-
A nurse is performing range-of-motion (ROM) exercises with a client on bed rest. Which is the CORRECT technique?
- Push through pain to regain full range
- Move each joint through its full available range slowly, smoothly, and gently; stop if the client reports pain; support the limb above and below the joint being exercised ✓
- Have the client do all the work without assistance
- Move joints as fast as possible to save time
RANGE-OF-MOTION EXERCISES maintain joint flexibility, prevent contractures, maintain muscle tone, improve circulation, and prevent complications of immobility. TYPES: PASSIVE ROM — nurse moves the client's joints through the range; used when client cannot participate (unconscious, complete paralysis…
-
A client is at risk for pressure injuries (pressure ulcers) due to prolonged bed rest. What is the PRIMARY nursing intervention?
- Apply alcohol to the skin daily
- Reposition the client every 2 hours, keep skin clean and dry, use pressure-redistributing surfaces (specialty mattress), and maintain adequate nutrition and hydration ✓
- Leave the client in one position to avoid disturbing them
- Apply heat lamps to affected areas
PRESSURE INJURIES (formerly called pressure ulcers or decubitus ulcers) are localized areas of injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from sustained pressure, shear, or friction. PATHOPHYSIOLOGY: pressure compresses capillaries, reducing blood flow; is…
-
A client is prescribed digoxin (Lanoxin) for heart failure. What should the nurse assess BEFORE administering each dose?
- Blood pressure only
- Apical heart rate for one full minute — if less than 60 bpm (or per provider parameters), hold the dose and notify the provider; also assess for signs of digoxin toxicity ✓
- Temperature
- Respiratory rate only
DIGOXIN (Lanoxin) is a CARDIAC GLYCOSIDE used for: heart failure (positive inotrope — increases cardiac contractility); atrial fibrillation/flutter (rate control — increases AV node refractory period, slowing ventricular rate). MECHANISM: inhibits Na-K-ATPase pump → increased intracellular sodium → …
-
A client is receiving IV heparin for deep vein thrombosis. Which laboratory value should the nurse monitor to assess therapeutic effectiveness?
- PT/INR
- aPTT (activated partial thromboplastin time) — therapeutic range is typically 60-100 seconds (1.5-2.5 times the control value of 30-40 seconds) ✓
- Platelet count
- Hemoglobin
HEPARIN is an anticoagulant that works by activating antithrombin III, which in turn inhibits thrombin and factor Xa — interrupting the intrinsic and common coagulation pathways. MONITORING: IV HEPARIN is monitored with aPTT (activated partial thromboplastin time); normal aPTT = 25-40 seconds; THERA…
-
A client returns from a cardiac catheterization procedure via femoral artery access. What is the PRIORITY assessment for the first 2 hours post-procedure?
- Pain tolerance
- Assess the puncture site and affected extremity every 15 minutes for bleeding, hematoma, pulses, color, temperature, capillary refill, sensation, and movement — the femoral artery site is at high risk for hemorrhage and vascular complications ✓
- The client's mood
- Weight
CARDIAC CATHETERIZATION via FEMORAL ARTERY ACCESS introduces a large catheter into the femoral artery. After removal, a small hole is left in a major artery — HEMORRHAGE and VASCULAR COMPLICATIONS are the primary post-procedure risks. PRIORITY POST-PROCEDURE ASSESSMENTS: SITE INSPECTION: bleeding (c…
-
A client's serum potassium level is 2.9 mEq/L. Which clinical finding does the nurse MOST expect to see?
- Muscle cramping and peaked T waves on ECG
- Muscle weakness, fatigue, cardiac dysrhythmias (PVCs, U waves on ECG), and constipation — these are signs of hypokalemia ✓
- Confusion and seizures only
- No symptoms — this is normal
HYPOKALEMIA is defined as serum potassium below 3.5 mEq/L. Normal range: 3.5-5.0 mEq/L. A level of 2.9 mEq/L is SIGNIFICANTLY LOW and clinically concerning. CLINICAL MANIFESTATIONS OF HYPOKALEMIA: CARDIAC: most dangerous; PVCs (premature ventricular contractions); U WAVES on ECG (prominent — a U wav…
-
A client with heart failure is assessed for fluid volume excess. Which finding is MOST consistent with this condition?
