid antitussives. The most significant side effect is respiratory depression, evidenced by a respiratory rate of 10, when normal is 12 to 20 breaths/min. Unused medication should be discarded after 4 days, not 7. Avoidance of smoking is necessary because smoking increases secretions and decreases ciliary action (option 2). Increasing fluids assists with thinning secretions (option 1). Rinsing the mouth after administration decreases oropharyngeal irritation (option 3). The Venturi mask has a dial to set the percentage of oxygen and can administer 50% oxygen. The nonrebreather mask (option 2) administers 60% to 100% oxygen. The partial rebreather mask (option 3) administers 70% to 90% oxygen. The nasal cannula (option 1) can administer up to 6 L/min, which is approximately 44% oxygen. Intravenous nitroglycerin (NTG) must be prepared in only glass bottles and infused via the manufacturer-provided tubing. The polyvinyl chloride in regular tubing will adsorb (leech out) the nitroglycerin. NTG is stable in a glass bottle for 24 hours and does not require laminar flow ventilation. Headache is a common side effect (not adverse reaction) related to the vasodilation properties of nitroglycerin. The incidence of headache decreases over time as the client develops tolerance to the medication. The client should be encouraged to continue its use as needed and to take acetaminophen or aspirin for headache, according to the preference of the physician. Adverse effects of beta-adrenergic blockers such as propranolol include their potential to cause bronchospasm and to mask hypoglycemia attacks. Therefore, the clients who are at risk for these conditions should not utilize beta-blockers as antihypertensive medications. Calcium channel blockers, alpha-blockers, and diuretics do not directly affect these conditions. Diltiazem (Cardizem) is a calcium channel blocker. It is usually administered before meals and at bedtime to increase the absorption of the medication. Postural hypotension may occur, so the client must be instructed to rise slowly to avoid dizziness and falling. The medication may cause a decrease in mental alertness until the body adjusts and the proper dosage is established. The client should notify the physician if he or she develops shortness of breath, irregular heartbeat, pronounced dizziness, nausea, or constipation. Nicardipine (Cardene) is a calcium channel blocker. Weight gain and edema are potential signs of heart failure and must be reported to the physician. The client taking this medication should keep track of angina episodes and report an increase in the episodes or a change in the pattern. The client may take a missed dose of medication if not too close to the next dose; otherwise, the dose should be omitted. The client should be taught to check his or her pulse, note the rate, and report if the heart rate is less than 50 beats per minute. Cough and loss of taste are common side effects of angiotensin-converting enzyme (ACE) inhibitors such as lisinopril. They disappear with discontinuance of the medication. The medications listed in the other options do not produce cough or change taste perception. Law is not the sole source of the ethical practice of nursing; numerous legal sources influence nursing practice. An individual should understand the ethics of a profession before becoming a member of that profession because those ethics may differ from personal ones. While each option contains “pneumonia,” the causative agent is different for each. Option 1 includes a pathogenic microorganism that is difficult to treat and requires droplet precautions. Losartan is an angiotensin II antagonist that inhibits the conversion of angiotensin I to angiotensin II. Because angiotensin II is a powerful vasoconstrictor, this inhibition results in vasodilation and normalizing blood pressure. The client should be monitored for dizziness, cough, and diarrhea while taking this medication. Lack of adherence to pharmacologic treatment strategies prevents the client from establishing good control of the disease and ultimately places him or her at risk for developing long-term complications of hypertension. Noncompliance with the therapeutic program is a significant problem in people with hypertension. The client should not skip doses of medications without consulting the physician. Adenosine (Adenocard) is an antidysrhythmic used in the treatment of paroxysmal supraventricular tachycardia (SVT). Cardiac performance must be determined before and throughout treatment by cardiac monitoring. An endotracheal tube may be used if an emergency necessitates mechanical ventilation, but the tube itself is a rather isolated item. An IV pump may be needed but is not a priority because this medication is administered rapidly by IV push. A pulse oximetry machine may be helpful in assessing oxygenation but is not a priority item. Anorexia, nausea, and yellow vision are signs of digoxin toxicity. Other signs include other visual disturbances, vomiting, and diarrhea. The clusters of other symptoms listed do not fit the profile of digoxin toxicity. Lidocaine is a class-I antidysrhythmic used to treat ventricular dysrhythmias. Other medications that might be ordered include procainamide, amiodarone, or magnesium sulfate. The other medications would not be used as a primary treatment of ventricular dysrhythmias because they are a cardiac glycoside (option 1), a beta-blocker (option 2), and a calcium channel blocker (option 3). Amiodarone is a class III antiarrhythmic used to treat life-threatening ventricular dysrhythmias that do not respond to the first-line drugs (like lidocaine). The client should have continuous EKG monitoring, and the medication should be infused through an IV pump. Oxygen therapy may be needed but is unrelated to this medication. Options 2 and 4 are not critical during administration of this medication, although they are generally useful adjuncts. Heparin is the drug of choice in pregnancy. Low molecular weight heparins, of which enoxaparin is an example, are not recommended for use during pregnancy (options 1 and 4). Epoetin alfa (Procrit) is a colony-stimulating growth factor and is not used for anticoagulation (option 2). Clients who have atrial fibrillation are at risk to develop emboli. Therapy with Coumadin is considered to be ongoing in nature in order to prevent such an occurrence. The other time frames are too short to achieve a preventative goal. In addition, the likelihood of emboli formation does not significantly diminish unless the client is anticoagulated on a long-term basis. A client taking ticlopidine should be monitored for potential blood dyscrasias that can occur with this drug. Monthly PT and INR levels are not indicated as follow-up for this medication but are used in conjunction with Coumadin therapy (option 2). ABGs are not indicated in the management of clients who are taking ticlopidine (option 3) There are no reported electrolyte imbalances with the use of this medication (option 4). ReoPro is often given IV following this type of procedure to help prevent possible reocclusion of the coronary artery that has been treated. It can be administered in conjunction with weight-based heparin therapy, but heparin is an anticoagulant agent (option 1). Plavix and ASA are examples of antiplatelet agents that are given orally and are not utilized in this particular acute-care setting (options 3 and 4). However, ASA can be given later as follow-up to the procedure to prevent possible complications related to vessel occlusion. Hepatitis A is an infectious disease transmitted by the fecal–oral route. Standard precautions are mandatory. Contact precautions are instituted if the client is incontinent of stool. Family members should avoid close contact with the client. They should not kiss the client or use the same eating utensils and bath towels. Masks are not necessary because the disease is not transmitted by the respiratory tract. Clients taking thrombolytic therapy should be monitored closely for the possibility of hemorrhage because therapy increases the risk of bleeding. Monitoring includes evaluating the skin for bruising and gums and venipuncture sites for bleeding, and testing stool and urine for occult or obvious blood. Headache, fever, and bone pain are not directly related to thrombolytic therapy (options 1, 2, and 4). The use of thrombolytic agents can cause cardiac irritation and lead to development of dysrhythmias that can be life threatening. The nurse must be aware of the serious likelihood that treatment can cause further cardiac compromise. Dry mouth, decreased urine output, and decreased clotting times (options 1, 2, and 3) are not seen with thrombolytic therapy. Folic acid (in large doses) can cause the urine to become discolored and turn to a darker yellow color. Dark green or black stools are more commonly associated with iron therapy (option 2). Temperature elevations and changes in pulse rate are not associated with folic acid (options 3 and 4). Liquid iron preparations can cause staining of teeth. It is important for the nurse to be aware of proper administration methods, which include drinking the mixture through a straw. Mixing medication with milk and carbonated beverages will decrease its absorption (options 1 and 4). The medication is usually taken with food to minimize GI upset (option 2). To calculate the dose, divide the desired dose (5,000) by the dose on hand (10,000 units) and multiply that by the quantity (1 mL). The result is 0.5 mL. Clients with seizure disorders rarely are able to stop taking the anticonvulsants. The last option is incorrect because of the word <i>never</i>. The first two options are incorrect statements. Extra doses are not taken related to stress, and there is no way to know at this time whether medication therapy could be terminated near the 1-year mark. Phenytoin (Dilantin) is an anticonvulsant most effective in controlling tonic-clonic seizures. Data collection before planning nursing care for a client with a seizure disorder should always include a history of seizure incidence. Option 4 may be a prodromal phase in some clients, but a history of incidence is more important data. Removal of dentures may be indicated during a seizure, but not at this time. Placing an airway or restraining a patient during a seizure could cause harm. The therapeutic blood levels of the anticonvulsant need to be maintained. The nurse should question the physician about alternate routes of administration. Omission of a dose is not prudent, nor is changing the route without a physician order. Destruction of the neurons of the basal ganglia in Parkinson’s disease results in decreased muscle tone. This gives the face a masklike appearance and causes a monotone speech pattern that can be interpreted as flat. If medication therapy was ineffective, the client would still exhibit symptoms of the disorder, such as flattened affect. The other options do not apply to this disease. Levodopa is the precursor of dopamine. It is converted to dopamine in the brain cells until needed as a neurotransmitter. Improved neural myelination, acetylcholine production, and regeneration of injured cells cannot be attributed to levodopa. Maintaining a healthy relationship is important during infertility treatments, which can be very stressful. Options 2, 3, and 4 may indicate ineffective coping strategies and warrant further investigation. Barbiturates decrease the body’s response to warfarin (Coumadin). As a result, there is less suppression of prothrombin; when inhibition caused by barbiturates disappears, hemorrhage could result. Withdrawal symptoms are not a priority concern if the client just takes the barbiturate for sleep (option 1). Absence of sleep is not likely to result in seizure activity (option 2). The control of seizure activity is not dependent on combined use of phenytoin and the barbiturate sleep aid (option 4). Diazepam is a benzodiazepine tranquilizer and an anticonvulsant used to relax smooth muscles during seizures. Diazepam does not slow cardiac contractions (option 1), dilate tracheobronchial structures (option 3), or provide amnesia of seizure activity (option 4). Morphine is a CNS depressant. Its major adverse effect is respiratory depression. It can also lead to lethargy, pupillary constriction, and depressed reflexes. Morphine does not slow the pulse rate (option 1), although it could lower blood pressure. It does not cause restlessness (option 2) or profuse sweating (option 3). Levodopa is the precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension. The medication should be administered with food to minimize gastric irritation (option 1). It is not monitored by weekly laboratory tests (option 2), nor does it cause initial euphoria followed by depression (option 3). Gingival hyperplasia is an adverse effect of long-term phenytoin (Dilantin) therapy. Maintaining therapeutic blood levels and meticulous oral hygiene, including regular check-ups with a dentist, can decrease the incidence of hyperplasia. It does not alkalinize oral secretions (option 2), destroy tooth enamel (option 3), or increase plaque and bacterial growth at gum lines (option 4). Phenobarbital depresses the CNS, particularly the motor cortex, producing side effects such as lethargy, loss of appetite, depression, and vertigo. The other side effects listed for phenobarbital do not include anal itching or dizziness upon standing (option 2), diarrhea or upper body rash (option 3), or decreased tolerance to common foods and constipation (option 4). Fever is not a side effect of methylphenidate. Insomnia (option 1), rash (option 3), and palpitations (option 4) are possible side effects of methylphenidate. The primary action is to reduce voltage, frequency, and spread of electrical discharges within the motor cortex, resulting in inhibition of seizure activity. The drug does not act directly on muscles (option 1), prevent CNS depression (option 2), or change permeability of cell membranes (option 4). OTC medications with alcohol (another CNS depressant) should be avoided unless specifically directed by the provider. The other statements would indicate understanding of the medication teaching. The Alzheimer’s client and family will need much support. Medication therapy will delay progression of symptoms but will not effect a cure. The primary concern is for the safety of the client, so constant supervision is necessary. The other options are incorrect approaches. Vaginal fluid pH is slightly alkaline, as is semen. Spermatozoa cannot survive in an acidic environment. Trichomoniasis vaginitis increases the acidity of the vaginal and cervical secretions, thus reducing the number of viable sperm. There is 10 mg per 2 mL on hand. The order is for 4 mg. The formula for calculating the answer would be: Cross-multiply to get 10x = 8; Divide both sides by 10. Tacrine (Cognex) increases the available acetylcholine in the brain; therefore, the parasympathetic system is stimulated. Blood pressure, mental status, and GI status would be affected. Hemoglobin, red and white blood cell count, liver function, electrolyte balance, and edema in legs do not relate to this medication. Tagamet may increase the levels of Elavil in the blood, causing seizures, tachycardia, hypertension, or toxicity. Acetaminophen (option 1), aspirin (option 2), and NSAIDs (option 3) do not have that effect. Dry mouth, constipation, and urinary retention or hesitancy are all possible side effects of anticholinergic medications. Fever is not a side effect of anticholinergic medications. Phenytoin inhibits folic acid absorption and potentiates effects of folic acid antagonists. Folic acid is helpful in correcting some anemias that can result from phenytoin administration. The other options are incorrect statements. Nalidixic acid is bactericidal and inhibits microbial synthesis of DNA. The spectrum includes most Gram-negative organisms except <i>Pseudomonas</i>. This medication does not belong to antispasmodic, antigout, or analgesic families. Spironolactone is a potassium-sparing diuretic that promotes sodium excretion while conserving potassium. Options 1 and 3 are diuretics but not potassium-sparing diuretics. Option 4 is not a diuretic; it is an antihypertensive of the beta-blocker type. Tea and coffee are poor choices for hydration. They are mild diuretics and can cause severe dehydration if used concurrently with diuretics. Taking medication at the same time each day improves compliance. In addition, taking Lasix in the morning and early evening are the best times so as not to interrupt sleep. Notifying the physician when edema is noticed is important and should be emphasized by the nurse. Thiazide diuretics are sulfa-based medications; therefore, a client with a sulfa allergy is at risk for an allergic reaction. The side effects of hydrochlorothiazide are hypokalemia, hyperglycemia, hyperuricemia, and hypercalcemia. Options 2, 3, and 4 are either partially or totally incorrect. Furosemide should be given at a rate of 20 mg/minute or less. Rapid injection of furosemide can cause hearing loss as a result of ototoxicity. It does not need to be further diluted before injection (options 2 and 4). Mumps in adult males can cause permanent blockage of the vas deferens, contributing to or resulting in infertility. The other responses are incorrect. Excessive dosing of oxybutynin produces nervousness, hallucinations, restlessness, tachycardia, confusion, flushed or red face, and signs of respiratory depression. Options 2, 3, and 4 are opposite effects of what would be expected in this case. Furosemide is a loop diuretic. The antihypertensive action involves renal and peripheral vasodilation, a temporary increase in glomerular filtration rate (GFR), and decreased peripheral vascular resistance. For this reason, it is the drug of choice for clients with low GFR as a result of renal insufficiency. Hydrochlorothiazide, chlorthalidone, and spironolactone are not associated with use in clients with low GFR. Anuria is the absence of urine formation and is a contraindication for using this medication. Diuretics such as bumetanide are used to increase the amount of urine excreted in clients with CHF (option 2), pulmonary edema (option 3), and hypertension (option 4). Acetazolamide is a carbonic anhydrase inhibitor. Inhibition of carbonic anhydrase decreases the rate of formation of aqueous humor and thereby reduces intraocular pressure. Acetazolamide may be used for treatment of edema caused by CHF, but it is not a first-line therapy. This medication does not have a therapeutic effect on hypertensive crisis or peripheral vascular disease. Some medications, such as phenytoin, rifampin, and phenobarbital, are known to reduce the level of cyclosporine in the body. Therefore, the cyclosporine level should be monitored regularly while the client is taking these