NCLEX- RN Practice Exam 8

EXPLANATION

✔Correct answer:

Initiate oxygen therapy and elevate the head of the bed. Pulmonary edema is a medical emergency characterized by fluid accumulation in the alveoli of the lungs, leading to severe respiratory distress. The priority intervention includes providing oxygen therapy to improve oxygenation and elevating the head of the bed to facilitate easier breathing and reduce the workload on the heart.

In heart failure, the heart's reduced ability to pump blood effectively can lead to increased pressure in the pulmonary circulation, causing fluid to leak into the alveoli. This impairs gas exchange and leads to hypoxia. Elevating the head of the bed helps reduce venous return to the heart, decreasing pulmonary congestion and easing breathing.

Imagine a sponge that is soaked with water (the lungs with fluid). Elevating the sponge allows excess water to drain away, making it easier to squeeze and manage (the lungs to breathe and function better).

Nurse Patel should immediately initiate oxygen therapy and elevate the head of the bed. Additionally, the nurse should be prepared for further medical interventions as prescribed by the healthcare provider, such as administering diuretics to reduce fluid overload and other medications to manage heart failure.

• Immediately start oxygen therapy using a mask or nasal cannula to improve oxygenation.
• Elevate the head of the bed to a semi-Fowler or Fowler position to ease breathing and reduce pulmonary congestion.
• Monitor vital signs closely, including oxygen saturation, respiratory rate, heart rate, and blood pressure.
• Be prepared to administer diuretics such as furosemide (Lasix) to help remove excess fluid from the lungs.
• Communicate with the healthcare provider for further medical orders and provide ongoing assessment and support to the patient.

✘Incorrect answer options:

Prepare to administer a bronchodilator and check blood glucose levels. Bronchodilators are used for obstructive airway diseases like asthma or COPD and are not the first line of treatment for pulmonary edema. Checking blood glucose levels is not immediately relevant in this context.

Start a continuous IV infusion of dextrose and monitor urine output. Dextrose infusion is not appropriate for treating pulmonary edema. The primary focus should be on oxygenation and reducing fluid overload, not glucose administration.

Administer an antihistamine and position the patient in a flat, supine position. Antihistamines are used to treat allergic reactions and are not relevant in the treatment of pulmonary edema. Positioning the patient flat would worsen breathing difficulties by increasing venous return and pulmonary congestion.

EXPLANATION

✔Correct answers:

"I should restrict playing football to just the weekends." High-impact and contact sports such as football can increase the risk of fractures in patients with hyperparathyroidism due to potential bone demineralization. Patients should avoid activities that put them at high risk for injury and focus on low-impact exercises.

"I should exercise in the evening to promote better sleep." Exercising in the evening can sometimes lead to increased alertness and difficulty sleeping. Patients with hyperparathyroidism should be encouraged to exercise earlier in the day to help regulate their sleep-wake cycle and prevent interference with sleep.

Think of your body like a delicate piece of pottery. High-impact sports are like rough handling that can cause cracks (fractures). Exercising earlier in the day is like gentle polishing that keeps it in good shape without disturbing its resting phase at night (sleep).

✔Incorrect answer options:

"I enjoy exercising but I need to be cautious." This statement shows awareness of the need to be careful with physical activities due to the risk of fractures and other complications associated with hyperparathyroidism.

"I should space out my activities throughout the day." This statement reflects a good understanding of the need to pace oneself and avoid fatigue, which is important in managing hyperparathyroidism.

"I should determine my activity level based on my energy." This shows an understanding of listening to one’s body and adjusting activity levels based on energy, which is crucial in managing fatigue and preventing overexertion.

EXPLANATION

✔Correct answer:

Politely refuse to sign the will. Nurse Sarah should politely refuse to sign the will as a witness. Healthcare professionals, including nurses, are typically advised not to sign legal documents such as living wills or advance directives for their patients to avoid any potential conflict of interest or legal complications. Witnessing such documents could compromise professional boundaries and might lead to questions about the validity of the document or the influence of the healthcare provider on the patient's decisions.

The integrity of legal documents, especially those related to healthcare decisions, is crucial. Healthcare professionals must maintain clear professional boundaries to ensure that their involvement is always in the best interest of the patient without any appearance of coercion or undue influence.

Think of a nurse signing a patient's legal document like a referee in a game. The referee must remain impartial and separate from the players to ensure fair play. Signing the document could blur those lines, leading to potential bias and disputes.

Nurse Sarah should explain to Mrs. Johnson why she cannot sign the document and suggest that Mrs. Johnson asks a neutral party who is not involved in her medical care to serve as a witness.

• Explain to Mrs. Johnson the importance of maintaining professional boundaries and the potential conflicts of interest that can arise from signing legal documents.
• Politely refuse to sign the document and provide a clear explanation to avoid any misunderstanding.
• Suggest that Mrs. Johnson ask a neutral party, such as a friend, family member, or another non-involved staff member, to witness the document.
• Ensure that Mrs. Johnson understands the process of completing her living will and offer assistance in finding an appropriate witness if needed.
• Maintain a supportive and professional demeanor throughout the interaction to ensure Mrs. Johnson feels respected and understood.

✘Incorrect answer options:

Sign the will, witnessing the signature only. Signing the will could still present a conflict of interest and is not advisable for healthcare professionals directly involved in the patient's care.

Consult the hospital lawyer before signing. While consulting the hospital lawyer might provide clarity, it is generally best practice for healthcare professionals to avoid signing legal documents for patients to maintain clear professional boundaries.

Sign the will, including her credentials and place of employment. This option increases the risk of conflict of interest and could compromise the document's validity and Nurse Sarah's professional integrity.

EXPLANATION

✔Correct answer:

A client experiencing chest pain after eating a spicy pizza. Chest pain is a potentially serious symptom that can indicate a range of conditions, including myocardial infarction (heart attack) or other cardiac events. Even though the chest pain may be related to gastrointestinal issues such as acid reflux, it is critical to prioritize this client to rule out life-threatening conditions. In emergency triage, symptoms suggestive of cardiac events take precedence because of the high risk and potential for rapid deterioration.

Chest pain can result from various causes, including angina, myocardial infarction, pulmonary embolism, and gastroesophageal reflux disease (GERD). The urgency lies in promptly identifying and treating cardiac causes to prevent severe outcomes.

Think of triaging patients like prioritizing repairs for different types of car issues. A car with a potential engine failure (chest pain) needs immediate attention over one with a flat tire (twisted ankle) or a scratch (small cut), as the engine problem could lead to the car breaking down completely.

Nurse Emma should immediately assess the client experiencing chest pain, including obtaining vital signs, conducting an ECG, and providing oxygen if needed. The client should be placed on continuous cardiac monitoring, and the healthcare provider should be notified immediately for further evaluation and management.

• Perform a rapid assessment, including obtaining a detailed history of the chest pain (onset, duration, quality, radiation, and associated symptoms).
• Obtain vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation.
• Conduct an electrocardiogram (ECG) to assess for any signs of cardiac ischemia or arrhythmias.
• Place the client on continuous cardiac monitoring and provide supplemental oxygen if necessary.
• Notify the healthcare provider immediately for further evaluation and management of potential cardiac conditions.

✘Incorrect answer options:

A client experiencing muscle aches, a headache, and general malaise. These symptoms are concerning and may indicate a viral infection or other non-life-threatening conditions. However, they are not as urgent as chest pain, which could indicate a cardiac event.

A client who twisted her ankle after a fall while rollerblading. While this client may be in pain and require evaluation and treatment, a twisted ankle is not immediately life-threatening and does not take precedence over potential cardiac issues.

A client with a small cut on his index finger from slicing an eggplant. This is a minor injury that, while needing attention, does not pose an immediate threat to the client's life or health.

EXPLANATION

✔Correct answers:

Observe the patient's ability to urinate. After a lumbar puncture, it is essential to monitor the patient’s ability to urinate as neurological complications or discomfort from the procedure could affect bladder function.

Keep the patient in a flat position. Maintaining a flat position for 4 to 6 hours post-procedure helps prevent cerebrospinal fluid (CSF) leakage and reduces the risk of post-lumbar puncture headache.

Check the patient's ability to move their limbs. Assessing the patient’s ability to move their limbs is crucial to detect any potential neurological changes or complications resulting from the lumbar puncture.

Examine the puncture site for any swelling, redness, or drainage. Inspecting the puncture site for signs of infection or CSF leakage is essential in preventing and identifying complications early.

Think of the care plan like a car maintenance checklist after a tune-up. You need to ensure all parts (like limbs) are functioning, check for any leaks (puncture site), monitor for any unusual changes (urination), and let the engine rest (flat position) to prevent any issues from arising.

✘Incorrect answer options:

Limit the patient's fluid intake for 2 hours. Increasing fluid intake rather than limiting it is recommended to help replace the CSF volume and reduce the risk of headache following a lumbar puncture.

Place the patient on a nothing-by-mouth (NPO) status for 24 hours. There is no need for the patient to be NPO for 24 hours post-lumbar puncture. Patients are typically encouraged to resume their normal diet as soon as they feel able.

EXPLANATION

✔Correct answer:

Nausea. Nausea is the most commonly associated side effect of Exelon (rivastigmine), which is a cholinesterase inhibitor used to manage symptoms of Alzheimer's disease. This class of medication works by increasing levels of acetylcholine in the brain, which can enhance cognitive function but also affects the gastrointestinal system, leading to symptoms such as nausea, vomiting, and loss of appetite.

Rivastigmine increases the concentration of acetylcholine by inhibiting its breakdown, which can stimulate the gastrointestinal tract and lead to side effects like nausea. These gastrointestinal side effects are dose-related and often more pronounced when the medication is first started or when the dose is increased.

Think of rivastigmine as increasing the fuel to a car's engine (acetylcholine in the brain). While this helps the engine run better (improves cognitive function), it also revs up the exhaust system (gastrointestinal tract), which can cause unpleasant fumes (nausea).

Nurse Laura should monitor Mr. Andrews for signs of nausea and other gastrointestinal side effects. She should also educate him and his caregivers about the potential side effects and ways to manage them, such as taking the medication with food to reduce gastrointestinal discomfort.

• Monitor Mr. Andrews for signs of nausea, vomiting, and appetite loss.
• Encourage taking the medication with food to minimize gastrointestinal side effects.
• Educate Mr. Andrews and his caregivers about the potential side effects and the importance of reporting severe or persistent symptoms.
• Ensure the dosage is titrated gradually to help minimize side effects.
• Maintain regular follow-up appointments to assess the medication's effectiveness and tolerance.

✘Incorrect answer options:

Urinary incontinence. While urinary incontinence can be a symptom associated with Alzheimer's disease, it is not a common side effect of Exelon (rivastigmine).

Headaches. Headaches are not typically associated with Exelon. While they can occur, they are not as common as gastrointestinal side effects like nausea.

Confusion. Exelon is used to treat symptoms of Alzheimer's disease, which include confusion. While it is aimed at reducing cognitive symptoms, confusion itself is not a side effect of the medication but a symptom of the underlying disease.

EXPLANATION

✔Correct answer:

"I'll bring you some juice and toast. Would you like anything else?" This response addresses Mr. Thompson's immediate concern of feeling hungry while avoiding a confrontation or causing further confusion. Offering him a small snack such as juice and toast is a compassionate approach that meets his current needs and helps alleviate his distress without challenging his perception of reality, which can be disorienting for someone experiencing confusion.

Confusion in patients, especially those with cognitive impairments, can cause them to forget recent events, such as having just eaten. Providing reassurance and addressing their expressed needs can help reduce anxiety and agitation.

Think of a confused patient like someone waking from a dream, unsure of what is real. Arguing about the dream's content (what they remember) won't help, but offering comfort and addressing their needs will.

Nurse Alex should focus on validating Mr. Thompson's feelings and providing reassurance. Addressing his hunger with a small snack is an effective way to meet his needs without causing additional confusion or distress.

• Offer a small snack to address Mr. Thompson's immediate need and reassure him.
• Monitor his nutritional intake and ensure he is receiving adequate nutrition throughout the day.
• Document the incident and communicate with the healthcare team about Mr. Thompson's confusion and possible interventions to manage it.
• Engage in regular orientation activities to help Mr. Thompson stay connected with time and place, such as discussing the date and daily schedule.
• Provide a calm and supportive environment to reduce anxiety and confusion.

✘Incorrect answer options:

"You had breakfast just 30 minutes ago." This response might cause frustration or confusion for Mr. Thompson, as it directly contradicts his current perception and may not effectively address his feeling of hunger.

"I'm sorry they missed you. I'll inform the charge nurse." This response could create unnecessary concern or anxiety about a problem that doesn't exist. It also doesn't immediately address his hunger.

"Lunch will be served soon, so you'll have to wait a bit." While this response informs him of the next meal time, it doesn't address his immediate need and could lead to increased agitation due to the wait.

EXPLANATION

✔Correct answer:

Sundowning. Sundowning refers to a state of increased confusion, agitation, and restlessness that typically occurs in the late afternoon and evening in individuals with dementia. It is a common symptom in Alzheimer's disease and other forms of dementia, where the individual's cognitive abilities worsen as the day progresses, leading to increased behavioral disturbances during these times.

The exact cause of sundowning is not fully understood, but it is believed to be related to changes in the circadian rhythms, fatigue, and the reduced lighting in the evening that may increase confusion and agitation. Environmental factors, such as overstimulation or unmet needs, can also contribute to this phenomenon.

Think of sundowning like a car's engine running smoothly in the morning but starting to sputter and misfire as it gets low on fuel in the evening. The brain of a person with dementia similarly becomes more confused and agitated as the day wears on and fatigue sets in.

Nurse Karen should implement strategies to manage and reduce sundowning symptoms, including maintaining a structured routine, ensuring the client has adequate lighting, minimizing environmental stimuli, and promoting relaxation techniques before bedtime.

• Maintain a consistent daily routine to provide a sense of structure and predictability.
• Ensure the client is exposed to natural light during the day to help regulate their circadian rhythm.
• Minimize environmental stimuli in the late afternoon and evening, such as reducing noise and avoiding large gatherings.
• Provide adequate lighting in the evening to reduce shadows and dark areas that may increase confusion.
• Engage the client in calming activities before bedtime, such as listening to soothing music or reading.
• Monitor the client for unmet needs, such as hunger, thirst, or the need to use the restroom, and address them promptly.

✘Incorrect answer options:

Chronic fatigue syndrome. Chronic fatigue syndrome is a long-term condition characterized by extreme fatigue that cannot be explained by an underlying medical condition. It is not specifically associated with dementia or increased confusion in the late afternoon and evening.

Normal aging. While some cognitive decline is associated with normal aging, the level of confusion and agitation described in the question is more severe and specific to sundowning in dementia patients, rather than a normal aging process.

Delusions. Delusions are false beliefs that are firmly held despite evidence to the contrary. While individuals with dementia may experience delusions, the specific pattern of increased confusion and agitation in the late afternoon and evening is characteristic of sundowning rather than delusions.

EXPLANATION

✔Correct answer:

A symptom of apraxia. Apraxia is the inability to carry out learned purposeful movements despite having the desire and the physical capacity to perform the movements. In Alzheimer's disease, apraxia can manifest as the inability to use objects correctly, even though the patient has the necessary motor skills and comprehension. When the client attempts to use a toothbrush to brush her hair, it indicates a difficulty in performing tasks that require a sequence of movements or the correct use of objects, which is characteristic of apraxia.

Apraxia in Alzheimer's disease results from damage to the parts of the brain that control and coordinate complex movements. This damage disrupts the neural pathways needed to recall and execute these learned movements, leading to the misuse of objects and an inability to perform tasks correctly.

Think of apraxia like having all the ingredients and tools to bake a cake but not being able to remember the correct order or method to mix and bake them. The client knows what the objects are but cannot correctly sequence the actions to use them properly.

Nurse Laura should gently correct the client's action and provide clear, simple instructions and demonstrations for performing daily tasks. She should use visual cues and physical guidance to help the client use objects correctly.