medications. Occasionally, dosage adjustment is required. The client is exhibiting signs of cholinergic toxicity, and atropine is the antidote. Phytonadione or Vitamin K (option 1) is the antidote to warfarin (Coumadin). Oxybutynin is indicated for use as a urinary antispasmodic. Epinephrine is used to treat severe hypersensitivity reactions (anaphylaxis). Loop diuretics have the disadvantage of requiring more frequent dosing but are advantageous in clients with creatinine clearance less than 30 mL/min. The other types of diuretics (osmotic in option 1, potassium-sparing in option 2, and thiazide in option 3) are not as useful when the client has a decreased creatinine clearance level. Oxybutynin (Ditropan) is an antispasmodic medication used to restore normal voiding patterns in clients with spasms of smooth muscle of the urinary bladder. It produces anticholinergic side effects such as dry mouth, constipation, urinary hesitancy, and decreased gastroenteritis motility. Periodic interruptions in therapy are recommended to monitor continued need for this medication. Phenazopyridine is a urinary analgesic with a local anesthetic effect on the urinary tract mucosa. This medication relieves pain during urinary tract infection. It causes the urine to have an orange to red color. It has no effect on volume of urine. Foul odor to the urine may be caused by urinary tract infection. Dopamine acts on the alpha- and beta- adrenergic receptors, resulting in vasoconstriction, increased systemic BP, and increased force and rate of myocardial contraction. Option 1 is a false statement. Option 3 is opposite of dopamine’s effect. Option 4 is true in low dose (2–5 mcg/kg/min), but the focus of dopamine for the client in shock who is not responding to fluids is to achieve vasoconstriction. Sperm penetration test, which tests for the ability of sperm to penetrate an egg, should be performed after 2 to 7 days of abstinence. Aldactone is a potassium-sparing diuretic that increases sodium excretion and decreases potassium secretion in the distal convoluted tubule. Potassium levels greater than 5.5 mEq/L are contraindicated with spironolactone because of increased risk of hyperkalemia. The elevated blood glucose in option 1 is not a priority issue related to this medication. The elevated sodium level could be alleviated by the medication, and thus it is not a reason to withhold the dose. The blood pressure is normal and does not warrant withholding a dose. Epinephrine and oxygen should be available at the bedside because of the risk of anaphylaxis during administration. An oral airway and suction machine are not the priority items, although maintaining an airway would be necessary if the client actually did go into anaphylaxis. Since an oral airway and portable suction machine are usually part of the contents of a code cart, the full cart would also not be necessary. Each dose of this medication should be administered with a full glass of water, and the client should be encouraged to maintain a high fluid intake. The client should not discontinue or decrease the dosage without consulting with physician. Sulfisoxazole does not discolor urine brown, but nitrofurantoin does, and it is not harmful (option 1). It is not necessary to restrict salt intake (option 3), and the dose should not be decreased even if symptoms improve (option 4). Epoetin is given to stimulate red blood cell production in the client with chronic renal failure. For this reason, the nurse should look at the hemoglobin and hematocrit as baseline measurements. A white blood cell stimulant such as filgrastim (Neupogen) would be given to raise white blood cell counts (option 3). Epoetin alfa will not treat creatinine or BUN levels (options 4 and 5); the client would be receiving dialysis to control these values. Omeprazole, pantoprazole, and rabeprazole must be swallowed whole. Lansoprazole and esomeprazole capsules may be opened and sprinkled on applesauce or dissolved in 40 mL of juice. Ciprofloxacin is not recommended for <i>Helicobacter pylori</i> infection during pregnancy. The other medications can be used after consulting with the physician. Bismuth-containing preparations, such as Pepto-Bismol, can cause all of the listed side effects, but transient darkening of the tongue and stool is a specific side effect to bismuth. The highest rate of eradication of <i>Helicobacter pylori</i> infection is by using a proton pump inhibitor and two antibiotics (usually clarithromycin and amoxicillin or metronidazole). The combinations of medications in options 1, 2, and 4 do not provide for this level of effectiveness. Promethazine is usually given 25 mg every 4 to 6 hours prn. Dosing may start at 12.5 mg every 4 to 6 hours prn depending on client status; however, 25 mg is the usual dose. Normal doses of the other medications are as follows: prochlorperazine 5 to 10 mg tid–qid; metoclopramide 10 mg 30 minutes AC and HS; and trimethobenzamide hydrochloride 250 mg tid–qid prn. Omeprazole can cause an increase in liver enzyme levels (AST, ALT, alkaline phosphatase, and bilirubin), leading to adverse reactions of liver necrosis and hepatic failure. For this reason, the nurse should monitor these lab values as they become available. Monitoring of BUN, uric acid, and WBC count have a lesser priority and are monitored only as indicated based on an individual client’s identified health need. The nurse needs to know the first day of the last normal menstrual period and the length of the menstrual cycle. Endometrial biopsy is performed on day 21 to 27 of the menstrual cycle to assess the endometrial response to progesterone and the degree of development of the luteal phase endometrium. All the medications listed are antiemetic agents, but transdermal scopolamine has the fastest onset of action. For this reason, it is most effective in providing relief from nausea for a prolonged period of time. Because of their antisecretory effect, proton pump inhibitors such as omeprazole are the drugs of choice for moderate to severe erosive esophagitis. The course of therapy is usually 4 to 8 weeks. The other medications may be helpful for certain clients; however, proton pump inhibitors are the medication classification of choice. Antacids should be chewed well and followed with 4 ounces of water for optimal effect. They should be taken regularly after meals, but the client should allow at least 2 hours between taking the antacid and any other oral medication. Antacids should not be taken longer than 2 weeks without further evaluation. They can be taken before gastric upset occurs for better symptom control. Clients with glaucoma should not take anticholinergic agents such as dicyclomine because the medication affects pupillary dilatation and therefore indirectly affects the outflow of aqueous humor. The other medications listed do not pose this problem to the client. Cimetidine decreases metabolism of beta blockers, phenytoin, procainamide, quinidine, benzodiazepines, metronidazole, tricyclic antidepressants, and warfarin, leading to increased risk of drug toxicity. Ranitidine, famotidine, and nizatidine are histamine blockers that are newer than cimetidine and have fewer side effects. Sucralfate forms an adhesive barrier on the surface of the gastric mucosa, protecting it from gastric acid. It does not reduce spasms, relieve nausea or vomiting, or act as an anticholinergic. Pancrease, a pancreatic enzyme replacement, increases digestion of starches and fats and thereby decreases the incidence of steatorrhea (fatty, frothy, foul-smelling stools). Each of the other options is only partially correct. Associated symptoms of fever, abdominal pain, and dehydration symptoms may suggest pathological diarrhea. The health care provider should be contacted for further evaluation. The other actions listed do not provide for the current physiological needs of the client. Bismuth subsalicylate contains small amounts of naturally occurring lead, but Reye syndrome is a theorized complication of salicylate use in young children. Taste and darkening of the tongue are not the issues being addressed in this question. Methylcellulose is a bulk-forming cellulose that absorbs intestinal fluids. This action helps prevent constipation and reduce or eliminate diarrhea. Bisacodyl and docusate sodium are laxatives, while dicyclomine is an antispasmodic. Hot tubs, saunas, and tight underwear can raise the temperature of the testes too high for efficient spermatogenesis and lead to decreased sperm numbers and motility. A serious adverse effect of misoprostol (Cytotec) is that a pregnant woman who takes medication may experience a miscarriage. Misoprostol should be discontinued at least 1 month before pregnancy occurs. Options 1 and 2 have lower priority, and option 3 may or may not be necessary for this client. Bisacodyl is a stimulant laxative that may cause fluid and electrolyte imbalance. This can have additive effects because the diuretic use would also contribute to this finding. For this reason, the nurse should assess the use of the laxative. The other options suggest items that would not help determine the cause of the client’s current symptoms. Bulk-forming laxatives, such as methylcellulose, absorb intestinal fluid, increasing stool volume, stimulating peristalsis, and decreasing straining on defecation. This type of laxative is the best choice for a client with a history of heart disease complicated by heart failure. The laxatives in the other options are more likely to cause straining at stool for the client and are therefore less helpful for the client’s overall status. Dicyclomine HCl is an antispasmodic drug. Peripheral side effects include hot, flushed, dry skin; hyperthermia; and intolerance to high temperatures manifested by dizziness. The client should be advised to drink extra fluids (nonalcoholic) if exposed to high temperatures to reduce this occurrence. Adverse/side effects during the first 2 to 3 months of treatment with growth hormone include hypercalciuria with resultant renal calculi. The client is not at increased risk for acute glomerulonephritis, bowel obstruction, or duodenal ulcer (options 1, 3, and 4). Clients with coronary artery insufficiency and hypertensive cardiovascular disease who take ADH are at increased risk for developing fluid overload and edema. Option 2 is the opposite of what would occur. Options 3 and 4 are not related to this client’s situation. Clients with known cardiovascular disease who are prescribed thyroid hormone replacement therapy may develop chest pain that could lead to myocardial infarction. For this reason, it is the most important manifestation for the client to report. The other manifestations, if they occurred in this client, would have a lesser priority. Clients with severe symptoms of hypothyroidism and a history of cardiac disease must be started on the lowest dose possible of hormone therapy and have the dose gradually increased in order to prevent onset of severe hypertension, heart failure, and myocardial infarction (MI). The other options could put the client at risk for chest pain and subsequent MI. Clients with acute adrenal insufficiency will complain of musculoskeletal symptoms of weakness and fatigue; GI complaints of anorexia, nausea and vomiting, and weight loss; integumentary symptoms of vitiligo and hyperpigmentation; and cardiovascular symptoms related to anemia, hypotension, hyponatremia, hyperkalemia, and hypercalcemia. The manifestations in options 1, 2, and 4 are opposite those seen with adrenal insufficiency and are therefore incorrect. Clients with Cushing’s syndrome or hypercortisolism have elevated levels of cortisol, low ACTH levels, increased blood glucose levels, elevated white blood cell counts, elevated lymphocyte counts, increased sodium levels, decreased serum calcium levels, and decreased serum potassium levels. Drug therapy will reduce serum cortisol levels when given as directed. The laboratory trends noted in options 2, 3, and 4 are opposite what would be expected in Cushing’s syndrome. In vitro fertilization usually creates multiple embryos, of which up to four are implanted. Cryopreservation of excess embryos is common, and they can be implanted at a later date. Graves’ disease is caused by elevated levels of thyroid hormone. Clients experience tachycardia, nervousness, insomnia, increased heat production, and weight loss. Medication therapy with an agent such as propylthiouracil will help control the disorder. Option 1 is irrelevant, while option 2 is indicated for hypothyroidism. A client with this disorder needs a high-calorie diet, not a low-calorie one (option 3). Cardiac problems related to Graves’ disease and hyperthyroidism include increased systolic blood pressure, a widened pulse pressure, tachycardia, and other dysrhythmias. Appropriate control of the disorder with medication therapy would prevent these manifestations from occurring. Management of hypoparathyroidism is aimed at correcting hypocalcemia, Vitamin D deficiency, and hypomagnesemia. Options 1 and 4 are incorrect because they are the opposite of effective treatment of hypoparathyroidism, while option 3 is an unrelated finding. Actos is a thiazolidinedione type of oral antidiabetic agent; its action enhances insulin action and promotes glucose utilization in peripheral tissues. This drug improves sensitivity to insulin in muscle and fat tissue and inhibits glucogenesis. Because of the potential for liver damage, clients taking drugs in this class must have liver function studies done before therapy is begun and periodically thereafter. Adrenocortical replacement therapy medications are divided into mineralocorticoids and glucocorticoids. Mineralcorticoids such as fludrocortisone increase resorption of sodium by increasing hydrogen and potassium excretion in the distal tubule. Glucocorticoids decrease inflammation by suppressing leukocyte migration and modifying the body’s immune response. The statements in the remaining options do not reflect these actions. If anorexia, nausea, or vomiting are present, sick-day diabetic management care requires clients to check their blood glucose level every 4 to 6 hours. Clients should not eliminate or adjust their doses of insulin or oral hypoglycemics. They also should drink 8 to 12 ounces of sugar-free liquids as tolerated every hour to prevent dehydration. Meals should be eaten at regular times, and they should consume foods and liquids that are more easily tolerated. To prevent diabetic ketoacidosis, this client must regularly check urine ketone levels if the blood glucose level is greater than 240 mg/dL. Thyroid hormones increase the effects of anticoagulants. Evaluation of PT or INR will determine if the anticoagulant dosage must be decreased. The nurse also assesses the client for evidence of bruising or bleeding. A CBC could detect anemia caused by bleeding as a complication of excessive warfarin therapy. APTT measures the effectiveness of heparin. Coumadin levels are not drawn. Hypercalcemia, hypomagnesemia, and digitalis toxicity may result when calcium supplements interact with digoxin. Clients must be instructed to take these two drugs at separate times of the day. Also, antacids must not be taken with digoxin. Hyperkalemia is not a concern with calcium supplementation. Primary osteoporosis most often occurs in postmenopausal women who are thin and lean-built. It is more prevalent in Caucasian and Asian women. Progesterone frequently is given along with estrogen as part of HRT to minimize the occurrence of endometrial or breast cancer. The other options do not relate to this medication. The psychological, cultural, and social ramifications of infertility can be extensive. You need to ascertain if the couple needs assistance in coping with their infertility and treatment. If diabetes is well controlled, blood glucose levels are not affected by mild consumption of alcohol. Male clients taking insulin may ingest two alcoholic beverages daily and female clients may ingest one alcoholic beverage with, or in addition to, the regular meal plan. Because of the risk of alcohol-induced hypoglycemia, diabetic clients must ingest alcohol only with or shortly after meals. In all cases, the client should confer with the prescribing physician and dietitian to determine whether alcohol should be utilized as part of the overall caloric intake. The following statements are commonly used to reinforce teaching for clients on how to combine insulins in one syringe: Gently roll the bottle of intermediate insulin to mix because vigorous shaking creates bubbles, leading to an inaccurate dose. Air must be injected into each bottle before withdrawing. Withdrawing the shorter-acting insulin first prevents the longer-acting insulin from mixing in the bottle with the shorter-acting insulin. Metformin is given to clients with stable type 2 diabetes mellitus to inhibit glucose production by the liver and increase sensitivity of peripheral tissue to insulin. The other three options contain factually incorrect statements. Vitamin D regulates calcium and phosphorus levels by increasing blood levels, increasing intestinal absorption and mobilization from bone, and reducing renal excretion of both elements. The statements in the other options are the opposites of the actions of Vitamin D. Alpha-hydroxy acids are useful keratinolytics that help reduce the effects of photoaging. Propylene glycol is used to treat ichthyosis. Salicylic acid and resorcinol are keratinolytics that are used to treat a variety of other skin disorders. Emollients contain petrolatum, oils, propylene glycol, or other substances and make the skin soft and pliable by increasing hydration of the stratum corneum. They do not dry the skin (option 2) or contain corticosteroids (option 3). Option 1 is not always necessary. Tretinoin is a retinoic acid derivative that needs to be applied once daily in a thin layer before retiring. The area to be treated should be washed at least 30 minutes before applying. Increased intake of Vitamin A, not Vitamin C, needs to be avoided. Mafenide is useful in treatment of partial- and full-thickness burns to prevent septicemia caused by organisms such as <i>Pseudomonas aeruginosa</i>. Mafenide does not have a defined use with the other infectious organisms mentioned. There is no cure for psoriasis. Psoriasis is notoriously chronic and recurrent. The cause is unknown. Each situation is individual, and the dermatologist who knows the client’s situation the longest is a good resource, but nevertheless the best answer for most clients is that the disease is recurrent and therapy will need to be continued. A 1% lotion of selenium sulfide is used to relieve the itching and flaking of the scalp associated with dandruff. A shampoo with lindane 1% (Kwell) would be used for pediculosis capitis. Corticosteroids have many uses, but dandruff is not one of them. Silver sulfadiazine is a cream used in the prevention and treatment of infection in partial- and full-thickness burns. In this situation, there was no nurse–client relationship. Although the neighbor offering the aspirin was a nurse, this action did not occur as a component of the nurse’s employment. All of the other requirements were present. Secondary infertility is the term for couples that have had one pregnancy but are unable to conceive again. Primary infertility describes the inability to conceive even once. Options 3 and 4 are not terms that are used when discussing fertility. Dry skin may occur in otherwise healthy skin and is usually worse in winter, when forced-air heating reduces humidity inside many dwellings. Excessive washing with harsh soaps (such as Dial) strips stratum corneum of its natural lipids and exacerbates dry skin. No shake lotion is made specifically for management of dry skin. Itching may occur with dry skin, but before an antipruritic lotion is used, an emollient lotion or emollient should be tried. Emollient lotions are dilute dispersions of emulsified lipids in water. These provide smooth application and the most rapid hydration if applied to dry skin, but they do not provide a protective effect on the lipid barrier. Emollients (e.g., petrolatum) are occlusive agents that make the skin soft and pliable by increasing hydration of the stratum corneum. Acyclovir is an antiviral agent that is useful in the treatment of herpes simplex viruses. The other conditions would require therapy with an antiinfective, but not of the antiviral type. Bacitracin is a topical antibiotic that is bactericidal against Gram-positive cocci and bacilli, including staphylococci and streptococci. These organisms might cause infection in a skin wound. Malathion (option 2) is an antiparasitic agent for pediculosis. Ketoconazole (option 3) is an antifungal agent. Mafenide (option 4) is an agent used for burns. Ulcers with necrotic material should be debrided, either by sharp debridement (e.g., using scalpel) or chemical debridement (e.g., wound cleanser such as an enzyme). An example of such a preparation is collagenase (Santyl), which is inactivated by metal salts, hexachlorophene, or acidic solutions. Hydrocolloid dressings can be helpful with uninfected wounds with fibrinous bases. Topical antibiotics will not help remove necrotic material. Allylamines are selected for fungal infections. Hydrogen peroxide is an oxidizing antiseptic that can be used to clean wounds or tracheostomy tubes. Options 1 and 3 as cleaning agents do not have the bubbling action of hydrogen peroxide. Mafenide is an antimicrobial used to treat burn injury. Proteolytic enzymes such as Elase ointment can be used to chemically debride tissue. These areas commonly include venous stasis ulcers, burn wounds, and pressure ulcers. The areas listed in the other options are not appropriate for treatment with proteolytic enzymes. A keratinolytic agent such as salicyclic acid is used to treat warts. Keratinolytics are also used to treat corns, calluses, and other keratin-containing skin lesions. Astringents cause topical vasoconstriction. Antiseptics inhibit bacterial growth. Proteolytic enzymes are used to debride tissue. Children have an increased risk of systemic toxicity from topically applied drugs because of the greater ratio of surface area to weight. The other responses are incorrect because they have similar body surface area to weight ratios. Acne can be successfully treated with the use of drying agents. Steroids would be of no benefit for this problem. Emollients and lubricants are moisturizers that may worsen the condition. Corticosteroids such as hydrocortisone are anti-inflammatory drugs. They do not exert antimicrobial action, and in fact, they can increase risk of infection by suppressing the inflammatory response. Corticosteroids are not moisturizing or drying agents. Infectious processes of the reproductive tract such as PID may result in tubal scarring and therefore tubal blockage. Rubella infection in childhood usually results in the development of active immunity to the disease. Smoking and alcohol present health risks to the woman but not related to tubal patency. Psoriatic plaques need to be lubricated so that they are easier to loosen and remove. Emollients and lubricants are fatty or oily substances that can be used for this purpose because they keep skin soft and prevent water evaporation. The other products listed are harsher and some may have a drying effect. Silver sulfadiazine is a metallic type of antiseptic that is widely used on burns. The silver in the solution is toxic to bacteria and prevents them from reproducing. The agents in options 3 and 4 would not be beneficial. Option 1 is a fictitious solution. A chlorine preparation such as Dakin’s solution is used for infected wounds when other treatments are ineffective. They are useful because they also dissolve necrotic materials and blood clots; however, a disadvantage is that they delay blood clotting, which may later interfere with wound healing. Options 1, 2, and 3 are not helpful in treating infections resistant to several antiseptics. Tegaderm is a protective dressing that is permeable to oxygen. The other products listed do not have this advantage. DuoDERM and Tegasorb are absorbent products that exclude bacteria and adhere to the site. Replicare excludes bacteria. Clients experiencing photophobia are instructed to wear dark sunglasses and to avoid bright lights. Not enough information is provided to warrant discontinuing the medication. Eyes should not be wiped with tissue immediately after instillation of drops, and no special glasses are required. Difficulty in adjusting quickly to changes in illumination occurs as a result of miosis, an effect of pilocarpine. The client will experience more difficulty seeing at night (option 1). Driving is not contraindicated (option 4); however, nighttime driving may not be possible because of the miosis. The diuretic effects of methazolamide may lead to electrolyte disturbances of hypokalemia and hypernatremia. Options 1, 2, and 3 are either partially or totally incorrect. Improvement of the infection should be noticed within a few days of beginning the antibiotic therapy. Superinfections are known to occur with this medication; therefore, 7 days is too long to seek further evaluation and treatment. Options 1, 3, and 4 are correct actions by the client experiencing any ear infection or disorder. Symptoms of systemic absorption of pilocarpine include diaphoresis, diarrhea, bradycardia, and hypotension. Options 2, 3, and 4 are incorrect because they are opposites of actual signs of systemic absorption. Cyclomydril and other mydriatics are applied topically to produce mydriasis (dilated pupil) to facilitate ocular examination. Options 1, 3, and 4 are incorrect because they do not constrict the pupil, provide anesthesia, or prevent infection, respectively. Because some semen is released before ejaculation, coitus interruptus has an 18% failure rate and would not be considered a very effective method for a couple wanting to avoid pregnancy. Systemic side effects of ophthalmic atropine include tachycardia, confusion, dry mouth, drowsiness, and slurred speech. Options 2 and 3 are opposites of known systemic side effects, while option 4 (diaphoresis) is unrelated. Ophthalmic solution that has darkened or become cloudy should be discarded. Most solutions are clear (option 2). Swabs should not be used to apply medication (option 3), and the medications generally have a shelf life of 3 months (option 4). Salicylates may cause tinnitus, vertigo, and hearing loss if ingested in high doses. Vitamin C (option 2), diphenhydramine (option 3), and Vitamin A (option 4) do not present this concern. Inserting objects into the ear canal, including medication droppers, may perforate the tympanic membrane. Though the ear canal may be obstructed with cerumen (option 1), there are other reasons, such as inappropriate instillation technique, for the medication to not flow into the ear canal (option 2). The client is instructed to lie on the unaffected side, not the affected side (option 3), to allow flow of medication into the ear. The recommended wait time between administrations of two ophthalmic solutions is 5 minutes. If an ophthalmic ointment is instilled, the waiting time is 10 minutes between the ointment and the next medication. The eye is cleansed with sterile irrigating solution or sterile normal saline to decrease risk of contamination. Options 1, 2, and 4 represent appropriate techniques demonstrated by the client. Timolol is a beta-adrenergic blocker that decreases the production of aqueous humor, thereby decreasing intraocular pressure. Sympathomimetics also decrease aqueous humor production. Prostaglandins increase the outflow of aqueous humor to decrease intraocular pressure. Carbachol causes miosis (pupil constriction), making quick changes in illumination difficult. Nighttime is particularly hazardous for the elderly client. The client and family are instructed on methods, such as lighting hallways and bathrooms at night, to reduce the potential for injury. Mydriasis (option 2) is not a concern. Systemic side effects of carbachol include diarrhea (option 3) and hypotension (option 4). Carbonic anhydrase inhibitors produce increased urinary elimination and subsequent increased excretion of potassium. Clients are monitored for fluid volume deficit (not excess as in option 1) and hypokalemia (options 3 and 4). Monitor electrolytes, intake and output, daily weights, mucous membranes, and skin turgor. Redness and swelling are signs of hypersensitivity to vidarabine. The medication should be discontinued, and the client should return to the clinic immediately for evaluation. Options 1, 2, and 4 are incorrect because they place the client at risk. Cervical mucus that is thin and clear indicates a rising level of estrogen and impending ovulation. Stretchability of the cervical mucus, or spinnbarkeit, is indicative of the fertile period and promotes motility of the sperm. Options 1 and 3 represent cervical mucus during the infertile period when sexual intercourse is unlikely to result in pregnancy. Viroptic, used in the treatment of viral infections such as herpes, is administered for an additional 5 to 7 days after healing has occurred. Ophthalmic medications are stored in a cool, dry place (option 3), and some are recommended for refrigeration (check label for instructions). Options 1 and 2 are incorrect because their time frames are too limited. The child’s pinna is pulled down and back for administration of otic solutions. The pinna in the adult is pulled up and back. Droppers should never be inserted into the ear canal, and the head is tilted toward the unaffected side. Acetazolamide, a carbonic anhydrase inhibitor, causes diuresis. The nurse should instruct the client to take the medication early in the day to avoid nocturia. Clients receiving acetazolamide are encouraged to consume at least 2,000 mL of fluid per day to avoid fluid volume depletion, and acetazolamide may be taken with juice or food to minimize gastrointestinal irritation. Proparacaine is administered to prevent pain during procedures such as tonometry and removal of foreign bodies. The medication has a rapid onset within 20 seconds and duration of 15 to 20 minutes. Options 1, 3, and 4 are incorrect actions taken by the nurse because of the time frames identified. Because vancomycin (Vancocin) can cause thrombophlebitis, this adverse effect is less likely to occur with central IV administration than with a peripheral IV administration (option 1). Dilution of the drug lessens irritation to the vein. Vancomycin is not absorbed in the GI tract, so oral route is used only to treat <i>Clostridium difficile</i> associated with antibiotic-induced pseudomembranous colitis (option 4). Intramuscular administration is contraindicated (option 3). Increased serum creatinine indicates renal dysfunction. Nephrotoxicity is a common adverse effect of aminoglycosides such as gentamicin. The urine creatinine clearance would be decreased in renal impairment (option 1). Coagulation disturbances and hypokalemia are not attributed to this class of antibiotic as a direct adverse reaction (options 2 and 4). Peripheral neuritis is the most common side effect of isoniazid (INH). Adding Vitamin B<sub>6</sub> (pyridoxine) to the client’s intake is the therapy to correct this side effect. The diet may be supplemented with Vitamin B<sub>6</sub>. Foods highest in Vitamin B<sub>6</sub> include beef, liver, chicken, and pork, including beef liver and chicken liver. Other foods listed are not high in pyridoxine. Foods other than meats that could be included are raw avocados, baked potatoes with skin, raw bananas, figs, and soybeans. Amphotericin-induced hypokalemia may potentiate toxicity of digoxin because hypokalemia is a primary cause for digitalis toxicity. Amphotericin B is available for only intravenous and topical routes. Antifungal agents and cardioglycosides do not compete for the same receptor sites. Eradication of the intestinal flora can occur during antibiotic therapy. Absorption of Vitamin K from the intestines can be interrupted, and prolonged bleeding may result because of inadequate serum level of prothrombin (hypothrombinemia). Vitamin K is essential to the synthesis of prothrombin (factor II) by the liver. Appropriate therapy in this case is to administer phytonadione or menadiol sodium diphosphate (Synkayvite). Since intestinal absorption may not be optimal, parenteral route is preferred. In addition, the nurse must assess for and protect against increased bleeding. ALT is specific for diagnosing and monitoring liver disease or impairment. Differential diagnosis of the etiology of jaundice between hepatic dysfunction and hemolysis of red blood cells is indicated by the bilirubin. AST may help to diagnose or monitor clients with heart disease or disease of the liver. The symptothermal method combines cervical mucus and BBT measurements and results in a lower failure rate than single assessments of the fertile period. This method is completely natural and acceptable to the beliefs of this religious group. Ovulation testing kits do not give enough warning of ovulation to prevent pregnancy. A minor rash is the most common side effect of the penicillins and may be relatively insignificant. Its presence does not signify an allergic reaction and does not prohibit future administration of penicillin. However, the nurse closely monitors for further hypersensitivity reaction because other clinical manifestations may develop, such as fever, urticaria, chills, erythema, Stevens-Johnson syndrome, respiratory distress, and anaphylaxis. If itching occurs, an antihistamine such as diphenhydramine (Benadryl) may be prescribed. All available antimicrobials are capable of stimulating an exaggerated immune response, but not all clients experience allergy with antibiotic therapy. Stevens-Johnson syndrome is a more serious aberration of the skin associated with antimicrobial adverse reactions; it resembles a second-degree burn in that necrolysis separates the epidermis from the dermis, causing blisters. Improvement in clinical manifestations of the infection should be noted within 48 to 72 hours. Otherwise, compliance with prescribed drug therapy should be assessed and adjustment of drug, dose, and/or administration frequency may be needed. Anorexia, nausea, and fluctuating febrile state may be common sequelae in systemic infections (options 3 and 4). The client’s ability to take in fluids can temporarily sustain his or her nutritional status for a few days, particularly if dietary supplements are also included, which is appropriate for client education (option 2). The volume of a household teaspoon may vary by 2 to 10 mL, so a calibrated device is necessary for accurate dosing. The suspension is to be shaken to disperse the particles just prior to measurement. It is recommended that a glass of water be given with the medication and that adequate urinary output be maintained (option 1). The medication is stable at room temperature, but the taste may be more palatable if cold (option 3). Food does not interfere with absorption of the medication and may help to minimize gastrointestinal side effects (option 2). Epinephrine is the primary drug used when bronchoconstriction causes inadequate respiratory exchange, as in anaphylactic shock. Marked improvement in respiration occurs within a few minutes after subcutaneous administration of 0.1 to 0.5 mL of 1:1000 strength epinephrine. Corticosteroids may be given to minimize the inflammation and edema but are not the initial agent given (option 2). Atropine may minimize secretions but would not be given unless vagal-induced bradycardia or asystole occurs; then atropine may be given as an IV bolus rapidly before, during, or after cardiopulmonary arrest (option 3). Dopamine HCl, a catecholamine (as is epinephrine), may be given to increase blood pressure if shock develops (option 4). A disulfiram-like effect is associated with certain drugs, including metronidazole (Flagyl). Onset is usually within 15 to 30 minutes of ingestion of alcohol but can occur up to 72 hours after Flagyl has been discontinued. The reaction lasts approximately 20 to 30 minutes but can remain up to 24 hours. Opportunistic infections or superinfections are manifested by these signs and symptoms. Common ones are vaginal and GI tract infections, including candidiasis and diarrhea. They often result from broad-spectrum antibiotic use that destroys bacteria in the normal flora, allowing the resistant pathogens to proliferate. Early recognition and intervention with administration of sensitive anti-infectives is important in controlling discomfort and the severity of the reaction. The other options represent incorrect conclusions about the data presented. Yogurt and buttermilk products can decrease the diarrhea as well as add protein to the diet to provide albumin for drug binding. Blood or mucus in the stool with increased number of stools indicates the possibility of pseudomembranous colitis that should be reported to the health care provider. Antacids would interfere with the effectiveness of the antibiotic (option 4). The route of administration of antibiotics is not the cause for destruction of normal flora (option 3). Clients are not usually taught to test their stool for occult blood (option 1). Disulfiram-like or antabuse-like reactions can occur when cephalosporins are taken with ingestion of alcohol during and up to 72 hours after discontinuation of the cephalosporin. Caffeine and the other medications listed would not cause this reaction. Vestibular ototoxicity as well as cochlear otoxicity can occur with administration of an aminoglycoside such as tobramycin. A positive Romberg’s test indicates vertigo