• Provide step-by-step instructions for tasks and use visual aids if possible.
• Demonstrate the correct use of objects and allow the client to mimic the actions.
• Encourage the client to take their time and offer physical assistance as needed.
• Ensure a safe environment by removing objects that may be easily confused or misused.
• Offer positive reinforcement and support to boost the client's confidence and reduce frustration.

✘Incorrect answer options:

A sign of agnosia. Agnosia is the inability to recognize and identify objects, people, or sounds despite having intact sensory function. If the client were experiencing agnosia, she would likely not recognize the toothbrush as a toothbrush, rather than using it incorrectly.

An indication of anomia. Anomia is the difficulty or inability to recall the names of objects. While this can occur in Alzheimer's disease, it does not typically result in the misuse of objects, but rather in the difficulty of naming them.

A case of aphasia. Aphasia is the impairment of language ability, affecting speech, comprehension, reading, or writing. Using a toothbrush to brush hair does not indicate a language problem but a difficulty in carrying out learned movements correctly, which is apraxia.

EXPLANATION

✔Correct answer:

Pain upon flexing the hip and knee. A positive Kernig’s sign is indicative of meningeal irritation, which is often seen in conditions such as meningitis. To test for Kernig’s sign, the patient lies flat on their back, and the clinician flexes the patient’s hip and knee to a 90-degree angle. Then, the clinician attempts to straighten the leg at the knee. A positive Kernig’s sign occurs if there is resistance to straightening or if the patient experiences pain in the lower back and along the back of the thigh when the leg is extended.

Meningeal irritation from meningitis causes inflammation and increased sensitivity in the meninges and spinal nerve roots. This irritation results in pain when the nerves are stretched, as occurs during the Kernig’s test.

Think of a positive Kernig's sign like trying to open a rusty, tightly hinged door. When you try to fully open it (extend the leg), the rust (meningeal irritation) creates pain and resistance, making it difficult to move smoothly. Similarly, when the patient's leg is extended after flexing the hip and knee, the inflammation of the meninges causes pain and resistance, indicating irritation and potential infection.

Nurse Sam should document the presence of a positive Kernig’s sign and report this finding to the healthcare provider. Additionally, Nurse Sam should monitor Jason for other signs of meningeal irritation and ensure appropriate isolation precautions are in place if bacterial meningitis is suspected.

• Document the positive Kernig’s sign, noting the patient's pain response upon hip and knee flexion and subsequent leg extension.
• Report the finding to the healthcare provider immediately, as it may assist in diagnosing meningitis.
• Monitor the patient for other signs of meningeal irritation, such as nuchal rigidity (stiff neck) and a positive Brudzinski’s sign (flexion of the neck causes involuntary flexion of the hips and knees).
• Ensure the patient is placed in appropriate isolation if bacterial meningitis is suspected to prevent the spread of infection.
• Provide supportive care, including managing pain and discomfort, while awaiting further diagnostic tests and treatment.

✘Incorrect answer options:

Stiffness when flexing the neck. This finding is more indicative of nuchal rigidity, another sign of meningeal irritation, but it is not specific to Kernig’s sign.

Discomfort when the head is turned to the left. This is not a characteristic finding of Kernig’s sign. Discomfort with head turning might indicate other neurological or muscular issues but is not related to the specific test for meningeal irritation.

Dizziness when changing positions. Dizziness upon position change is not related to Kernig’s sign and is more commonly associated with issues such as orthostatic hypotension or vestibular disorders.

EXPLANATION

✔Correct answer:

A case of Prinzmetal’s angina. Imitrex (sumatriptan succinate) is a medication used to treat migraine headaches by constricting blood vessels in the brain. However, it also affects other blood vessels in the body, including those in the heart. Sumatriptan is contraindicated in patients with a history of Prinzmetal’s angina because it can cause coronary artery vasospasm, which can worsen or trigger an angina episode and potentially lead to serious cardiac events.

Prinzmetal’s angina, also known as variant angina, is characterized by episodic chest pain due to transient coronary artery spasms. These spasms can restrict blood flow to the heart muscle, causing ischemia and chest pain. Medications like sumatriptan that cause vasoconstriction can provoke these spasms, making it unsafe for patients with this condition.

Imagine a hose with occasional kinks that restrict water flow (Prinzmetal’s angina). Using a medication that tightens the hose further (sumatriptan) would worsen the kinks and restrict water flow even more, which is dangerous.

Nurse Jenna should report the history of Prinzmetal’s angina to the doctor immediately. The physician may need to consider alternative migraine treatments that do not pose a risk of exacerbating cardiac conditions.

• Immediately inform the physician about the patient’s history of Prinzmetal’s angina.
• Review the patient’s medical history for any other contraindications or cardiovascular risk factors.
• Monitor the patient for any signs of chest pain or other cardiac symptoms if sumatriptan has been inadvertently administered.
• Educate the patient on the importance of informing all healthcare providers about their history of Prinzmetal’s angina.
• Discuss alternative migraine treatments with the healthcare team that are safer for patients with cardiovascular conditions.

✘Incorrect answer options:

A history of diabetes. While diabetes is a significant health condition, it is not a direct contraindication for the use of sumatriptan. However, diabetes-related cardiovascular issues might warrant careful monitoring.

A diagnosis of cancer. Cancer itself is not a contraindication for sumatriptan use. However, the specific type of cancer and treatment regimens might require consideration of drug interactions and side effects.

A history of cluster headaches. Sumatriptan is also used to treat cluster headaches, so this history is not a contraindication. In fact, it can be an indication for its use.

EXPLANATION

✔Correct answer:

A diagnosis of tuberculosis. The symptoms described—blood-tinged hemoptysis (coughing up blood), fatigue, night sweats, and a mildly elevated temperature—are classic signs of tuberculosis (TB). TB is a bacterial infection caused by Mycobacterium tuberculosis, primarily affecting the lungs but potentially involving other parts of the body.

Tuberculosis is transmitted through airborne droplets when an infected person coughs or sneezes. Once inhaled, the bacteria can settle in the lungs and multiply, leading to the formation of granulomas. The body’s immune response to these bacteria causes the symptoms of TB, including persistent cough (sometimes producing blood-tinged sputum), fatigue, night sweats, weight loss, and fever.

Think of tuberculosis like a slow-burning fire in the lungs. The symptoms (coughing, blood-tinged sputum, night sweats, fatigue) are like the smoke signals that alert you to the fire smoldering inside.

Nurse Emily should prioritize infection control measures, such as placing the patient in an airborne isolation room, wearing an N95 respirator, and ensuring that the patient receives diagnostic testing (such as a sputum culture and chest X-ray) to confirm the diagnosis of TB.

• Immediately place the patient in airborne isolation to prevent the spread of TB.
• Wear appropriate personal protective equipment (PPE), including an N95 respirator.
• Obtain a detailed medical history and assess for additional symptoms or risk factors for TB.
• Arrange for diagnostic tests, including a chest X-ray, sputum smear, and culture for acid-fast bacilli.
• Educate the patient on the importance of medication adherence if TB is confirmed, as treatment typically involves a lengthy course of multiple antibiotics.
• Monitor the patient's respiratory status and overall health, providing supportive care as needed.

✘Incorrect answer options:

A case of pneumonia. While pneumonia can cause fever, fatigue, and a cough, it is less commonly associated with night sweats and blood-tinged hemoptysis. These symptoms are more characteristic of TB.

A reaction to antiviral medication. The described symptoms are not typical of a reaction to antiviral medication. Such reactions more commonly present with symptoms like rash, gastrointestinal upset, or allergic reactions.

A superinfection caused by a low CD4 count. This option suggests an HIV-related context. While low CD4 counts can predispose individuals to various infections, the specific symptoms described (blood-tinged hemoptysis, night sweats, fatigue) strongly indicate TB, which can indeed occur in immunocompromised individuals but is not exclusively indicative of a low CD4 count superinfection.

EXPLANATION

✔Correct answer:

Assess the patient for bladder distention. A postpartum fundus that is firm and positioned at the level of the umbilicus but shifted to the right often indicates bladder distention. After childbirth, a full bladder can push the uterus to one side (commonly the right) and interfere with uterine contractions, which can lead to inadequate involution (the process of the uterus returning to its pre-pregnancy size).

Bladder distention postpartum can impede the normal positioning and contraction of the uterus. A full bladder can displace the uterus, preventing it from contracting properly and increasing the risk of postpartum hemorrhage. Ensuring the bladder is emptied can help the uterus return to its correct position and function more effectively.

Imagine trying to fold a piece of fabric evenly but there's a bulky object underneath it. The object (full bladder) causes the fabric (uterus) to be misaligned. Removing the object (emptying the bladder) allows the fabric to lay flat and fold correctly.

Nurse Kelly should assess Maria for bladder distention and encourage her to empty her bladder. If Maria is unable to void, further interventions such as assisting her to the bathroom or using a urinary catheter may be necessary.

• Ask Maria if she feels the need to urinate and when she last emptied her bladder.
• Assist Maria to the bathroom and encourage her to urinate.
• If Maria is unable to void, consider non-invasive measures such as running water or using a warm compress on the lower abdomen.
• If necessary, use a bladder scanner to assess the volume of urine in the bladder.
• If non-invasive measures are unsuccessful, consider catheterization to empty the bladder.
• Reassess the fundus after the bladder is emptied to ensure it has returned to the midline and is firm.

✘Incorrect answer options:

Measure the patient's blood pressure to check for hypotension. While monitoring blood pressure is important postpartum, the displacement of the uterus to the right is more directly associated with bladder distention rather than hypotension.

Verify if an oxytocic medication was administered. Oxytocic medications promote uterine contractions and are important postpartum, but the current issue of the fundus being shifted to the right is more likely due to bladder distention. Oxytocic medication administration does not directly address the positional shift caused by a full bladder.

Inspect for the presence of small blood clots. While assessing for blood clots is important, the primary concern with a fundus shifted to the right is likely bladder distention. Addressing the bladder distention first can help ensure proper uterine positioning and function.

EXPLANATION

✔Correct answer:

Call for security assistance and prepare to administer a sedative. In situations where a patient becomes uncontrollably angry and starts threatening others, safety is the highest priority. Nurse Jamie should call for security assistance to help manage the situation and prevent harm to other clients, staff, and Mr. Wilson himself. Preparing to administer a sedative as prescribed can help calm Mr. Wilson and reduce the immediate risk of violence.

Aggression and threatening behavior in psychiatric settings can escalate quickly, potentially leading to physical harm. Immediate intervention is necessary to de-escalate the situation and ensure a safe environment for all. Sedatives can be used as a pharmacological intervention to reduce agitation and aggression.

Think of a fire alarm going off in a building. The immediate response is to call for emergency help and take action to prevent the fire from spreading, ensuring everyone's safety. Similarly, when a patient becomes aggressive, calling for security and preparing to administer a sedative ensures safety and helps manage the situation effectively.

Nurse Jamie should follow established protocols for managing aggressive behavior, including calling for security, ensuring other clients are safe, and preparing to administer a sedative if ordered. Documentation of the incident and communication with the healthcare team are also essential.

• Call for security assistance to help manage the situation and prevent harm.
• Ensure the safety of other clients and staff by removing them from the immediate area if necessary.
• Prepare to administer a sedative as prescribed to help calm the patient and reduce aggression.
• Maintain a calm and non-confrontational demeanor to avoid further escalating the situation.
• Document the incident, including the patient's behavior, actions taken, and the response to any interventions.
• Communicate with the healthcare team to develop a plan for ongoing management and support for Mr. Wilson.

✘Incorrect answer options:

Ask the client to calm down and suggest playing cards as a distraction. While distraction techniques can be useful for mild agitation, they are not appropriate for managing uncontrollable anger and threats. This approach would likely be ineffective and could escalate the situation.

Warn the client that continued behavior will result in punishment. Threatening punishment can escalate aggression and is not an appropriate or therapeutic way to manage behavioral issues in a psychiatric setting. This approach could further provoke the patient and lead to more severe aggression.

Leave the client alone until he regains composure. Leaving an uncontrollably angry and threatening patient alone can be dangerous as it does not address the immediate risk of harm to the patient or others. Continuous monitoring and intervention are necessary to ensure safety.

EXPLANATION

✔Correct answer:

30 minutes before meals. Nexium (esomeprazole) is a proton pump inhibitor (PPI) used to reduce stomach acid production, which is beneficial for treating conditions like erosive gastritis. Administering esomeprazole 30 minutes before meals allows the medication to be absorbed and effectively inhibit the proton pumps in the stomach lining before food stimulates acid production. This timing ensures the maximum efficacy of the drug in reducing gastric acid secretion.

Proton pump inhibitors like esomeprazole block the hydrogen-potassium ATPase enzyme system (the proton pump) of the gastric parietal cells, thereby reducing the production of stomach acid. By taking the medication before meals, it can inhibit the proton pumps as they become active with food intake, providing better control of acid secretion and promoting healing of the gastric mucosa.

Think of Nexium as a shield that protects your stomach lining from acid attacks. To be most effective, the shield needs to be in place before the acid starts to flow, which is why taking it 30 minutes before meals works best.

Nurse Amanda should educate Mrs. Jensen on the proper timing and administration of esomeprazole to ensure its effectiveness. This includes taking the medication with a glass of water 30 minutes before meals, ideally in the morning before breakfast if only once daily.

• Instruct Mrs. Jensen to take esomeprazole 30 minutes before meals, preferably before breakfast if taken once daily.
• Advise her to swallow the medication whole with a glass of water, not to crush or chew the tablets, to ensure proper absorption.
• Educate Mrs. Jensen on the importance of adhering to the prescribed schedule to maximize the medication’s effectiveness in managing her erosive gastritis.
• Inform her about potential side effects, such as headache, diarrhea, or abdominal pain, and to report any severe or persistent symptoms to her healthcare provider.

✘Incorrect answer options:

With meals. Taking esomeprazole with meals is not recommended because food can reduce its absorption and effectiveness in inhibiting acid production.

Immediately after meals. Administering esomeprazole immediately after meals may not provide optimal acid suppression, as the medication needs to be absorbed and act on the proton pumps before they are stimulated by food intake.

At bedtime. While some medications for acid-related conditions can be taken at bedtime, esomeprazole is most effective when taken before meals to reduce acid production in response to food.

EXPLANATION

✔Correct answer:

Hib vaccine. At 4 months of age, infants are scheduled to receive several vaccines as part of the routine immunization schedule. In addition to the DPT (Diphtheria, Pertussis, Tetanus) and polio vaccines, the baby should also receive the Haemophilus influenzae type b (Hib) vaccine. The Hib vaccine protects against Haemophilus influenzae type b, which can cause serious infections like meningitis, pneumonia, and epiglottitis, especially in young children.

Haemophilus influenzae type b is a bacterium that can lead to severe, potentially life-threatening infections. Vaccination significantly reduces the incidence of Hib disease and is a crucial part of infant immunization schedules to ensure early protection.

Think of vaccines as a series of safety nets that protect a child from dangerous falls (diseases). The Hib vaccine is one of these nets, ensuring the child is safe from specific serious infections.

Nurse Sarah should ensure the 4-month-old baby receives all recommended vaccines, including the Hib vaccine, and provide parents with information about the importance of these immunizations and the potential side effects to monitor.

• Administer the Hib vaccine along with the DPT and polio vaccines during the visit.
• Educate the parents on the purpose of the Hib vaccine and the diseases it prevents.
• Provide information on common side effects of the vaccine, such as mild fever or localized swelling at the injection site, and advise on how to manage them.
• Emphasize the importance of completing the full vaccination schedule for optimal protection.
• Answer any questions the parents may have about the vaccines and their benefits.

✘Incorrect answer options:

Mumps vaccine. The mumps vaccine is typically administered as part of the MMR (Measles, Mumps, Rubella) vaccine, which is given at 12-15 months of age. It is not part of the 4-month immunization schedule.