or loss of balance and may suggest a vestibular problem. Babinski’s reflex present in the adult reflects a possible lesion in the corticospinal tract (option 4). Chvostek’s sign is seen in tetany and hypocalcemia (option 3). One method of assessing peripheral circulation is to check the capillary refill (option 1). Griseofulvin does not cause increased bleeding unless the client is also on anticoagulant therapy (option 2). The agent also has no known effect on blood pressure or known interaction with calcium intake (options 3 and 4). However, griseofulvin can interfere with the effectiveness of estrogen-containing oral contraceptives (option 1). Made of polyurethane, the female condom does not require a prescription but can be difficult to insert and can cause discomfort. It is effective against both sexually transmitted infections and pregnancy. Bacteriostatic agents inhibit or retard bacterial growth and replication, but they do not kill the entire bacteria. These agents depend on the host’s defense mechanisms to complete elimination of the bacteria. Bactericidal agents actually kill and lyse the bacteria. Tetracyclines are bacteriostatic. Supplemental Vitamin B<sub>6</sub> is indicated with isoniazid (INH) administration (option 3). Iron, as well as antacids and laxatives, food, and dairy products, should be separated 1 hour before or 2 hours after administration of a tetracycline (option 2). These substances interfere with the absorption of tetracyclines. Option 4 is unnecessary. The prothrombin time (PT) and the international normalization ratio (INR) values are standard tests to monitor warfarin (Coumadin) levels. The beta-lactam antibiotics may cause increased PT and INR. The bleeding time (option 1) evaluates the integrity of the vascular and platelet factors associated with stagnated blood. Thrombin time (option 2) evaluates the fibrinogen to fibrin conversion factor that can be used to gauge heparin effectiveness. However, the APPT (option 4) is currently used most often in regulating heparin therapy. The PPD injection stimulates a local inflammatory response at the injection site in the client who has been exposed to the tubercle bacillus in the past. The client develops a cellular response to tubercle bacillus at 3 to 10 weeks after infection. A positive PPD result does not indicate the client currently has active tuberculosis or is in an infectious state (options 1 and 2). Follow-up sputum tests for tubercle bacillus and/or chest films are done to clarify current status. Antibiotics, especially the aminopenicillins such as ampicillin, may decrease the effectiveness of oral contraceptives. The other clinical manifestations are not related to penicillin therapy. Oprelvekin (Neumega) can cause cardiopulmonary insufficiency with irregular heart rate and fluid retention. Thus, it is a nursing priority to monitor the client frequently for signs and symptoms of congestive heart failure. The other options do not address this priority concern. Mycophenolate (Cell Cept) is administered orally 72 hours after transplant. The time frames listed in each of the other options is incorrect. It is recommended that every client have a tetanus vaccine every 10 years to prevent infection caused by tetanus. The primary opportunity for this questioning is following a laceration. Delayed wound healing is a possibility with corticosteroid therapy, but assessment of tetanus immunization status takes priority. Temperature and blood pressure measurement (options 1 and 3) do not address the risk of infection caused by trauma while the client is in the emergency room. Antirabies serum, equine 55 U/Kg IM, can be applied to the animal bite wound. The medication does not need to be administered parenterally (options 1, 2, and 4). Beta 1b (Betaseron) reduces the severity of acute exacerbations of multiple sclerosis. The drug decreases the demyelination in brain tissue. The other responses do not accurately reflect the action of this medication. Adequate fluid intake greater than 2,000 to 3,000 mL per day allows for the kidneys to flush renal toxins and prevents renal insufficiency. Option 1 is a general measure to prevent constipation. Option 2 would be a monitoring function but would not prevent renal insufficiency from occurring. The nurse would not instruct the client to take additional medication that is not specifically part of the plan of care (option 4). Intrauterine devices are usually recommended for women who have been pregnant and are in a monogamous relationship so that they are at a low risk for sexually transmitted disease. The most significant laboratory test to utilize prior to medication therapy with azathioprine is creatinine level because renal and hepatic function should be assessed. Option 2 is irrelevant, while options 3 and 4 evaluate blood clotting and components of the blood, respectively. Other risks of azathioprine would be increased white cell count (infection) and decreased platelet count. Azathioprine (Imuran) is administered to treat multiple sclerosis, and allopurinol (Zyloprim) is administered to treat symptoms of gout. When these two medications are administered together, the dose of azathioprine should be reduced. The uric acid level and client symptoms should be monitored to determine the control of gout. Edrophonium (Tensilon) is used for diagnostic purposes. Clients who receive an injection of edrophonium and exhibit a temporary relief of symptoms are diagnosed with myasthenia gravis, which is characterized by a decrease in the concentration of acetylcholine in the neuromuscular junction. The medications listed in the other options are not used to diagnose myasthenia gravis. Medications used to treat symptoms of multiple sclerosis have been noted to increase pulmonary edema, leading to chest pain and shortness of breath. Option 2 could increase risk of urinary tract infection. Option 3 is useful to avoid infection but does not specifically relate to medication teaching. Option 4 could increase fatigue if done to excess and lead to exacerbation of symptoms. Immune serum globulin should not be administered to clients with a history of coagulation disorders. The other options do not represent contraindications to administration of this medication. Physostigmine (Eserine) is an anticholinesterase agent that crosses the blood–brain barrier. It is used as an agent to correct anticholinergic poisoning. The other medications listed do not have this effect. The intravenous administration of physostigmine (Eserine) should be no faster than 1 mg per minute to prevent toxic adverse reactions. The other options do not relate to toxicity of physostigmine. Diabetes insipidus is a complication for any client who has undergone removal of a pituitary tumor. Edema of the remaining pituitary gland may cause reduction in the release of antidiuretic hormone (ADH), resulting in movement of water from the glomerulus into the collecting tubules of the nephron. The client excretes large volumes of urine with a low specific gravity. As water is removed from the vascular compartment, the serum sodium becomes concentrated. Thus, the lab result indicates hypernatremia. The serum potassium, osmolality, and hematocrit would not be low (options 2, 3, and 4). Furosemide inhibits reabsorption of sodium, water, and potassium from the distal renal tubules and the loop of Henle, leading to a diuresis. The most common electrolyte disturbance associated with furosemide administration is hypokalemia. BUN and creatinine may be either elevated or lowered depending on a client’s individualized response to therapy. Similarly, the hematocrit could rise or fall depending on the amount of fluid retained in the vascular compartment. Hypokalemia is an almost universal complication of loss of gastric hydrochloric acid. In this scenario, loss of the hydrogen ions results in a metabolic alkalosis. In turn, compensation for this loss takes place in the nephron where hydrogen ions are retained. The nephron is obligated to excrete potassium, which may result in profound hypokalemia and require vigilant IV replacement. Other electrolytes may be affected, but not to the degree that potassium homeostasis is altered. Spermicides must be used within 30 minutes of intercourse, have a failure rate of 21%, and do offer some protection against sexually transmitted infections. Other key information needed is the sexual history of the client and her partner(s) to more accurately assess risk for STIs. Option 1 provides advice, which the nurse should not give. Options 2 and 3 are false statements. Elevated uric acid levels are commonly seen with gout, and this is the initial question to ask the client. Uric acid does not rise with gallbladder disease and is not affected by green tea. Although the client could experience renal stones from precipitation of uric acid crystals (causing flank pain), this is not the initial question to ask since renal stones are not a complication of gout. Serum creatinine is the best indicator of renal function. Often, decreases in serum creatinine are dramatic following renal transplantation. Regular monitoring of serum creatinine levels is imperative in determining the function of the transplanted kidney. Hemoglobin levels may increase postoperatively because of blood transfusions. Serum phosphate may decrease long term as the kidney increases excretion of phosphates. However, this is not a reliable indicator of renal function. Serum sodium levels may fluctuate according to individual client’s sodium–water balance. The hematocrit is an indicator of the proportion occupied by the cells in a given volume of blood. The hematocrit may decrease when cell volume of the blood is decreased because of blood loss. In addition, the hematocrit may decrease when the liquid portion of the blood volume increases, as would be the case when large volumes of intravenous fluid are administered. Hemoglobin would not be increased in this client situation, nor would sodium and calcium balance be altered. Neutrophils are responsible for destruction of bacterial invaders. In acute bacterial infections, such as appendicitis, the percentage of neutrophils (especially immature bands) in the complete blood count will increase. This presence of an increased number of bands in the CBC is known as a “shift to the left.” Lymphocytes are responsible for destruction of viruses. Erythrocytes and platelets are not affected by infections. Lymphocytes are responsible for the destruction of viruses. Thus, the presence of lymphocytes in the cerebrospinal fluid (CSF) suggests that the meningitis is viral in etiology, which is significant because the infection is most commonly self-limiting and will not respond to antibiotic therapy (as would bacterial meningitis). The presence of neutrophils would suggest bacterial meningitis. Normally, CSF is free of all cell types. A positive leukocyte esterase suggests a urinary tract infection. Leukocytes (white blood cells) contain esterases that react with substances contained in urine. More than 100,000 colonies of bacteria (per high-powered field) are needed before the patient can be diagnosed with a UTI. Testing for the presence of leukocyte esterase may be done using a voided urine sample, which is simple compared to the need for a catheterized urine sample. Nitrites may be positive in this situation. White blood cells may be elevated. Potassium in the urine is unaffected and rarely measured. The goal for total serum cholesterol is to keep the value below 200 mg/dL. Although options 1 and 2 are within the normal range, the best outcome of therapy is the value that is the lower of the two. Albumin is a protein responsible for increasing osmotic pressure and maintaining intravascular fluid volume. Low albumin levels result in a decrease in intravascular colloid osmotic pressure, which in turn allows fluid to move out of the blood vessel and into interstitial tissues. This condition will be observed as fluid retention in the form of edema, crackles, and so on. Skin turgor will be elastic when fluid shifts into the interstitial spaces. Bowel sounds and mucous membranes would not be affected. The loss of stomach acids creates an imbalance leading to an excess of alkaline fluids in the body. The source of the loss is metabolic, not respiratory. Troponin is a specific marker for cardiac injury. Elevations in serum levels usually begin 4 to 6 hours after onset of symptoms and peak in 12 to 24 hours. Drawing the blood in the first 2 hours would be too soon, and waiting longer than 24 hours would miss the times for peak levels. When using the device, the woman should wash her hands with soap and water, remove the device within 24 hours of intercourse, clean the device with soap and water, and seek treatment for vaginal infections before reusing the device. In cirrhosis, the damaged liver is unable to properly metabolize amino acids and synthesize albumin, resulting in decreased serum concentrations. The damaged liver is unable to completely break down bilirubin, and serum levels are elevated. Ammonia is normally converted to urea; serum levels are increased with liver damage. Prothrombin times are increased when the liver is unable to synthesize clotting factors. Prothrombin times should be 1.5 to 2 times the control when anticoagulation therapy is being given, indicating the Coumadin is effective. The level is in the therapeutic range, and the next dose should be given as scheduled. Encouraging the client to eat foods high in Vitamin K would reduce effectiveness of the Coumadin. The client would be at risk for bleeding, not for deep vein thrombosis, when prothrombin times are prolonged. In hypothyroidism, the thyroid gland does not produce thyroxine (T<sub>4</sub>) despite being stimulated by the pituitary gland (TSH, thyroid-stimulating hormone) to do so. Elevated TSH and T<sub>4</sub> levels are seen with secondary hyperthyroidism caused by excessive TSH production by the pituitary. A decreased TSH and elevated T<sub>4</sub> are seen with primary hyperthyroidism. Decreased TSH and T<sub>4</sub> levels are seen in hypothyroidism secondary to insufficient pituitary secretions. Dehydration results in loss of fluids, causing a hemoconcentration of the BUN, which is elevated. Sodium would be elevated, not normal, with dehydration. The potassium level is normal and would most likely be lower because of losses from the vomiting. The hematocrit would also be elevated secondary to hemoconcentration. Hemoglobin is the oxygen-carrying component of red blood cells. When levels are decreased the client will be fatigued and tire easily. Altered nutrition may be the cause of the low hemoglobin, but it is not of highest priority, since intolerance to activity involves safety concerns. Constipation and risk for deficient fluid volume would not be as high in priority. Hypocalcemia causes excitability of skeletal, cardiac, and smooth muscle tissues. Evidence of this is seen in the Trousseau sign, a carpopedal spasm. Hypokalemia, hyponatremia, and hypochloremia would not cause this sign. Tissue injury can cause an increase in WBCs. The WBC count could decrease with rheumatoid arthritis, alcoholism, and viral infections (options 1, 2, and 3). The normal range for the white blood cell count is 5,000 to 10,000/mm<sup>3</sup>. For this reason, the nurse would be concerned about the risk of infection if the count exceeded 10,000. The area is anesthetized using a local anesthetic before skin biopsy, so the client should only feel discomfort while the anesthetic is administered. Analgesics are not given before the procedure (option 1), and the procedure is not pain-free (option 2). The client may take medication such as acetaminophen following the procedure (option 4), but this does not address the client’s question about pain during the procedure. Because a contrast agent will be used for the test, it is most important for the nurse to ask about an allergy to iodine or shellfish. While it is good to know if the client has had a similar test for anxiety reduction, it is not the priority. The client should not have anything to eat or drink for 4 hours prior to the test. It is generally helpful for the client to void before leaving the unit to avoid having to do so during the test, but this is also a lower priority item than questioning for allergy. Long-term exposure to secretions, spermicides, and bacteria trapped inside the cap can result in abnormal Pap smear results. This client has a history of an abnormal Pap smear; cervical cap use could negatively impact this finding, and another method should be explored for this client. The other options have no relationship to use of the cervical cap. Because the MRI scanner uses magnets, the client cannot wear any metal, and clients who have implanted metal may be ineligible for this study. The client does not need to withhold food or fluids before the test. The client does not need to remain in the department for additional observation after the test and can drive himself or herself home. The amount of residual radioactivity following radionuclide scanning is very small and poses no risk to visitors or staff. Using standard precautions in handling blood or body fluids is sufficient for protection. It is unnecessary to stand 6 feet away from the client, use a private room, or place the client on contact precautions. The most important question is to determine whether the client could be pregnant, since x-rays are contraindicated during pregnancy, especially during the first trimester. The second question in importance would be asking about whether the client is wearing any metal, but possible pregnancy is a priority. It is helpful, but not of highest priority, to know if the client has had an x-ray before to alleviate concerns. Asking about fear of small or closed spaces would be important for MRI machines and possibly for CT scanning machines. There is no special aftercare following pelvic ultrasound. For this reason, the nurse should make the client comfortable and ask if she needs anything before leaving the room. The client does not need to drink fluids, should not have cramping pains, and does not need to wait an hour before eating. Before offering food or fluids to a client following bronchoscopy, it is essential to ensure that gag and swallow reflexes have returned. A local anesthetic is used to numb the throat to ease passage of the bronchoscope, and if protective reflexes have not returned, the client could aspirate. The other client data is also normal but would not indicate whether the client can safely swallow. The finding that should be of greatest concern to the nurse is the adverse change in the distal pulse on the leg that underwent angiography. Skin that is paler and cooler is also of concern, but the reason for these adverse changes is the reduced circulation to the leg, which is in turn caused by the decreased pulse. A bandage that has a small amount of old blood is expected and is not of concern at this time. The client is asked to lie still except for specific requests, such as to cough or deep breathe to aid in catheter movement or to terminate cardiac dysrhythmias caused by irritation of the catheter. The procedure is done in a special cardiac catheterization room in the radiology department, not in the operating room. The lights in the room may be dimmed at times so catheter movement can be visualized on a fluoroscopy screen. The catheter insertion site is anesthetized with a local anesthetic, so the client should feel pressure but not pain. There is no restriction of food or fluids prior to a cardiac (or any) echocardiogram. This test uses sound waves emitted from and reflected back to a transducer, and it is noninvasive. Options 2 through 4 are all variations of an incorrect response. The client should go about his or her usual daily activities and exercise pattern while wearing the monitor and should record activities and any symptoms experienced in the diary. The client does not need to make diary entries every 30 minutes, but as needed, to provide an overview of activity so that it can be correlated with any cardiac abnormalities on the time-stamped electrocardiogram being recorded. The client should not take a bath or a shower while wearing the device, which has electrical circuitry. The client does not need to walk a total of 3 miles during the 24-hour period. The client has 15 mL less than the expected minimum urine output of 240 mL in 8 hours. The first step by the nurse would be to determine the client’s fluid intake and encourage the client to drink increased fluids. Although it is not incorrect to measure specific gravity, the nurse could expect the value to be high if the urine output volume was low because of poor intake. Documenting the value is insufficient because further nursing action is warranted. The nurse should call the physician if the reduced output continues after increasing the client’s fluid intake. Autonomy refers to the right to make one’s own decisions. Justice refers to fairness; fidelity refers to trust and loyalty; confidentiality refers to the right to privacy of personal health information. Antibiotic use can decrease the effectiveness of oral contraceptives. Oral contraceptives can help prevent iron-deficient anemia by decreasing menstrual blood flow. Weight gain and anemia are not related to the effectiveness of birth control pills. The nursing assistant should wash the client’s hair to remove the paste or colloidon that was used to secure the electrodes to the head for the diagnostic test. The client should be able to eat and drink and can resume usual activity unless otherwise ordered. There is no dye used in this diagnostic test. Following myelogram with water-based contrast, the head of the bed needs to be elevated to 60 degrees to reduce the risk of meningeal irritation from any residual contrast in the spinal fluid. If an oil-based contrast was used, the head of the bed would need to remain flat. The other options indicate incorrect responses because the head of the bed is too low to prevent headache from meningeal irritation as a complication of the procedure. The client should limit joint movement, including walking, for 2 to 3 days after arthroscopy. Analgesics are often needed to manage pain, and the client should be instructed about what to use and how often to take it. The physician may order ice to control swelling, but not heat, which would aggravate swelling. Increased swelling and bleeding after discharge should be reported because these are abnormal findings and could indicate a complication of the procedure. Because the throat is anesthetized so the client can tolerate the endoscope, the client’s gag and swallow reflexes are temporarily lost during any upper endoscopy procedure, such as esophagogastroscopy. The nurse’s priority is to monitor for return of these protective airway reflexes. While mildly elevated temperature and reports of heartburn and sore throat also bear continued monitoring, they are of lesser priority than concerns related to the client’s airway. The client should not eat or drink anything for 8 to 12 hours before the test, and so the client should not eat or drink anything after midnight. Oral medications are usually withheld before the procedure as well. The diet may be resumed after colonoscopy, but the client usually tolerates it better if it is resumed gradually. The client should not drive for about 24 hours until all medications have fully worn off. It is normal to pass gas and feel bloated because of the carbon dioxide used to insufflate the colon to visualize the area. It is abnormal for bleeding to be present, and the client should notify the physician if it occurs. The client should avoid using any skin products, such as lotions or deodorant, on the skin of the breast or underarm prior to a mammogram. The client may eat and drink as usual. Although the procedure may cause some women discomfort with compression of the breast, it is not necessary to premedicate with analgesics. There is no activity restriction following the test. A Mantoux test (or PPD test) to screen for tuberculosis should be read in 48 to 72 hours. If the test was planted on Monday, the result must be read in 2 to 3 days, which is Wednesday or Thursday. The other options are either partially (options 1 and 3) or completely incorrect (option 4). Selected drugs (antacids, steroids, cholinergics, and anticholinergics) and coffee and alcohol should be restricted for at least 24 hours prior to test; note on test request form if client has not complied with restrictions. There is no reason to withhold a cardiac glycoside or a diuretic because these medications would not affect the test results. Placing the hands <i>directly on</i> the incision during coughing will diminish the discomfort associated with coughing. Each of the other options indicates correct procedure on the part of the client. Oral contraceptives can reduce acne, result in signs and symptoms of early pregnancy including chloasma, and accelerate the progress of gallbladder disease. Birth control pills do not provide protection against STIs that can result in PID. The child fears separation from parents. The child has no previous experiences to compare to this experience, so he or she will not anticipate pain. The child cannot anticipate any changes in his or her body and does not worry about communication. Taping a wedding band in place is acceptable for the client who does not wish to remove it, unless there is danger the finger may swell during or after surgery. The other options are incorrect because option 1 assumes the ring is tight and that the client wishes to remove it. Option 3 is a false statement, while option 2 creates unnecessary fear during a time when anxiety is likely to be already enhanced. Option 1 is correct because with increased age, there is a greater likelihood that the kidneys will start to degenerate. All the other options are incorrect: Hunger does not necessarily cause hyperacidity, comprehension is not altered in all older adults, and cardiovascular problems do not necessarily diminish pain sensations. Corticosteroids may lead to weight gain because of salt and water retention and may also delay wound healing. An antidysrhythmic helps to regulate the cardiac rhythm (option 1). A sedative-hypnotic may interfere with the uptake of the anesthetics but does not affect healing (option 2). An oral hypoglycemic agent is used for diabetes, but the medication itself does not pose added risk to the client during surgery (option 4). Nephrectomy is a major type of surgery because the kidney is a major vital organ, loss of blood is more likely to be greater than with the other mentioned surgeries, and there is more likelihood of complications. Options 1, 2, and 3 are all examples of minor surgery because they do not involve a high degree of risk. Dementia affects the person’s understanding of the proposed surgery and ability to cooperate with the perioperative care; it also affects the medications given. Cultural differences should not pose a risk unless the client’s beliefs are contrary to the proposed measures. Mild anxiety will not create a risk, and previous surgeries may be helpful for the client to draw on previous experiences. Abrasions, pustules, or other skin conditions have to be observed and documented because they may interfere with wound healing or increase the risk of infection. Hair growth—lack of it or presence of lanugo or fine hair—will not interfere with the skin preparation. Pulsation is not always visible or available to observe depending upon the part of the body being operated on. Previous surgeries can reveal possible difficulties or problems with certain anesthetic agents but do not necessarily interfere with absorption of anesthetics (option 1), hinder comprehension of instructions (option 2), or affect the central nervous system (option 3). However, they may affect the physiological or psychological responses of the client to the planned surgery. Alcohol affects the central nervous system and therefore the client’s response to surgery and the anesthetic itself. Smoking, not alcohol (in small amounts), poses respiratory risks. Alcohol effects cannot be reduced by the use of sedatives or hypnotics. Past and recent intake of alcohol can impact responses which can be either slowed down or escalated. The ability of the client to see and hear may affect the preoperative and postoperative teaching methods used. Social resources and accident prevention rely not only on the client’s vision and hearing (options 1 and 2) but also on family supports and the client’s physical and mental status. <i>Unexpected needs</i> is a very general term that can be applied not just to vision and hearing but also to any area of client functioning (option 3). Oral contraceptives with a combination of estrogen and progestin are not recommended in the first 6 weeks of lactation. In addition, the long-term effects on the infant are not known. The use of female condoms and a diaphragm are associated with sexual intercourse. Progestin-only pills are safe for lactating women. Anticoagulants inhibit clotting of the blood, putting the client at increased risk for bleeding postoperatively. Delirium tremens needs to be monitored for clients who had problems with alcohol use (option 1). Respiratory compromise may occur if clients take sedatives or hypnotics (option 2). If clients are taking diuretics or cardiovascular agents, fluid volume may be a problem (option 4). Wound and cardiovascular complications are more common among clients who are obese. The heart is stressed from its workload, and the added stress of surgery may place the client at risk. The client has no risk for excess fluid volume (option 4), and decreasing fluid intake could complicate wound healing. Weight loss would not concern the nurse (option 2); while impaired skin integrity would be a concern, it would be less worrisome than option 3. Antiembolic stockings facilitate venous return from the lower extremities. Smoking may contribute to cardiovascular events, but cessation will not necessarily lessen the chance of thrombophlebitis in the immediate postsurgical period. Observation of the leg will help with detection, but it will not prevent thrombophlebitis. Homan’s sign is pain on dorsiflexion of the leg, and this is also a means of detection, not prevention. A surgical procedure that relieves symptoms of disease or pain but does not cure is described as palliative. The other options are incorrect explanations. A wide scar occurs in tertiary intention because the edges are not approximated, and they regenerate via granulation. Options 1 and 3 refer to secondary healing, while option 2 is characteristic of primary healing. Purulent drainage is made up of tissue debris, WBCs, and bacteria; it may be of different colors depending upon the type of bacteria, and it is thick in consistency. It often indicates wound infection. The next action by the nurse would be to gather additional data that could indicate infection, such as elevated temperature and WBC count. The nurse would document the findings at some point, but this is not the priority action. There is no reason to monitor for bleeding within the wound or to measure pulse and BP. Covering the wound with sterile, saline-moistened gauze keeps the wound moist and protects it from infection. Option 1 is incorrect; in wound dehiscence, the layers of the wound are disrupted, but there is no protrusion of vital organs. In addition, pushing back organs such as the intestines is extremely dangerous because it could cause strangulation. A hydrocolloid dressing is not indicated (option 2) because its absorptive properties are not needed. Option 4 would be ineffective and does not protect underlying tissue. By keeping the stomach empty during surgery, the risk of vomiting and aspiration is decreased. The other options are unrelated to NPO status. Return demonstration is the best way to evaluate teaching of a procedure. Ideally, the teaching is done over a few days and is then evaluated. Having the client explain the procedure is also appropriate because it indicates that the client has the necessary knowledge to perform the procedure. Giving a paper-and-pencil quiz and critiquing a video would measure cognitive aspects of learning but are not realistic. Asking the client detailed questions during the procedure is not helpful because it detracts from learning. Amniocentesis for genetic testing is usually done early in the second trimester. This test, on a client who has diabetes and is at 38 weeks’ gestation, is probably being done to assess lung maturity in anticipation of delivery. Norplant is a subdermal contraceptive implant that has about the same failure rate as surgical sterilization, is effective for 5 years, and must be surgically removed. The test, completed on an outpatient basis, is done under guidance of ultrasound visualization. The test is done without anesthetic or with a local anesthetic. The client is positioned on her back with a wedge under her left hip to avoid hypotension from pressure of the uterus on the vena cava. The amount of lecithin increases as the fetal lungs mature. The ratio of lecithin to sphingomyelin is used to assess lung maturity; changes in color (options 2 and 4) are not. Option 1 is not a therapeutic response. Most women view invasive antenatal testing with anxiety because of the reason for the test, the impending results, and concern about maternal and fetal complications. Because of the small amount of fluid removed, option 4 is unnecessary. Options 1 and 2 are completely incorrect. Contractions elicited during the test could cause increased bleeding if an abruption is present. Intrauterine growth restriction, diabetes mellitus, and postterm pregnancy are all indications for completing a contraction stress test. The client has stated that she is worried, which creates anxiety. The information presented does not represent denial or immaturity. There is insufficient data to determine whether the client’s coping is effective or ineffective at this time. Percutaneous umbilical blood sampling (PUBS) obtains an actual sample of fetal blood for analysis. The other options provide information about fetal well-being but do not directly sample the fetal erythrocytes. A concealed abruption may result in a Couvelaire uterus, which doesn’t contract effectively after delivery, leading to uterine atony. The other complications may occur in any client. Prophylactic antibiotics are given during labor to prevent bacterial endocarditis. The other medications may need to be given based on additional assessment findings and may not be needed at all for a client with class II heart disease. The client is likely to lose some blood with a placenta previa. Increasing iron in her diet is a positive response that does not interfere with her religious beliefs. Option 1 is not a true statement. Option 2 does not address the client’s need or right to care. The client with multiple partners is at high risk for sexually transmitted diseases and ascending infection that may lead to blockage in the fallopian tubes. Ultimately, this process could lead to ectopic pregnancy. The other options do not address this particular pathophysiological concern. The medication is administered intramuscularly every 80 to 90 days. Anemia, while important to the client’s health, is not related to Depo-Provera use. The drug does not provide protection against sexually transmitted infections; counseling regarding the consistent use of condoms would be an effective intervention to prevent the reoccurrence of pelvic inflammatory disease. The transmission of HIV is less than 1% if the infant is delivered by cesarean prior to membrane rupture. Only the client with active herpes lesions should be delivered by cesarean to prevent transmission of the virus during vaginal birth. A short-term outcome of maintained weight is appropriate while the client is being stabilized in the hospital. An outcome is the result of nursing care. Options 1 and 3 are nursing interventions. Option 4 does not address the nursing diagnosis. Breastfeeding should be encouraged because it benefits both the mother and her infant. It is not contraindicated for diabetic mothers (option 1), may or may not help prevent future pregnancy during lactation (option 3), and does not necessarily lead to loss of blood glucose control with careful management (option 4). The client with premature ruptured membranes is at risk for developing an infection and should have her vital signs monitored every 2 hours, specifically temperature. The client may be on bedrest, not ambulating, following rupture of the membranes (option 1). Promoting rest (option 3) and providing clear liquids (option 4) are slightly lesser priorities for this client. Ultrasound confirms the diagnosis of molar pregnancy that is indicated by the client’s symptoms. The client will have high hCG levels and low maternal serum alpha-fetoprotein levels, but these are not conclusive for hydatidiform mole. Option 1 is inappropriate before the third trimester because it evaluates the fetus. The rate of transmission of HIV to the newborn is decreased from 17% to less than 7% if the mother is given prophylactic zidovudine (Retrovir) orally during pregnancy and by IV during labor. There are no indications presented in the question for any of the other medications listed, although an antibiotic could be administered if the mother acquired an infection secondary to ruptured membranes. Option 1 is a therapeutic response to the client’s concerns. The nurse should remain nonjudgmental when clients reveal information about substance abuse. Option 2 is nontherapeutic because it does not explore the