Hepatitis B vaccine. The Hepatitis B vaccine series is started at birth, with additional doses given at 1-2 months and 6-18 months. By 4 months, the infant would have already received the first two doses, so it is not typically due at this visit unless the schedule is adjusted.

MMR vaccine. The MMR vaccine is given at 12-15 months of age and again at 4-6 years. It is not administered at the 4-month visit.

EXPLANATION

✔Correct answer:

Counteract drug toxicity and avert tissue damage. Trimetrexate is a potent chemotherapy drug used to treat certain types of cancer, including leukemia. It works by inhibiting dihydrofolate reductase, an enzyme necessary for DNA synthesis and cell replication. While effective against cancer cells, this mechanism can also cause significant toxicity to healthy cells. Leucovorin calcium (Wellcovorin) is used as a rescue agent to mitigate the toxic effects of Trimetrexate by providing a source of reduced folate that can bypass the metabolic block caused by Trimetrexate.

Trimetrexate disrupts the folate pathway, essential for DNA synthesis. Leucovorin calcium, a form of folinic acid, helps to restore the normal function of this pathway in healthy cells, reducing the risk of severe side effects and tissue damage caused by the chemotherapy drug.

Think of Trimetrexate as a powerful cleaning agent that removes tough stains but can also damage the fabric if left on too long. Leucovorin calcium acts like a neutralizer that stops the cleaner's harsh effects, protecting the fabric while still allowing it to do its job.

When administering Trimetrexate and leucovorin calcium, Nurse Laura should closely monitor Mr. Thompson for signs of toxicity and ensure that leucovorin is given at the correct times and dosages to provide optimal protection against side effects.

• Administer leucovorin calcium exactly as prescribed, often beginning 24 hours after Trimetrexate infusion to ensure protection against toxicity.
• Monitor Mr. Thompson's blood counts, renal function, and liver function tests regularly to detect any early signs of drug toxicity.
• Educate Mr. Thompson on the importance of taking leucovorin as directed and not skipping doses, as this is crucial for preventing severe side effects.
• Assess for symptoms of toxicity, such as mouth sores, gastrointestinal distress, and severe fatigue, and report any concerns to the physician promptly.
• Encourage adequate hydration to help flush the chemotherapy drug from Mr. Thompson's system and reduce potential kidney damage.

✘Incorrect answer options:

Address iron-deficiency anemia induced by chemotherapy. Leucovorin calcium is not used to address iron-deficiency anemia. Its role is specifically to counteract the toxic effects of folate antagonists like Trimetrexate.

Enhance the treatment effectiveness and reduce its duration. While leucovorin calcium does enhance treatment by reducing toxicity, its primary purpose is not to reduce the duration of the chemotherapy treatment but to make the treatment safer.

Boost the count of circulating neutrophils. Leucovorin calcium is not used to boost neutrophil counts. Other medications, such as colony-stimulating factors (e.g., filgrastim), are used for this purpose.

EXPLANATION

✔Correct answer:

The umbilical cord stump needs time to naturally detach. During the first two weeks of a baby's life, the umbilical cord stump is still attached. It is crucial to keep this area dry to promote natural healing and prevent infection. Sponge baths are recommended instead of full immersion baths to ensure the cord stump remains dry and can naturally fall off without being compromised by moisture.

The umbilical cord stump typically dries out and falls off within the first 1-2 weeks of life. Keeping it dry helps prevent bacterial growth and infection, which can occur if the area becomes too moist. A sponge bath allows parents to clean the baby without soaking the cord stump, thus aiding in the healing process.

Think of the umbilical cord stump like a scab on a cut. Just as you wouldn't soak a fresh scab in water because it might not heal properly, you shouldn't soak the umbilical cord stump to allow it to dry out and fall off naturally.

Nurse Megan should educate new parents on the proper technique for giving a sponge bath, emphasizing the importance of keeping the umbilical cord stump dry and observing for any signs of infection, such as redness, swelling, or foul odor.

• Demonstrate how to give a sponge bath, gently cleaning the baby's body with a damp cloth while avoiding the umbilical cord stump.
• Advise parents to pat the baby dry gently and ensure the stump remains exposed to air as much as possible to aid in drying and detachment.
• Educate parents on the signs of infection in the umbilical cord area and instruct them to contact their healthcare provider if they notice any concerning symptoms.
• Reassure parents that sponge baths are a safe and effective way to keep their newborn clean during the first few weeks of life.

✘Incorrect answer options:

It allows new parents to get comfortable with holding their baby. While giving a sponge bath can indeed help parents become more comfortable handling their newborn, this is not the primary reason for recommending sponge baths during the first two weeks.

The newborn's skin can be easily damaged by regular washing. Newborn skin is delicate, but the recommendation for sponge baths is specifically related to the care of the umbilical cord stump, not solely due to skin sensitivity.

The risk of the baby getting chilled is higher than the benefits of a full bath. While keeping the baby warm during bathing is important, the primary concern during the first two weeks is the care and natural detachment of the umbilical cord stump.

EXPLANATION

✔Correct answer:

"I'll be sure to have breakfast within 10 minutes after my insulin injection." Novolog (insulin aspart) is a rapid-acting insulin that begins to work within 10-20 minutes after injection, peaks in about 1-3 hours, and lasts for 3-5 hours. Because of its rapid onset, it is crucial for patients to eat shortly after administering this type of insulin to prevent hypoglycemia.

Rapid-acting insulins like Novolog mimic the body's natural insulin response to meals, providing quick action to manage the rise in blood glucose levels that occurs after eating. If a patient delays eating after injecting Novolog, they risk developing hypoglycemia due to the insulin lowering their blood glucose without sufficient dietary intake to balance it.

Think of Novolog like a sprinter ready to take off at the sound of a starting gun. Once injected, it quickly begins to lower blood sugar, so it's like needing to fuel the sprinter right away with food to keep them going strong.

Nurse Tina should ensure Mr. Hernandez understands the importance of timing his meals with his insulin injections to avoid hypoglycemia. This involves educating him on the onset, peak, and duration of Novolog insulin and the necessity of eating promptly after administration.

• Instruct Mr. Hernandez to inject Novolog within 10-15 minutes before meals to coordinate the insulin's peak action with the rise in blood glucose from food intake.
• Educate him on recognizing the signs and symptoms of hypoglycemia (e.g., sweating, dizziness, confusion) and the importance of always having a quick source of glucose available.
• Reinforce the need for regular blood glucose monitoring to track the effectiveness of his insulin therapy and make necessary adjustments.
• Discuss meal planning and the importance of not skipping meals to maintain stable blood glucose levels.

✘Incorrect answer options:

"I'll need to always have candy or a form of sugar with me." While it's important for diabetics to have a quick source of glucose on hand to treat hypoglycemia, this response does not address the timing of Novolog's peak action.

"I'll have a snack at about three in the afternoon." This response might indicate an understanding of managing mid-afternoon hypoglycemia, but it does not directly relate to the peak action of Novolog, which peaks within 1-3 hours after injection, not necessarily in the afternoon unless the insulin was taken at lunch.

"I can keep my dessert from dinner for a bedtime snack." This response does not reflect an understanding of Novolog's peak action, as the peak effect is generally within 1-3 hours post-injection and not related to bedtime or dessert.

EXPLANATION

✔Correct answer:

Split pea soup, mashed potatoes, pudding, milk. For a patient who has experienced a facial stroke, which can affect swallowing and chewing abilities (dysphagia), a soft or pureed diet is most appropriate. The selected meal option should include foods that are easy to swallow and require minimal chewing to reduce the risk of aspiration. The split pea soup, mashed potatoes, pudding, and milk offer a variety of textures that are easier to manage for someone with swallowing difficulties.

A facial stroke can cause weakness or paralysis in the muscles involved in chewing and swallowing, leading to dysphagia. This condition increases the risk of food or liquids entering the airway (aspiration), which can cause choking or respiratory infections such as pneumonia. Therefore, it is crucial to provide a diet that minimizes these risks.

Think of swallowing with dysphagia like trying to drive on a bumpy road with poor traction. Softer foods are like smoother, more manageable roads that reduce the risk of slipping or getting stuck.