client’s concern. Option 3 is inaccurate, and option 4 is judgmental. The left lateral position facilitates uteroplacental perfusion. Semi-Fowler’s position would decrease maternal cerebral perfusion, Trendelenburg puts the weight of the gravid uterus against the maternal lungs, and knee-chest is unlikely to be maintained by a client in shock. The client with DIC is at risk for hemorrhage, which takes priority over the non-life-threatening options 1 and 4. The client could experience bruising or other areas of local bleeding from the disorder, but hypovolemia from hemorrhage takes priority over risk for injury (option 3). Glucocorticoids such as betamethasone are contraindicated for use in diabetic clients because they raise the blood glucose level even further. The other disorders are not contraindications for giving betamethasone. The most common side effects of Depo-Provera are amenorrhea and irregular bleeding. With a failure rate similar to oral contraceptives, Depo-Provera does not interfere with lactation. Typically, the estrogen component of hormonal contraceptives is associated with thromboembolic disease; Depo-Provera contains only progestin. An increase of 30 mmHg systolic and 15 mmHg diastolic on two occasions is diagnostic for PIH. The blood pressures in each of the other options do not meet the criteria for increase in either the systolic or the diastolic blood pressure reading. The majority of early abortions are related to abnormal chromosomes. The client may fear that she has caused the loss and should be provided with accurate information. The other responses are not accurate. An LGA infant who demonstrates respiratory immaturity may have a diabetic mother. The infant produces his own insulin during pregnancy and stores the excess glucose as fat to compensate for high maternal glucose loads. However, after delivery the infant is at high risk for hypoglycemia because excess maternal glucose is now absent from the infant’s circulation. Cervical trauma and scarring may result in cervical incompetence during pregnancy. The other options are unrelated to cone biopsy. Variability of fetal heart rate indicates fetal well-being. Loss of variability or decreased variability (less than 2 to 5 beats per minute) is associated with depression of the autonomic nervous system that regulates heart rate. Hypoxia can cause loss of variability of the FHR, as can maternal sedation and fetal sleep, though the latter two are less serious signs. The presence of variability is observed by internal fetal monitoring, since there is less artifact that could be mistaken for variability of heart rate. Fetal heart tones are heard loudest over the fetal back. In breech presentation, this tends to be above the umbilicus. Fetal heart tones are heard just below the midline of the umbilicus in shoulder presentation or transverse lie. The nurse should suspect CPD because of the lack of progress since the last exam. The physician may assess the maternal pelvis by CT, MRI, or other means, or may stimulate contractions with oxytocin (Pitocin) opting for a trial of labor (TOL). Lack of progress may be caused by inadequate contractions and a vaginal delivery could be possible, so it is too early to anticipate cesarean delivery. Encouraging rest and continued observation will do nothing to resolve the problem. Flexing the thighs against the abdomen (McRoberts maneuver) increases the pelvic angle from symphysis pubis to sacrum and facilitates delivery by making the bony pelvis less restrictive. Corticosteroids such as betamethasone have been shown to enhance fetal lung maturity and prevent respiratory distress. Betamethasone does not stop labor or cervical changes. A side effect is increased risk of infection. Signs of premature labor may include abdominal cramping and pressure or persistent back pain. The client should be instructed to empty her bladder, lie down on her side, and drink 3 to 4 cups of water. If symptoms do not disappear within an hour, the health care provider should be notified. Unusual vaginal discharge should be reported sooner. Excessive fetal movement can sometimes indicate fetal distress but is not a sign of premature labor. Some clients report mild pain after the procedure, which is usually relieved with analgesics. Changes in menstruation, sexual function, or other hormonal symptoms are not typical. Fetal heart rate greater than 160 beats per minutes is considered fetal tachycardia, an early sign of distress. Meconium passage often occurs in breech presentation because of pressure on the presenting part and is not an indication of fetal distress in this situation. Mild variable decelerations and increased variability are not indications of fetal distress and occur more frequently in breech presentations. Dilatation has stopped (arrested) after considerable progress. Causes may be hypotonic uterine contractions, malposition, or cephalopelvic disproportion. The terms <i>prolonged</i> (option 1) and <i>protracted</i> (option 2) mean that progress occurs at a very slow rate. Arrest of descent (option 3) occurs when the station rather than cervical dilatation does not change. Bandl’s ring forms when labor is obstructed. The upper uterine segment continues to thicken while the lower segment thins and retracts. If left untreated, uterine rupture can occur. Bandl’s ring necessitates cesarean section. Frequent contractions and increased uterine muscle tone impede the blood flow through uterine arteries to the placenta. The incidence of umbilical cord compression is not increased, and hypertonic contractions are not necessarily associated with placental separation. While maternal exhaustion and lactic acid accumulation may occur over time, this does not immediately threaten fetal well-being. The risk of infection is increased after rupture of membranes. Therefore, the nurse should assess for signs of infection, including fever, foul-smelling amniotic fluid, and tenderness. Blood pressure, pulse, and fetal movement are checked more often during active labor. Color and consistency of amniotic fluid is observed immediately after rupture and each time the under pad is changed. Although not always preventable, uterine inversion can occur because of excessive traction on the umbilical cord during the third stage of labor with or without vigorous fundal massage to remove the placenta, especially if the placenta is implanted in the fundus. The other options are not associated with inversion. While all of the answers are appropriate goals, establishing a trusting relationship with the client and her family is a priority. In an emergency situation, the nurse may have little time to ensure that the client knows what to expect or to protect her privacy. It is not always possible to prevent fear and anxiety. A trusting relationship increases the likelihood of cooperation and compliance during a crisis. Uteroplacental insufficiency (UPI) is believed to be the cause of late decelerations. The insufficiency or decreased uteroplacental blood flow leads to fetal hypoxia. Several factors, including maternal hypotension, anemia, vasoconstriction, uterine tetany, and dehydration, can be primary causes of UPI. Head compression (option 1) causes early deceleration, and cord compression (option 2) causes variable deceleration. Option 4 is incorrect because it may or may not lead to UPI and eventual late deceleration. A trial of labor means that the client will be followed closely and given more time to show progress before considering a cesarean. Options 2 and 3 make cesarean delivery seem inevitable and can increase the client’s anxiety. Option 4 is incorrect because the client will be allowed to continue laboring as long as some progress is made. Cephalopelvic disproportion (CPD) means that the fetal head is too large to pass through the bony pelvis. Options 1 and 2 refer to a smaller than normal pelvis but do not take into account the fetal head size. Option 3 refers to shoulder dystocia. Beginning around the fourth week of pregnancy, vasocongestion in the pelvic area results in a bluish color to the vulva, vagina, and cervix, known as Chadwick’s sign. Hegar’s sign is a softening of the lower uterine segment, Goodell’s sign is a softening of the cervix, and McDonald’s sign is an ease in flexing the body of the uterus against the cervix; none of these other signs involve color changes. The Bishop score is an assessment of the mother’s physical readiness for labor, taking into account cervical dilatation, effacement, consistency, cervical position, and station before contractions begin. The higher the score, the more likely a client can be successfully induced. Self-image refers to how a client feels about herself. A positive self-image enables a client to deal with labor and delivery realistically, even in the event of complications. Research has shown that self-image impacts the laboring patient’s psyche. Other options have not been identified as having a significant impact during labor. Hypotonic uterine dysfunction occurs most often during the active phase. It is characterized by contractions that have become farther apart, less intense, and of shorter duration. Contractions are typically 2 to 3 minutes apart, strong, and last 45 to 60 seconds in the active phase of labor. Suction applied over the occiput commonly causes edema and bruising of the scalp. Although it may appear to be a deformity of the fetal head, the edema disappears in 2 to 3 days. Suction is not applied to the face (options 2, 3, and 4). A rapid labor and delivery may cause exhaustion of the uterine muscle and prevent contraction of the uterus after delivery, which controls the amount of bleeding. The infants in the other options either were not identified for length of labor (option 1) or were delivered after 9-hour and 12-hour labors (options 3 and 4). A hematoma is a collection of blood in the pelvic tissue caused by damage to a vessel wall without laceration of the tissue. A gestational diabetic client is more prone to have a large baby that could cause tissue trauma during delivery. She had to be delivered with forceps, which is also another high-risk factor for developing a postpartum hematoma. Maternal age does not affect the development of a hematoma (options 1 and 4). The size of the newborn, rather than the number, determines risk for hematoma formation (option 3). Late postpartum hemorrhage occurs anytime after the first 24 hours postdelivery. The causes of early hemorrhage are uterine atony, DIC, hematomas, and lacerations. This leaves retained placental fragments as the cause for late postpartum hemorrhage. The retained fragments undergo necrosis, forming fibrin deposits. These deposits form polyps, which eventually detach from the myometrium, causing hemorrhage. Adequate fluid intake (up to 3,000 mL/day) prevents urinary stasis, dilutes urine, and flushes out waste products, all of which help to prevent UTI. Bedrest is of no value (option 1). The client should attempt to void every few hours rather than waiting to regain a sense of a full bladder (option 2). While intake of juices is healthy (option 4), it is the large volume of fluid consumed that aids in flushing out wastes. Increasing the rate of IV fluids is an effective initial measure necessary to replace lost fluid volume that occurs in uterine inversion caused by hemorrhage. Blood products may also be necessary but generally take some time to obtain from the blood bank. Oxygen would be given (option 1) also to increase perfusion to tissues but does not restore circulating volume. An oxytocic drug (option 2) will help to limit further bleeding but will not restore circulating volume. Monitoring pulse is an assessment and will not limit the condition (option 3); an intervention is needed in this situation. A common risk associated with VBAC is uterine rupture. Pain in the abdomen and between the scapulae may occur when the uterus ruptures, the hemorrhage is concealed, and blood accumulates under the diaphragm. This is an emergency and requires immediate medical intervention, which is initiated by calling the physician. The client may be put in modified Trendelenburg to manage shock, not Trendelenburg (option 1); uterine atony is not the problem (option 2); and IV fluids would be increased rather than maintained (option 3). During pregnancy, increased estrogen production results in an increased amount and thickening of vaginal secretions. The uterus grows by cell hypertrophy, not by adding more cells. Red and hard breasts or a cervix dilating during the second trimester are not normal findings. The traditional definition of early postpartum hemorrhage after a vaginal birth is greater than 500 mL in the first 24 hours. With this in mind, each of the other options is incorrect. Maintaining contraction of the uterus is important in controlling bleeding from the placental site. Examining the fundus every 15 minutes helps assure that this is taking place. Early detection of a boggy uterus can lead to actions that will prevent hemorrhage. While the other examinations may be appropriate for the client, they will not help to detect early postpartum hemorrhage. Late-postpartum hemorrhage most frequently occurs because of retained placental tissue. Dilatation and curettage is the vaginal procedure of choice to remove retained tissue from the uterus. The other procedures are abdominal surgeries and are not used to treat this condition. Before providing further instructions, explain that these are signs of postpartum blues, which is a normal process related to hormonal changes. Option 1 does not address the client’s concern (in this case, the husband is the client). Option 3 is excessive, and option 4 is unnecessary and excessive. Uterine atony accounts for 80% to 90% of all early (within first 24 hours) hemorrhage. Infants weighing between 5 and 7 pounds would not overdistend the uterus (option 1). The client’s age (option 2) also does not increase the incidence of postpartum hemorrhage. Endometritis (option 3) could cause late postpartum hemorrhage, not early hemorrhage. Excessive bleeding must be evaluated and managed immediately to prevent excessive loss of blood and shock. Repositioning the client will do nothing. Waiting will only hurt the client. Bleeding should be monitored immediately. Calf pain upon dorsiflexion of the foot indicates a positive Homan’s sign, a sign of thrombophlebitis. If there is any question of thrombus formation, the legs, especially the calves, should not be massaged because doing so may dislodge a potential clot. Petechiae are not a clinical sign of thrombophlebitis. The fundus should be midline, two fingerbreadths below the umbilicus with dark red lochia, which may contain small clots. This explains lochia rubra. Option 1 explains lochia alba, which does not occur until about 10 days postpartum. Option 3 describes lochia serosa, which usually occurs between days 4 and 9 postpartum. Option 4 describes a complication of subinvolution. Option 3 indicates the mother is interacting with her infant and accepting responsibility for self-care and care of her infant. Options 1 and 2 indicate potential psychiatric problems, which require additional investigation. Option 4 requires investigation of why the mother is not eating well, which is important during the postpartum period. Applying a cold pack will minimize swelling, bleeding, and discomfort. Labial hematomas do not necessarily need to be drained (option 3); they will usually resolve on their own. A hot pack is incorrect because it will increase engorgement at the site via vasodilation (option 1). Witch hazel will not decrease the swelling in the area (option 2). Pressure on the vena cava from the gravid uterus may cause a decrease in blood flow to the right atrium and result in a decrease in blood pressure. Dizziness is a symptom of hypotension. The pulse rate could stay the same or increase as the workload of the heart increases during the course of pregnancy. There is an increase in the number of red blood cells to meet physiological demand. Option 4 is not a cardiovascular change during pregnancy, although abdominal fullness occurs as the pregnancy progresses. Bedrest is recommended following a diagnosis of thrombophlebitis to help prevent an embolus. Clients receiving heparin therapy should avoid aspirin or nonsteroidal anti-inflammatory drugs because they will potentiate the action of heparin. Once the thrombophlebitis resolves, the client should not experience any residual effects. A woman can continue to breast-feed while on heparin. Heparin will not affect the breast-feeding and requires no special precautions. Heparin does not pass to the breast milk. These symptoms are suggestive of mastitis and require prompt attention by the client’s physician. It is not therapeutic to wait for the symptoms to resolve on their own. Breastfeeding does not have to be stopped if mastitis is present. DIC is a disorder of widespread microvascular clotting that can then result in bleeding once clotting factors are consumed. Vaginal bleeding can be excessive if a coagulation disorder is present. Antibiotics will not affect a clotting disorder, DIC does not affect a client’s reflexes, and Homan’s sign is associated with thrombophlebitis, not DIC. Symptoms of pulmonary embolus include sudden onset of dyspnea, chest pain, anxiety, diaphoresis, elevated pulse, and hypotension. Confusion can also occur because of decreased oxygenation to the brain resulting from loss of adequate gas exchange in the affected area of the lung. The client would not experience chills or fever; these are more indicative of infection. Feeding a baby orally with a respiratory rate greater than 60 breaths/min increases the risk of aspiration. A heart rate of 118 is slightly below the normal range of 120 to 160 beats/min, but it is not a contraindication to feeding the infant. A hypothermic or SGA infant are both at risk for hypoglycemia and require a consistent source of glucose. Families are often in a state of denial with the birth of a sick newborn. It is important for nurses to gently encourage the parents to be realistic. By agreeing with the parent’s statement (option 1), the nurse is prolonging the state of denial and making it more difficult for the parents to see the situation realistically. Some parents do benefit from professional counseling, but nurses still need to provide support when working with families. It is not important if the nursery is ready yet (option 4) and this distracts from the real issues this family is facing at this time. The act of taping family pictures to the sides of the isolette promotes bonding and infant stimulation. Parents should wash their hands when they enter the unit but do not need to wear gloves when in contact with their infant. Young children often harbor organisms that could be transmitted to vulnerable newborns and should not have