When planning meals for a patient with dysphagia, Nurse Ramirez should ensure the food consistency is appropriate for the patient's swallowing ability. This involves choosing soft, well-cooked, or pureed foods and avoiding hard, dry, or sticky items.

• Provide foods that are soft, moist, and easy to swallow, such as soups, mashed vegetables, and pudding.
• Avoid hard, crunchy, or dry foods like potato chips, sandwiches with crusty bread, and raw vegetables.
• Ensure liquids are of an appropriate consistency, possibly thickened if needed, to reduce the risk of aspiration.
• Monitor the patient while eating to observe any signs of difficulty swallowing, coughing, or choking.
• Collaborate with a speech therapist or dietitian to assess the patient’s swallowing ability and recommend appropriate dietary modifications.

✘Incorrect answer options:

Roast beef sandwich, potato chips, pickle spear, iced tea. This meal includes hard and crunchy items that require significant chewing and can pose a choking hazard or be difficult to swallow for someone with dysphagia.

Tomato soup, cheese toast, Jello, coffee. While the tomato soup and Jello are appropriate, the cheese toast may be too difficult to chew and swallow safely for a patient with a facial stroke.

Hamburger, baked beans, fruit cup, iced tea. The hamburger and baked beans can be challenging to chew and swallow due to their texture, making them less suitable for a patient with swallowing difficulties.

EXPLANATION

✔Correct answer:

Visitation is limited to 30 minutes while the implant is in place. When a patient is undergoing treatment with a radioactive vaginal implant, there are strict guidelines regarding visitation to minimize radiation exposure to family members and staff. The radioactive material used in the implant can emit radiation that poses health risks to others who are in close proximity for extended periods. Therefore, visitation times are often restricted to short durations, typically around 30 minutes, to ensure the safety of visitors.

Radioactive implants, also known as brachytherapy, deliver high doses of radiation directly to the cancerous area while minimizing exposure to surrounding healthy tissues. However, radiation can still scatter and affect individuals nearby. Limiting the time spent near the patient reduces the risk of radiation exposure to safe levels.

Think of radiation like sunlight. Being in the sun for a short period is usually safe, but prolonged exposure can cause sunburn. Similarly, short visits to a patient with a radioactive implant are safe, but longer exposure increases the risk of harmful effects.

Nurse Parker should explain the importance of limiting visitation time due to radiation safety protocols. She should reassure Mr. Davis that his wife's care is being closely monitored and that the staff will ensure her comfort and safety during the treatment.

• Explain to Mr. Davis the need for limited visitation to protect his health from potential radiation exposure.
• Provide information on the specific visitation guidelines, including the 30-minute time limit.
• Reassure Mr. Davis that the healthcare team will provide continuous and attentive care to his wife during her treatment.
• Encourage Mr. Davis to visit his wife during designated times and to maintain communication through phone calls or other means when not physically present.
• Offer support resources, such as counseling or patient education materials, to help both Mr. and Mrs. Davis cope with the treatment process.

✘Incorrect answer options:

Hospital policy does not permit overnight stays by family members. While this may be true in some cases, it does not directly address the specific safety concerns related to radiation exposure from the vaginal implant.

There is no need for you to stay; our staff will provide adequate care. This response is dismissive of Mr. Davis's concerns and does not provide the necessary explanation regarding the safety issues associated with radiation exposure.

Your wife will rest better knowing you are comfortable at home. While this statement may have some truth, it does not adequately address the critical issue of radiation safety and the need for limited visitation time.

EXPLANATION

✔Correct answer:

Press a finger into the swollen area and observe for pitting. Evaluating peripheral edema by pressing a finger into the swollen area and observing for pitting (indentation that persists after the pressure is released) is a standard and effective method to assess the extent of edema. This method helps determine the presence and severity of pitting edema, which is commonly graded on a scale from 1+ to 4+ based on the depth and duration of the indentation.

Peripheral edema occurs when there is an accumulation of fluid in the interstitial spaces of the body, often due to conditions such as heart failure, kidney disease, or venous insufficiency. Pitting edema indicates that the fluid accumulation is significant enough to leave an indentation when pressure is applied, suggesting a higher severity of fluid retention.

Imagine pressing your finger into a soft pillow. If the pillow leaves a dent after you remove your finger, it indicates the material is soft and retains the shape. Similarly, pressing a finger into the swollen area and seeing a dent indicates the presence of fluid that retains the indentation.

When assessing for pitting edema, Nurse Anderson should use a systematic approach to ensure accurate grading and documentation. This involves pressing the skin over a bony prominence (such as the shin or ankle) and observing the depth and duration of the indentation.

• Press firmly but gently with your thumb or finger on the swollen area, typically over a bony prominence like the shin, ankle, or foot.
• Hold the pressure for about 5 seconds, then release and observe the area for indentation.
• Grade the pitting edema based on the depth and duration of the indentation:
  • 1+: Slight pitting, no visible distortion, and indentation disappears rapidly.
  • 2+: Deeper pit, no detectable distortion, and indentation disappears within 15 seconds.
  • 3+: Deep pit, noticeable swelling, and indentation lasts more than a minute.
  • 4+: Very deep pit, significant swelling, and indentation lasts 2-5 minutes.
• Document the findings, including the location, grade, and any associated symptoms or changes in the condition.
• Monitor for other signs of worsening edema, such as changes in skin color, temperature, and pain.

✘Incorrect answer options:

Measure the circumference of the affected limb with a tape measure. While this method can provide useful information on the overall size and progression of the edema, it does not offer the same immediate assessment of the severity and nature of the fluid accumulation as the pitting method.

Assess for discoloration and temperature changes in the affected area. Assessing for discoloration and temperature changes is important for evaluating overall circulation and the presence of other complications, but it does not specifically assess the extent of edema.

Ask the patient to rate the severity of the swelling on a scale from 1 to 10. This subjective measure may provide insight into the patient's perception of their condition but does not offer a standardized or objective assessment of the extent of the edema.

EXPLANATION

✔Correct answer:

Proceed with administering both medications together. Lisinopril (Zestril) and furosemide (Lasix) are commonly prescribed together to manage hypertension and heart failure. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that helps to lower blood pressure by relaxing blood vessels. Furosemide is a loop diuretic that reduces fluid buildup by increasing urine output. When used together, these medications can have a synergistic effect, improving blood pressure control and reducing the risk of complications associated with hypertension.

Lisinopril works by inhibiting the enzyme that converts angiotensin I to angiotensin II, a potent vasoconstrictor. This results in vasodilation and a decrease in blood pressure. Furosemide works on the loop of Henle in the kidneys to increase the excretion of sodium, chloride, and water, which decreases blood volume and, subsequently, blood pressure.

Think of managing hypertension like trying to control the water level in a bathtub. Lisinopril helps by turning down the water tap (reducing blood pressure), while furosemide helps by increasing the drainage (removing excess fluid). Using both together can be more effective than using one alone.

When administering these medications together, Nurse Johnson should monitor the patient for signs of hypotension, electrolyte imbalances, and renal function. Both medications can cause a significant drop in blood pressure and affect kidney function, so close monitoring is essential.

• Check the patient’s blood pressure and pulse before administering the medications to ensure they are within a safe range.
• Monitor the patient for signs of hypotension, such as dizziness, lightheadedness, or fainting, especially after the first dose.
• Assess the patient’s electrolyte levels, particularly potassium, as furosemide can cause hypokalemia, while lisinopril can cause hyperkalemia.
• Monitor renal function tests (e.g., serum creatinine, blood urea nitrogen) as both medications can affect kidney function.
• Educate the patient on potential side effects and the importance of adhering to the prescribed medication regimen.

✘Incorrect answer options:

Clarify the order with the physician. It is not necessary to clarify the order with the physician as prescribing lisinopril and furosemide together is a common and appropriate practice for managing hypertension.

Administer each medication separately. While it is important to monitor the patient’s response to each medication, administering them separately does not offer any additional benefit and may lead to confusion or non-compliance with the treatment regimen.

Consult with the pharmacy. Consulting with the pharmacy is not necessary in this case as both medications are known to be commonly used together, and their combined use is well-documented and safe when properly monitored.

EXPLANATION

✔Correct answer:

The phlebostatic axis. The phlebostatic axis is the correct anatomical landmark for zeroing the manometer when measuring central venous pressure (CVP). The phlebostatic axis is located at the fourth intercostal space, at the midpoint of the anterior-posterior diameter of the chest. This point represents the right atrium of the heart and provides a consistent reference level for accurate measurement of central venous pressure.

CVP measurement is used to assess the pressure in the thoracic vena cava near the right atrium, reflecting right ventricular preload and overall fluid status. Correct positioning of the manometer is crucial to obtain accurate readings. The phlebostatic axis aligns with the right atrium, providing a reliable reference point for measuring pressures within the central venous system.

Think of the phlebostatic axis as the "zero point" on a ruler used for measuring length. To get an accurate measurement, you need to start from the correct zero point; similarly, for CVP measurement, the manometer must be zeroed at the phlebostatic axis to ensure accurate pressure readings.

To measure CVP correctly, Nurse Patel should position the manometer's zero mark at the phlebostatic axis. This involves ensuring the patient is in a supine position, aligning the manometer at the fourth intercostal space, and confirming the midpoint of the anterior-posterior chest diameter.

• Ensure the patient is in a supine position with the head of the bed at 0-60 degrees, depending on the patient's clinical status.
• Locate the fourth intercostal space along the mid-axillary line, which represents the phlebostatic axis.
• Align the zero mark of the manometer with this point to ensure accurate CVP measurement.
• Record the CVP reading, ensuring the measurement is taken at the end of expiration for consistency.
• Monitor for any signs of hemodynamic instability and report abnormal CVP readings to the healthcare provider.

✘Incorrect answer options:

The point of maximal impulse (PMI). The PMI is the point on the chest where the heartbeat is most strongly felt, typically located at the fifth intercostal space at the midclavicular line. It is used to assess heart size and position but is not related to CVP measurement.

Erb’s point. Erb’s point is an auscultation point on the chest, located at the third intercostal space left of the sternum. It is used for listening to heart sounds, particularly murmurs, but is not relevant for zeroing a CVP manometer.

The tail of Spence. The tail of Spence is an extension of breast tissue that extends into the axilla (armpit). It is relevant in breast examinations but has no connection to CVP measurement or the positioning of a manometer.

EXPLANATION

✔Correct answer:

Lower legs and feet. In patients with left-sided congestive heart failure (CHF), the heart's reduced ability to pump blood effectively can lead to fluid accumulation, or edema, in various parts of the body. The lower legs and feet are common sites for edema because gravity causes fluid to pool in these areas, particularly when a patient is upright or sitting for extended periods.

Left-sided heart failure results in increased pressure in the pulmonary veins as the left ventricle fails to effectively pump blood out to the systemic circulation. This increased pressure can cause fluid to leak into the interstitial spaces, leading to pulmonary congestion. Over time, this can result in systemic venous congestion and edema, particularly in dependent areas like the lower legs and feet.

Think of the heart as a water pump. If the pump is weak and cannot push water out effectively, water will start to back up and pool at the lowest point, similar to how fluid pools in the lower legs and feet when the heart is not pumping efficiently.

When assessing a patient for edema, nurses should look for signs such as swelling, shiny or taut skin, and pitting (indentation left when the skin is pressed). It is important to measure and document the extent of edema, as this information can help guide treatment and monitor the patient's response to therapy.

• Assess the lower legs and feet for swelling and pitting edema by gently pressing on the skin and noting any indentation.
• Measure and record the circumference of the lower legs to monitor changes over time.
• Evaluate for other symptoms of heart failure, such as shortness of breath, fatigue, and weight gain.
• Educate the patient on the importance of elevating the legs when sitting and avoiding prolonged standing to reduce edema.
• Administer prescribed diuretics as ordered and monitor for effectiveness and potential electrolyte imbalances.

✘Incorrect answer options:

Sacrum. Edema in the sacral area is more commonly seen in patients who are bedridden or immobile for long periods. While it can occur in heart failure, it is less typical in ambulatory patients and not the primary site to check first.

Hands. Edema in the hands can occur but is less common in left-sided heart failure compared to the lower extremities. It is usually not the primary site for assessing fluid accumulation in these patients.

Abdomen. Abdominal edema, or ascites, is more often associated with right-sided heart failure or liver disease. It is not a primary site for edema in left-sided heart failure, where fluid typically accumulates in the lungs and lower extremities first.

EXPLANATION

✔Correct answer:

Turkey breast. Among the listed options, turkey breast is the lowest in saturated fats. Lean poultry, such as turkey breast, is a good source of protein and generally contains lower levels of saturated fats compared to other animal-based foods. It is an excellent choice for individuals looking to follow a diet low in fat and cholesterol.

Saturated fats are found in higher amounts in foods such as fatty meats, full-fat dairy products, and certain processed foods. Consuming a diet high in saturated fats can raise levels of LDL cholesterol in the blood, which is associated with an increased risk of heart disease. Therefore, selecting lean protein sources like turkey breast helps manage cholesterol levels and supports heart health.

Think of saturated fats like thick mud that can clog up a pipe (your arteries). Choosing lean meats like turkey breast is like using a cleaner to keep the pipes clear and allow the water (blood) to flow smoothly.

Nurses should educate patients on identifying and choosing foods that are low in saturated fats to promote heart health. This includes providing examples of lean protein sources, encouraging the intake of fruits and vegetables, and advising on cooking methods that reduce fat content.

• Encourage patients to choose lean cuts of meat, such as turkey breast, chicken breast, and fish, which are lower in saturated fats.
• Advise patients to avoid processed and fatty meats, like sausage and bacon, which are high in saturated fats.
• Provide tips on healthy cooking methods, such as grilling, baking, or steaming, rather than frying.
• Educate patients on reading food labels to identify and avoid products high in saturated fats and trans fats.

✘Incorrect answer options:

Macaroni and cheese. This dish is typically high in saturated fats due to the cheese and butter used in its preparation. Cheese is a significant source of saturated fats, making macaroni and cheese a less suitable option for a low-fat diet.

Shrimp with rice. While shrimp is relatively low in fat, it contains some cholesterol. The preparation method and any added sauces or butter can also increase the saturated fat content. It's not the worst option, but lean turkey breast is a better choice for minimizing saturated fats.

Spaghetti. The saturated fat content of spaghetti depends on the sauce and any added ingredients. If prepared with a meat-based or creamy sauce, it can be higher in saturated fats. Plain spaghetti with a tomato-based sauce is a better option, but still, turkey breast is lower in saturated fats compared to most pasta dishes.

EXPLANATION

✔Correct answer:

Keep the medication stored in its original brown bottle. Nitroglycerine is highly sensitive to light, heat, and moisture, which can degrade the medication and reduce its effectiveness. Storing nitroglycerine in its original brown glass bottle helps protect it from light and ensures its stability and efficacy. The bottle is designed to keep out light and moisture, maintaining the integrity of the tablets.

Nitroglycerine works by dilating blood vessels, which reduces the workload on the heart and increases blood flow to the heart muscle, relieving angina (chest pain). Because of its chemical instability, proper storage is crucial to ensure that the medication remains effective when needed.

Think of nitroglycerine tablets like chocolate that melts easily. Just as chocolate needs to be stored in a cool, dark place to keep from melting, nitroglycerine tablets need to be stored in their special bottle to keep from degrading and losing effectiveness.

Nurses should emphasize the importance of proper storage to patients and educate them on the correct method to ensure the medication remains effective. This includes keeping the bottle tightly closed and at room temperature, away from heat and moisture.

• Instruct the patient to keep the nitroglycerine tablets in their original brown bottle and to keep the bottle tightly closed when not in use.
• Advise the patient to store the bottle at room temperature, away from heat, moisture, and light.
• Educate the patient on the signs of nitroglycerine degradation, such as discoloration or a lack of potency, and to replace the medication if these signs are observed.
• Ensure the patient knows how to use the medication correctly, including placing the tablet under the tongue and not swallowing it whole.