contact until the infant is moved out of the neonatal intensive care unit. A healthy respiratory rate for all newborns is 30 to 60 breaths/min. The other interventions are not timely for a 28-week-gestation infant at 1 week of age. An LPN/LVN is qualified to perform certain procedures and care for stable patients (option 3). An LPN/LVN is not qualified to admit a client, administer blood, or make nursing diagnoses. The infants identified in the other options require assessment and care by a registered nurse. Nurses, along with physicians, can be charged with negligence for failing to recognize the incorrectly prescribed dosage of a commonly known drug. The other responses are incorrect interpretations of possible consequences. Urinary frequency usually disappears in the second trimester. Thirst and urinary frequency may be a sign of developing gestational diabetes and warrants further investigation. Deep tendon reflexes are assessed during a physical examination and are not reported to a health care provider by the client. It is important to protect the infant’s eyes from the bililight to prevent permanent damage. The infant should be unclothed to allow as much skin exposure to the bililight as possible. Breastfeeding is not contraindicated with hyperbilirubinemia. Loose, green stools are a side effect of bilirubin excretion through the intestines. Narcotics cross the placenta and, if given close to delivery, can cause respiratory depression in the newborn. The other three answers may warrant further investigation, but the priority at delivery is to establish and maintain an airway. Preterm infants have minimal adipose tissue, so they lose heat more quickly through their skin. The skin is thin with blood vessels near the surface, which increases the amount of heat lost through the skin. Because they are weak and neurologically immature, they aren’t able to lay in a tight fetal position, allowing exposure of a greater percentage of the body to the air, which causes heat loss. In general, infants are not able to shiver to produce body heat when they are cold. The primary sign of an oral yeast infection, or thrush, is the presence of white patches in the mouth that tend to bleed if they are touched. This is not a normal finding, and is unrelated to whether Vitamin K was given at delivery, or maternal history of herpes simplex. Signs of dehydration in an infant include dry mucous membranes, sunken fontanel, and dry skin turgor. The other assessment data are expected findings in an infant. The highest priority after delivery is to maintain and support respiratory function. This infant is demonstrating initial signs of respiratory deficiency. Once this is done, the nurse may then check the umbilical cord for bleeding, measure temperature, and finally, check for visible deformities. Infants use additional oxygen and glucose when faced with cold stress. Infants with RDS are already compromised, so it is important to keep environmental temperatures stable to minimize their oxygen and glucose requirements. A complete examination could increase oxygenation requirements even further (option 2). Chest physiotherapy (option 3) may or may not be needed. There is no specific evidence in the question that meconium is present (option 4). This infant has been receiving high levels of oxygen for several weeks and is at risk for retinopathy of prematurity (ROP). All preterm infants who receive oxygen should have a thorough eye exam done by an ophthamologist prior to discharge. It is important to administer the minimum amount of oxygen to infants to decrease the risk that this condition will develop. Oxygen should be weaned and not withdrawn suddenly. Artificial surfactant may be administered within the first several days of life to decrease the risk of respiratory distress syndrome (RDS). Hepatosplenomegaly (enlarged liver and spleen) may be an early sign of HIV infection in an infant. All other data are within normal limits. An infant of a diabetic mother is at risk for hypoglycemia and should be monitored closely after delivery. All other interventions are important but are not the highest priority. Therefore, these can be completed once the blood glucose level has been measured and treated if necessary. By the twelfth week of gestation, the uterus should have increased in size to be palpable at the symphysis pubis. Factors affecting this finding include abnormal fetal growth or the presence of a multiple gestation. Phototherapy assists the body in converting unconjugated bilirubin to conjugated bilirubin, which is water soluble and easier for the body to eliminate. The other statements do not reflect accurate explanations. This infant has signs of Erb-Duchenne paralysis. It is important to provide passive range of motion on the affected side to prevent muscle wasting. The infant should not be positioned on the affected side. Occasionally, a splint may be applied, but a cast is not indicated. Narcotics cross the placenta and can cause respiratory depression in a neonate when given shortly before delivery. Naloxone (Narcan) is the drug of choice to reverse respiratory depression in the neonate caused by narcotics. Insulin would be given for hyperglycemia. Double doses of Vitamin K are not given. Magnesium sulfate is given to the mother to prevent eclampsia. SGA infants often experience intrauterine growth restriction related to decreased blood flow to the placenta, which increases their risk for infection. In comparison, the infants in the other options are at less risk for infection. Infants with fetal alcohol syndrome have an increased risk of feeding difficulties related to hyperactivity. Nutrition is a key concern for this infant for proper growth and development. Infection prevention is the next concern, since this will help to maintain healthy physiological condition. The immunization schedule has third priority because it is also related to prevention of communicable diseases and infection. Finally, although toy safety is important, it is the fourth priority because newborns are not developed sufficiently to play with toys. The client’s history suggests fluid volume deficit and dehydration. Sunken eyes, altered mental status and behavior, and dry, furrowed tongue are reliable signs of fluid volume deficit in infants. Bulging fontanels, peripheral edema, and neck vein distention are seen with fluid volume excess. Venous congestion results from fluid volume excess and causes full, bounding pulses, delayed hand vein emptying, and S<sub>3</sub> heart sounds. Flat neck veins with head of bed elevated is an indicator of the absence of venous congestion. Ascites is a form of third-space fluid. Therapy is aimed at moving third space fluid back into the circulation where it can be eliminated by the kidneys. When this fluid is drawn back into the vascular space (leading to a rise in BP and venous pressure), the kidneys increase the urine output to eliminate the excess fluid. Loss of fluid results in loss of weight. Those who exercise in hot climates need to continuously replace both fluid and electrolyte losses. Sports drinks provide carbohydrates, water, and electrolytes. Drinking large amounts of only water fails to replace electrolytes, which can lead to water intoxication. Salt tablets are no longer recommended because too much salt has a hypertonic effect, causes diuresis, and can actually worsen fluid loss. A TURP procedure can place a client at risk for developing hyponatremia in the postoperative period due to increased fluid irrigation used during and after surgery. Clients with a TURP procedure have a CBI (continuous bladder irrigation) as a routine part of their postoperative care. The other options do not place a client at risk for development of sodium imbalances because they do not require lengthy fluid and dietary restrictions or excessive fluid irrigation. This test, which measures the level of maternal serum alpha-fetoprotein, is most sensitive between 16 to 18 weeks’ gestation. However, it can be performed up to 22 weeks’ gestation. Hyponatremia can also be referred to as dilutional hyponatremia or water intoxication. Water restriction would be an important part of the treatment plan when caring for a client who has hyponatremia. The restriction of Gatorade (electrolyte-rich solution), eggs, cheese products, and salt on the diet tray are not indicated because the client is experiencing a sodium deficit. Clients with hypernatremia are thirsty and need water replacement to balance the increased sodium levels. Cough medication and lactulose can further increase sodium levels and should not be administered unless there is sufficient clinical information to warrant their use. Three percent saline is a hypertonic solution that would also increase serum sodium levels and should not be given to this client. The frequent use of Alka-Seltzer can cause an increase in serum sodium levels. It is important during an initial history to obtain information about all medications (prescription and OTC) that a client is taking. Options 1 and 2 are incorrect because they do not relate to potential sodium imbalance. They are helpful in determining the client’s support system and mobility status. Option 3 suggests that the client may have diabetes, but this does not relate to increases in serum sodium levels. During periods of major trauma, potassium shifts from the ICF to the ECF because of cell death, leading to high serum levels of potassium. Hypokalemia is not seen in burn clients during the time of fluid shifting secondary to trauma. The client with burns is more likely to be hypovolemic and hypocalcemic at this point in time because there is fluid and electrolyte loss caused by altered capillary integrity. In clients with cirrhosis, increased amounts of aldosterone are secreted, which leads to sodium retention and potassium excretion from the kidneys; these clients are likely to become hypokalemic. Clients with COPD, malignant melanoma, and CRF are likely to develop hyperkalemia due to retention of acids. Potassium is never given as a bolus when it is administered intravenously. All of the other orders are within a safe and therapeutic range. KCl should never be given rapidly or by IV push because serious arrhythmias or cardiac arrest can occur. A serum potassium level of 3.5 mEq/L is at the low end of the normal range. With a low normal level, it is better to continue to monitor the client and offer foods that are good sources of potassium. In the absence of additional medical history, it is not advisable to use additional treatment options at this point in time. Therefore, options 1 and 3 would not be indicated: they would be included for a client who is hypokalemic. The use of salt substitutes would require more background information because the client may have other conditions in which their use is not advisable. A client who is at risk for developing hypocalcemia requires monitoring of serum albumin (provides information relative to physiologically available calcium) and magnesium levels (decreased magnesium levels are usually seen concurrently with low serum calcium levels). The other options reflect elements that would be included for a client who would be at risk to develop hypercalcemia. Calcium is absorbed in the intestines only under the influence of Vitamin D, which is activated in the kidneys. Option 1 is incorrect because parathyroid hormone directly opposes calcitonin. Option 2 is incorrect because renal disease prevents activation of Vitamin D, thereby reducing the body’s ability to absorb calcium. Option 4 is incorrect: there are other ways to obtain Vitamin D in the body (such as exposure to sunlight). Anticonvulsants such as phenytoin (Dilantin) alter Vitamin D metabolism and lead to hypocalcemia. Options 2 and 3 represent calcium sources, and the inclusion of these in a treatment plan would lead to increased serum calcium levels. Option 4 is incorrect because thiazide diuretics can lead to calcium retention. According to Nägele’s rule, the estimated date of birth can be calculated by subtracting 3 months from the beginning date of the last menstrual period and then adding 7 days to that date. Clinical manifestations of hypercalcemia include personality changes. All other options are signs and symptoms of hypocalcemia. Clinical manifestations of hypocalcemia include a positive Trousseau’s sign, which is an ischemia-induced carpopedal spasm. A positive Chvostek’s sign is associated with hypocalcemia, while hypoactive bowel sounds are a sign of hypercalcemia. Kernig’s sign is an indication of meningeal irritation. Addison’s disease, known also as adrenal insufficiency, can cause increased magnesium levels resulting from volume depletion. Cushing’s disease is hyperfunction of the adrenal gland. Diabetes could lead to low magnesium levels if osmotic diuresis is present from hyperglycemia. Splenomegaly is an unrelated finding. SVT is seen with decreased magnesium levels, as are premature ventricular contractions and ventricular fibrillation. The other three options are findings with hypermagnesemia. Either hemodialysis or peritoneal dialysis is used to remove excess magnesium in the client with renal failure. Diuretics will not be effective if the kidneys are not functional. Fluid restriction would be ineffective, and high-volume IV fluid replacement would be contraindicated in renal failure. Decreased magnesium level (option 4) may occur in toxemia of pregnancy, preeclampsia, and eclampsia, in turn causing convulsions (seizures). The other responses are incorrect because they are directed at sodium (options 1 and 2) or increased magnesium level (option 3). Cushing’s syndrome causes low potassium and magnesium levels and an increase in sodium and chloride levels. The moon face and buffalo hump are also symptoms of excess corticosteroids. Option 1 is incorrect because Addison’s disease causes low sodium and increased magnesium and potassium. Option 3 is incorrect because burn states cause significant fluid and electrolyte disturbances (loss of sodium, chloride, and magnesium with alterations in potassium depending on stage of burn), but the presence of a moon face and buffalo hump is characteristic of Cushing’s syndrome. Option 4 is incorrect because SIADH is associated with hyponatremia. The home health nurse should be most concerned with the decreased chloride level because it can lead to complications such as dilutional hypochloremia. The client’s history of CHF places the client in a higher risk category for fluid retention, electrolyte disturbances, and acid-base disorders. All of the other options reflect laboratory values that are within normal range and are reassuring. Poor nutritional intake, vomiting, diarrhea, and the overuse of antacid are related to alcoholism and alcohol abuse. These can lead to hypophosphatemia. During oliguria, the kidneys are unable to excrete phosphorus (option 2). Clients with prolonged (not short-term) gastric suction are more likely to experience hypophosphatemia (option 3). Prolonged or continuous use of aluminum-containing antacids (not occasional use) leads to hypophosphatemia (option 4). Calcium and phosphorus have an inverse relationship in the body. For this reason, when phosphorus levels are high, calcium levels are low (option 3). The other responses do not address this relationship. Maternal folic acid deficiency has been linked to infant neural tube defects. Folic acid may be obtained from prenatal vitamin supplements as well as foods. The other responses contain incorrect statements and do not indicate understanding of prenatal nutrition. Hyperkalemia exists when the serum potassium level rises above the upper limit of normal, which is 5.1 mEq/L. A prolonged fasting state can lead to dehydration. During fasting, the body reverts to cellular breakdown to maintain energy, and lactic and pyruvic acids build up in the body. This accumulation of acids leads to the development of metabolic acidosis. Options 2 and 4 are incorrect because alkalosis would not occur. Option 3 is incorrect because the primary disturbance is not respiratory. Vomiting leads to the loss of hydrochloric acid from gastric acids. Hydrogen ions must leave the blood to replace this acidity in the stomach. Option 2 reflects metabolic alkalosis—elevated pH and HCO<sub>3<sup>-</sup></sub> and normal PaCO<sub>2</sub>. Option 1 is incorrect because it reflects respiratory acidosis with partial compensation—decreased pH, elevated PaCO<sub>2</sub> and HCO<sub>3<sup>-</sup></sub>. Option 3 is incorrect because it reflects a mixed acid-base imbalance—metabolic alkalosis with respiratory acidosis—normal pH and elevated PaCO<sub>2</sub> and HCO<sub>3<sup>-</sup></sub>. Option 4 is incorrect because it reflects respiratory alkalosis—increased pH, decreased PaCO<sub>2</sub>, and normal HCO<sub>3<sup>-</sup></sub>. Clients with respiratory acidosis from ingestion of barbiturates would have slow and shallow respirations, leading to hypoventilation. Palpitations are a subjective complaint reported by the client; the nurse cannot directly assess this symptom. In addition, palpitations are associated with respiratory alkalosis. Tetany symptoms and increased deep tendon reflexes are also associated with respiratory alkalosis. Clients with renal failure have difficulty synthesizing HCO<sub>3<sup>-</sup></sub> in the renal tubules secondary to the renal failure. These clients also retain K<sup>+</sup> and subsequently develop metabolic acidosis. Option 2 reflects uncompensated metabolic acidosis. Option 1 is incorrect because it reflects metabolic alkalosis—increased pH and HCO<sub>3<sup>-</sup></sub> and normal PaCO<sub>2</sub>. Option 3 is incorrect because it reflects respiratory acidosis—decreased pH, increased PaCO<sub>2</sub>, and normal HCO<sub>3<sup>-</sup></sub>. Option 4 is incorrect because it reflects a mixed acid-base imbalance—metabolic alkalosis with a respiratory acidosis—normal pH, increased PaCO<sub>2</sub> and HCO<sub>3<sup>-</sup></sub>. A client with atelectasis has collapsed alveoli that retain CO<sub>2</sub>, which can lead to respiratory acidosis. The client would most likely have hypoventilation as a respiratory pattern, which would further contribute to the development of respiratory acidosis. Options 1 and 3 are incorrect because the client would not be in an alkalotic state. Option 2 is incorrect because the primary disturbance is respiratory; clients with respiratory problems can report “chest pain.” Further information would be needed to rule out cardiac problems. Obesity can lead to chest wall abnormalities and hypoventilation. Respiratory acidosis results from hypoventilation. Option 1 is incorrect because prolonged diarrhea likely leads to the development of metabolic acidosis. Option 2 is incorrect because DKA leads to the development of metabolic acidosis. Option 4 is incorrect because diuretic