✘Incorrect answer options:

Replace your nitroglycerine supply every 3 months. While it is important to ensure the medication is not expired and is still effective, there is no strict rule that nitroglycerine must be replaced every 3 months. Patients should follow the expiration date provided by the pharmacy and monitor for any signs of degradation.

Take one tablet every 15 minutes if you experience pain. The standard instruction for taking nitroglycerine for angina is to take one tablet sublingually (under the tongue) and wait 5 minutes. If the pain persists, they can take another tablet every 5 minutes, up to a total of three tablets in 15 minutes. If the pain does not subside after three tablets, the patient should seek emergency medical help immediately.

Crush the tablets and take them with water. Nitroglycerine tablets should never be crushed or taken with water. They are designed to be dissolved under the tongue for rapid absorption into the bloodstream. Crushing the tablets would destroy their efficacy and could result in a lack of therapeutic effect when needed.

EXPLANATION

✔Correct answer:

Heart rate of 60 beats per minute. Digitalis (digoxin) is a medication commonly used to improve the efficiency of the heart and control the heart rate in patients with various cardiac conditions, including ventral septal defect (VSD). One of the most critical aspects of monitoring a patient on digoxin is observing for signs of bradycardia, or an abnormally slow heart rate. For a 6-month-old infant, a normal heart rate typically ranges from 90 to 160 beats per minute. A heart rate of 60 beats per minute is significantly below the normal range and may indicate digoxin toxicity, which can be life-threatening.

Digoxin works by increasing the force of myocardial contractions and slowing down the heart rate through its effects on the vagus nerve. However, excessive levels of digoxin can lead to severe bradycardia, conduction disturbances, and other signs of toxicity.

Think of digoxin as a coach who trains the heart to pump more effectively and at a steady pace. If the coach pushes too hard, the athlete (heart) may slow down too much or even collapse, which is why monitoring the heart rate is crucial.

Nurses should immediately report any signs of bradycardia in a patient on digoxin to the physician. This includes conducting a thorough assessment, such as checking the apical pulse before administering the medication, monitoring for other symptoms of digoxin toxicity (e.g., nausea, vomiting, visual disturbances), and ensuring regular blood tests to monitor digoxin levels.

• Hold the dose of digoxin if the heart rate is below the established threshold for the patient and notify the physician immediately.
• Conduct a thorough assessment for other signs of digoxin toxicity, including gastrointestinal symptoms and changes in mental status.
• Ensure that serum digoxin levels are regularly monitored to stay within the therapeutic range (0.5-2 ng/mL).
• Educate caregivers on the importance of monitoring the infant's heart rate and signs of toxicity.
• Administer activated charcoal or digoxin-specific antibody (digoxin immune Fab) if ordered by the physician in cases of confirmed toxicity.

✘Incorrect answer options:

Blood pressure reading of 126/80. While this blood pressure reading is elevated for a 6-month-old, it is not immediately indicative of digoxin toxicity and is less urgent compared to bradycardia. Elevated blood pressure should still be monitored and reported, but it is not as critical as a significantly low heart rate in this context.

Blood glucose level of 110 mg/dL. This blood glucose level is within the normal range for an infant, especially considering variations due to feeding and stress. It does not warrant immediate reporting in the context of monitoring for digoxin toxicity.

Respiratory rate of 30 breaths per minute. This respiratory rate is within the normal range for a 6-month-old infant, which typically varies between 30 to 60 breaths per minute. It is not a concerning finding in the context of digoxin therapy.

EXPLANATION

✔Correct answer:

Monitor the patient's blood glucose level. Diazoxide (Hyperstat) is a potent vasodilator used to manage hypertensive emergencies. One of the known side effects of diazoxide is hyperglycemia, as it inhibits insulin release from the pancreas. Monitoring blood glucose levels is essential to detect and manage this potential adverse effect promptly.

Diazoxide works by relaxing the smooth muscles of the blood vessels, leading to vasodilation and a subsequent reduction in blood pressure. However, its mechanism of action also impacts pancreatic beta cells, inhibiting insulin secretion and leading to elevated blood glucose levels. This can be particularly concerning for patients with diabetes or those at risk for hyperglycemia.

Imagine diazoxide as a gardener who waters the plants (reduces blood pressure) but accidentally pours some herbicide (inhibits insulin release) into the water, which can harm the plants (raise blood glucose levels). To keep the garden healthy, you need to regularly check and ensure the plants aren't being damaged (monitor blood glucose levels).

Nurses should routinely monitor the patient's blood glucose levels before and after administering diazoxide, especially if the patient has a history of diabetes or glucose intolerance. Additionally, the nurse should educate the patient on the signs and symptoms of hyperglycemia and report any significant changes to the healthcare provider.

• Educate the patient about potential side effects, including signs of hyperglycemia such as increased thirst, frequent urination, and fatigue.
• Regularly monitor blood pressure and blood glucose levels to ensure therapeutic efficacy and detect adverse effects early.
• Be prepared to administer insulin or other antidiabetic medications if hyperglycemia occurs.
• Document the patient's response to the medication and any interventions performed.

✘Incorrect answer options:

Use an infusion pump for administration. While using an infusion pump is important for many intravenous medications, diazoxide is typically administered as a rapid intravenous bolus injection rather than a continuous infusion, making an infusion pump unnecessary for this particular medication.

Position the patient in the Trendelenburg position. The Trendelenburg position, where the patient's head is lower than their feet, is not required for the administration of diazoxide. This position is generally used to treat hypotension or shock, not for hypertensive crises.

Protect the medication solution from light by covering it with foil. Diazoxide does not require protection from light; hence, covering it with foil is unnecessary. Some medications do need to be protected from light to maintain their efficacy, but diazoxide is not one of them.

EXPLANATION

✔Correct answer:

Inform the doctor immediately if you experience muscle weakness. Rosuvastatin (Crestor) is a statin medication used to lower cholesterol levels and reduce the risk of cardiovascular disease. A crucial point for patients to understand is the potential side effect of muscle weakness or pain, known as myopathy or rhabdomyolysis, which, although rare, can be serious. Promptly informing the doctor about any signs of muscle weakness or pain is essential for early intervention and management of this potential adverse effect.

Statins work by inhibiting the enzyme HMG-CoA reductase in the liver, which plays a crucial role in the production of cholesterol. While effective in reducing cholesterol levels, statins can also affect muscle cells, leading to muscle pain, weakness, or more severe conditions such as rhabdomyolysis, which involves the breakdown of muscle tissue and release of muscle fiber contents into the bloodstream, potentially leading to kidney damage.

Think of the muscles in your body as the strings of a guitar. Normally, they are tight and able to produce sound (function properly). If the strings become loose or break (muscle weakness or damage), the guitar (your body) can't play music (function) as it should. Reporting these issues early can prevent further damage and get the guitar (your body) fixed quickly.

Nurse Thompson should provide detailed instructions on monitoring for and responding to side effects, emphasizing the importance of communication with healthcare providers.

• Educate Mr. Allen on the signs of muscle weakness or pain and the importance of reporting these symptoms immediately.
• Advise on regular follow-up appointments to monitor cholesterol levels and assess for any side effects.
• Discuss the importance of adhering to the prescribed dosage and not discontinuing the medication without consulting the doctor.
• Encourage a heart-healthy diet and lifestyle changes to complement the effects of the medication.

✘Incorrect answer options:

Be patient, as the medication may take about six months to show results. Statins typically begin to show a reduction in cholesterol levels within 2 to 4 weeks of starting the medication, not six months. Advising a patient to wait six months before seeing results could lead to unnecessary worry or non-compliance with the treatment regimen.

Take this medication alongside some fruit juice. While it is essential to take medications as prescribed, it is not necessary to take rosuvastatin specifically with fruit juice. In fact, grapefruit juice can interact with some statins, increasing the risk of side effects. Rosuvastatin is not significantly affected by food or drink, but it should be taken consistently at the same time each day.

Request a complete blood count from your doctor before starting the medication. While monitoring certain blood parameters is crucial when taking statins, such as liver function tests, a complete blood count (CBC) is not specifically required before starting rosuvastatin. More relevant tests would include lipid profiles and liver enzymes.