administration leads to the development of metabolic alkalosis. Clients who have metabolic acidosis develop Kussmaul respirations (rapid and deep respirations). Weight gain and melena are not associated with the development of metabolic acidosis. Option 4 is incorrect because shallow breathing is associated with the development of metabolic alkalosis. Alkalosis, especially respiratory, makes the client more sensitive to the effects of digoxin; toxicity can develop even at therapeutic levels. A serum digoxin level should be obtained and the client evaluated for potential digoxin toxicity; warfarin affects clotting factors; metformin may cause the development of lactic acidosis; and ibuprofen may cause gastric irritation. Acute pain usually leads to hyperventilation, which causes CO<sub>2</sub> to be blown off, leading to an increased pH and decreased CO<sub>2</sub> level. If the client has not compensated, the bicarbonate level would be normal. If the client is compensating, then the bicarbonate level would decrease in an attempt to restore the pH. Option 1 is incorrect because it reflects only a slight elevation of PaCO<sub>2</sub>; if the client is in severe pain, the level would likely be higher. Option 3 is incorrect because the pH is only slightly acidotic. Option 4 is incorrect because the oxygen saturation is within normal limits. Both peanuts and hamburger are good sources of folic acid, but since the client is a vegetarian, peanuts is a better recommendation. The other options do not contain significant amounts of folic acid. The pH is low, indicating acidosis; the PaCO<sub>2</sub> is elevated, indicating a respiratory basis; and the HCO<sub>3<sup>-</sup></sub> is elevated, indicating that compensatory mechanisms are partially working. Option 1 is incorrect because compensation is taking place because of increased HCO<sub>3<sup>-</sup></sub> level. Option 2 is incorrect because the client is not alkalotic. Option 4 is incorrect because the primary disturbance is respiratory. The change in the PaCO<sub>2</sub> level is greater than the change in the HCO<sub>3<sup>-</sup></sub> level, which indicates a respiratory disturbance. The pH is just below the high limit and the HCO<sub>3<sup>-</sup></sub> is elevated, indicating a metabolic problem. The PaCO<sub>2</sub> is elevated, indicating that compensation is taking place. Option 1 is incorrect because the client is not acidotic. Option 2 is incorrect because the CO<sub>2</sub> would be decreased rather than elevated. Option 3 is incorrect because the primary disturbance is metabolic and the CO<sub>2</sub> is elevated rather than decreased. Excessive use of oral antacids can lead to metabolic alkalosis. Use of ibuprofen and acetaminophen is not associated with the development of metabolic alkalosis. Overdoses of aspirin can be associated with the development of respiratory alkalosis and eventually lead to metabolic acidosis. Clinical manifestations of metabolic alkalosis are associated with the presence of tetany-like symptoms. Clients should be monitored for the presence of these symptoms because they usually correlate with low levels of calcium. Although it is important to monitor all serum electrolyte values to obtain a comprehensive picture, the presence of hypocalcemia can cause the client to have significant clinical symptoms. Early monitoring and prompt intervention can result in restoration of balance. The client’s pH is high, indicating alkalosis. The PaCO<sub>2</sub> is abnormal, indicating a respiratory basis. The HCO<sub>3<sup>-</sup></sub> is normal, indicating that compensation has not started. Option 1 is incorrect because the HCO<sub>3<sup>-</sup></sub> level would decrease with compensation. Options 2 and 4 are incorrect because the primary disturbance is respiratory, as indicated by the decrease in the CO<sub>2</sub> parameter. A client who has prolonged nasogastric suction is apt to have higher levels of bicarbonate because of hydrogen ion loss. Bicarbonate excess leads to a metabolic disturbance and the development of metabolic alkalosis. Options 1 and 3 are incorrect because the client will not experience acidosis. Option 4 is incorrect because the primary disturbance is caused by retained levels of bicarbonate in the body. The pH indicates alkalosis; HCO<sub>3<sup>-</sup></sub> is high, indicating a metabolic basis; and the PaCO<sub>2</sub> is normal, which indicates that compensation has not taken place. Option 1 is incorrect because with compensation the PaCO<sub>2</sub> level would be increased. Options 2 and 4 are incorrect because the primary disturbance is metabolic, as reflected by the increased bicarbonate level. ABG results reflect elevated pH, indicating alkalosis; normal PaCO<sub>2</sub> and an increased HCO<sub>3<sup>-</sup></sub>, indicating metabolic alkalosis. Vomiting is a common cause of this condition. The presence of diarrhea is associated with metabolic acidosis. COPD and smoking are associated with respiratory acidosis. The pH is just within normal range, so the blood gas results are either normal or compensated. However, the PaCO<sub>2</sub> is high, indicating a respiratory problem and thus the ABGs cannot be normal. The HCO<sub>3<sup>-</sup></sub> is also high, which along with a normal pH indicates complete compensation. Options 2 and 3 are incorrect because the primary disturbance is respiratory, as reflected by the correlation between an elevated PaCO<sub>2</sub> and a pH toward the low end of normal. Option 4 is incorrect because the HCO<sub>3<sup>-</sup></sub> level would be normal if there was no compensation taking place. Respiratory alkalosis is caused by hyperventilation. Stress and anxiety are two things that can cause hyperventilation. It is important for clients who are prone to develop respiratory alkalosis to be aware of how to manage causative factors. Options 1 and 3 are incorrect because antacids and diuretics are associated with the development of metabolic alkalosis. Option 4 is incorrect because diarrhea is associated with the development of metabolic acidosis. Iron supplementation can cause gastric distress, constipation, and diarrhea. It does not cause a red, raised rash (option 1), blood in the stool (option 3), or headache (option 4). The pH and HCO<sub>3<sup>-</sup></sub> are decreased, indicating metabolic acidosis. The PaCO<sub>2</sub> is normal, indicating that compensatory mechanisms have not started working. Options 2 and 4 are incorrect because the primary disturbance is metabolic, as indicated by the low bicarbonate level. Option 3 is incorrect because with compensation, a decrease in PaCO<sub>2</sub> to restore balance would be expected. Clients with COPD are highly susceptible to respiratory infections such as influenza, so they should be immunized yearly. Clients with COPD should undergo a progressive rehabilitation program to increase their activity tolerance. Fluid restriction is not needed with COPD unless there is fluid retention from another etiology. The impaired gas exchange occurring with COPD is caused by the loss of alveolar surface area available for gas exchange. Destruction of alveoli is not related to increased dead space air, pulmonary emboli, or chronic dilation of bronchioles. With COPD there is progressive narrowing of bronchioles. Symptoms of COPD typically appear in the fifth and sixth decades of life following chronic abuse to pulmonary tissues by smoking or environmental pollutants. Onset of the physiological changes compatible with COPD is most often associated with a hereditary deficiency of alpha-1-antitrypsin, an enzyme that protects lung tissue against loss of elasticity. Onset of heavy smoking during childhood and heavy secondary smoke exposure during childhood are not typically associated with early onset of physiological alterations of COPD. Use of smokeless tobacco during childhood is associated with development of oral cancer. One of the primary alterations occurring with ARDS is the collapse of alveoli and therefore loss of ventilation in those areas. Perfusion may be normal, but gas exchange is impaired due to inadequate ventilation. Surfactant production decreases with ARDS, a factor that impairs adequate gas exchange. Air does not become trapped in hyperinflated alveoli in ARDS; instead alveoli collapse. Coughing, deep breathing, and adequate hydration are essential for achieving effective airway clearance. Insertion of a tracheostomy or O<sub>2</sub> therapy are not primary treatments to maintain airway clearance. Elevating the head of the bed may help the client to cough more forcefully, but head elevation alone is not an effective maneuver. The nurse should help the client and family to approach the diagnosis of lung cancer from a realistic perspective. Symptoms of lung cancer usually appear late in the course of the disease. Tumor growth does typically begin in a bronchus and progress upward, but this information has no relation to the client’s psychological adaptation to the disease. Administration of anticoagulants (option 3) is an effective intervention to prevent pulmonary embolism. Thrombolytic drugs (option 1) may be used to dissolve a clot that is already formed. Vitamin K (option 2) and protamine sulfate (option 4) facilitate clotting and counteract the effect of anticoagulants. Increased respiratory rate, tachycardia, and agitation are all early signs of respiratory distress. Cyanosis develops later in the progression of respiratory distress. Symptoms associated with pulmonary embolism typically have a sudden onset. The client often feels panic because of the sudden dyspnea. Increase in heart rate and respiratory rate is abrupt, not slow. Cyanosis of the upper torso is associated with embolism of a central vein other than the pulmonary vasculature. Bilateral wheezing is more often associated with asthma than with pulmonary embolism. Iron is absorbed best on an empty stomach (not after a full meal) and in the presence of Vitamin C. It may or may not be taken at the same time as other vitamin supplementation. It does not replace the need for other vitamins. The finding of crepitus at any time is associated with pneumothorax and should be immediately reported to the physician. Oozing of blood from the thoracentesis puncture site is not uncommon and does not require emergency intervention, as would crepitus. Diminished breath sounds on the affected side and fever may or may not be related to the thoracentesis. All of these findings should be noted and reported to the physician, but the finding of crepitus is clearly related to development of pneumothorax and signals immediate need for intervention by the physician. The primary physiological alteration occurring with COPD is alveolar air trapping and alveolar hyperinflation, which lead to alveolar rupture and loss of area available for gas exchange. Decreased surfactant production is associated with ARDS and is not a primary alteration of COPD. Lung compliance is decreased but is due to the alveolar air trapping and hyperinflation. Viral pneumonia is considered less serious for the client because symptoms are not as apparent compared to bacterial pneumonia. Viral pneumonia is associated with nonproductive cough, low-grade fever, normal white blood cell count, and normal or minimal chest x-ray findings. Ghon's tubercles are seen on x-ray in clients with tuberculosis. Anticholinergics such as ipratropium are contraindicated in clients with angle-closure glaucoma, because it can inhibit flow of aqueous humor and raise intraocular pressure. The other options do not address this concern. Clients with mild and infrequent asthma symptoms are treated with regular daily administration of an anti-inflammatory inhaler and a short-acting beta-agonist inhaler for quick relief in acute episodes. Bronchodilators and corticosteroids as oral or inhaled medication are used for clients with more severe and frequent episodes of asthma. A primary physiological alteration occurring with ARDS is shunting of blood around nonventilated alveoli. Alveoli collapse in ARDS, and ventilation decreases. Blood perfusing to these areas cannot undergo adequate gas exchange. Epinephrine is a bronchodilator used to increase the diameter of the airways. The best position is semi- to high-Fowler’s. Corticosteroids and antibiotics may be used but will not ease respiratory distress immediately. RSV is the cause of bronchiolitis in most cases; RSV can live for several hours on nonporous surfaces and can be transferred by the hands. Maintaining strict I & O will provide immediate notification of signs of dehydration; children with bronchiolitis may already have a history of poor fluid intake when initially seen by medical personnel. Because of respiratory difficulty, the child should be kept quiet with limited stimulation and visitors. If the child is tachypneic, oral fluids present a risk of aspiration. Meconium ileus in the newborn period is often the first indication of cystic fibrosis. The other options are unrelated to this question. Increased calcium intake can lead to formation of kidney stones. A calcium supplement is not expected to affect leg cramps, color of mucous membranes and conjunctiva, or resting heart rate. Bronchodilators open the airways and afford easier removal of secretions. Options 2 and 3 are unnecessary. Option 4 could be done after the procedure if necessary. Clear breath sounds indicate effective airway clearance and decreased mucosal swelling and obstruction. Tripod position is a clinical manifestation of a child in distress caused by epiglottitis. Pale lips and mucous membranes may indicate hypoxia. Tachypneic and dysphonic are symptoms of the disease. Tracheostomy suctioning can be stressful to the child and increases risk for hypoxia, infection, and mucosal damage. Each pass of the suction catheter should be limited to no more than 5 seconds, and the child is allowed to rest between passes with supplemental oxygen if needed. Toddlers are naturally inquisitive and explore things with their hands and mouths. It is developmentally inappropriate to attempt to teach a toddler to stop normal hand-to-mouth activity. Small objects and foods should be kept out of reach. Teen babysitters are unrelated. Handwashing is the most important infection control practice and decreases spread of RSV and other organisms. Option 1 is unnecessary because gloves are discarded in the trash basket. Options 2 and 3 are not timely. Swimming is recommended for children with asthma because prolonged expiration under water is beneficial. Cromolyn sodium is used prophylactically to prevent exercised-induced asthma, and immediate access to rescue inhaler is also recommended. Aerosol therapy such as a nebulizer is frequently used during hospitalization to administer medications. An advantage is that this route delivers medication directly to the airways. Chest physiotherapy and postural drainage for children with cystic fibrosis help loosen pulmonary secretions and facilitate removal from airways. It is not used for epiglottitis and bronchopulmonary dysplasia because it may increase respiratory distress in those conditions. It will not remove the foreign body. Steroids given via metered-dose inhaler on oral mucosa increase risk for yeast infection. A spacer avoids the mucus membranes and works directly on the airways. Excess fluid in the alveoli is a manifestation of bacterial pneumonia. The sound produced by fluid in the airways is crackles. Retractions are asymmetrical chest wall movements which are seen in any client having respiratory difficulty. Wheezes are often typical of pneumonia caused by RSV or conditions where the air passages are narrowed, such as asthma. Apnea is a pause in respirations, which is under the control of the central nervous system. The measles, mumps, and rubella vaccine contains live, attenuated virus and could cause disease and harm to the fetus during pregnancy. It should be given after delivery, and the woman should avoid conceiving for 3 months. Ribavirin is an antiviral drug that causes crystallization of soft contact lenses and is associated with conjunctivitis. The other options are satisfactory items in the care of this client. A CK level above 150 with over 5% MB isoenzyme indicates myocardial damage from acute myocardial infarction. Elevated potassium is not indicative of myocardial infarction. Elevated WBC is an indicator of many conditions, including MI. Nausea and anorexia are signs of digitalis toxicity. The other laboratory values would not explain the client’s symptoms and therefore are not priorities to assess before telephoning the physician. Furosemide increases potassium loss and low potassium levels potentiate digoxin. As a result, monitoring potassium levels is important to the care of this client. The client’s heart rate is bradycardic, and metoprolol, a beta-blocker, decreases the heart rate. Neither the captopril nor the hydrochlorothiazide lower the heart rate, and either may be safely administered to maintain control of the hypertension. When a dose of medication is withheld, it is the responsibility of the nurse to notify the physician of the action and rationale. A client with endocarditis is at risk for thrombus formation, and chest pain and anxiety are signs of pulmonary embolism (PE), which is a life-threatening complication requiring immediate attention. Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires monitoring; a temperature of 101°F requires additional evaluation, and a client who is ambulating for the first time will be monitored by the nurse. However, the client who needs to be assessed for PE is the most emergent. A serious complication of atrial fibrillation is pulmonary embolism. Chest pain and hemoptysis are common symptoms of pulmonary embolism. Irregular pulse is expected with atrial fibrillation. Fatigue may accompany atrial fibrillation in some individuals. Fever is not associated with atrial fibrillation and is not necessarily included in discharge teaching. However, it could be a sign of illness that could increase the workload of the heart, and therefore it would be the second-most important item to report if it occurred. Renal failure is a common cause of hypocalcemia, and a value of 7.0 mg/dL is below the normal range of serum calcium. Options 1 and 2 are within the upper limits for potassium and sodium, and option 4 is within the therapeutic range of digoxin. The client is not allowed to ambulate for 24 hours to prevent dislodging of the electrodes. Normal sinus rhythm, heart rate of 80, and a BP of 120 over 80 do not reflect pacemaker function. Paced beats indicate that the pacemaker is functioning. Symptomatic aortic stenosis has a poor prognosis without surgery. Restricting activity limits myocardial oxygen consumption. Since the incidence of sudden death is high in this population, it is prudent to decrease the strain on the heart while awaiting surgery.