- Poor skin turgor and dry mucous membranes
- Peripheral edema, crackles in lung bases, weight gain of 2 kg in 2 days, elevated blood pressure, and jugular vein distension ✓
- Decreased urine output with concentrated urine
- Rapid, weak pulse with low blood pressure
FLUID VOLUME EXCESS (FVE), also called hypervolemia or fluid overload, occurs when too much fluid is retained in the body. In HEART FAILURE, the failing heart cannot pump blood forward effectively; fluid backs up in the venous system and lungs. HALLMARK SIGNS OF FVE: PERIPHERAL EDEMA — dependent ede…
-
A post-operative client develops a fever of 101.5°F (38.6°C) on day 2 after abdominal surgery. What is the MOST common cause of early post-operative fever (within the first 48 hours)?
- Wound infection
- Atelectasis (partial collapse of alveoli due to retained secretions) — the most common cause of fever in the first 1-2 days post-operatively; treated with deep breathing, ambulation, and incentive spirometry ✓
- Blood transfusion reaction
- Urinary tract infection
Post-operative fever has a timing-based differential using the '5 W's' mnemonic: WIND (POD 1-2): ATELECTASIS — partial alveolar collapse from splinting (guarding breathing to avoid pain), anesthesia effects, and secretion retention; causes fever due to inflammatory response; TREATED with: ambulation…
-
A client is prescribed metformin (Glucophage) for type 2 diabetes. Which instruction is MOST important to include in client teaching?
- 'Take metformin on an empty stomach only.'
- 'Hold metformin before any procedure involving iodinated contrast dye and for 48 hours after, as the combination can cause lactic acidosis; also report signs of lactic acidosis immediately' ✓
- 'Metformin can cause low blood sugar if you miss a meal.'
- 'Stop metformin if your blood sugar reaches 200 mg/dL.'
METFORMIN (Glucophage) is the FIRST-LINE oral medication for type 2 diabetes. MECHANISM: decreases hepatic glucose production (gluconeogenesis); increases insulin sensitivity in peripheral tissues; mild GI effects slow glucose absorption. CRITICAL PATIENT EDUCATION — CONTRAST DYE: Metformin + iodina…
-
A client with chronic obstructive pulmonary disease (COPD) is receiving supplemental oxygen. The nurse knows which statement about oxygen therapy in COPD is TRUE?
- Give the maximum oxygen flow rate possible
- In some COPD clients, oxygen should be titrated to maintain SpO2 88-92% — excessive oxygen in hypercapnic COPD can suppress the 'hypoxic drive,' potentially decreasing respiratory effort; avoid suppressing this drive by giving too much O2 ✓
- Oxygen has no special risks in COPD
- Oxygen therapy is contraindicated in all COPD clients
OXYGEN THERAPY IN COPD requires special consideration. NORMAL PHYSIOLOGY: the primary drive to breathe is a RISE IN CO2 (CO2 chemoreceptors are the dominant stimulus). COPD HYPOXIC DRIVE: some patients with SEVERE CHRONIC COPD retain CO2 chronically (hypercapnia); their CO2 receptors have adapted ('…
-
A client with a nasogastric (NG) tube in place. Before giving a tube feeding, which action is the FIRST priority?
- Warm the formula
- Verify tube placement by aspirating gastric contents and checking the pH (less than 5 confirms gastric placement) AND auscultating for placement sounds (insufflation of air is no longer recommended as a primary method); then check residual volume ✓
- Begin the feeding immediately
- Clamp the tube
NASOGASTRIC TUBE FEEDING SAFETY: confirming tube placement BEFORE each feeding is a CRITICAL PATIENT SAFETY STEP. A misplaced tube (in the respiratory tract) with feeding infusion can cause ASPIRATION, PNEUMONIA, and potentially DEATH. TUBE PLACEMENT VERIFICATION: RECOMMENDED — ASPIRATION AND pH TES…
-
A client has a serum sodium level of 125 mEq/L (normal 135-145 mEq/L). Which clinical manifestations does the nurse MOST anticipate?
- Extreme thirst and dry mucous membranes
- Headache, nausea, confusion, seizures (in severe cases), and lethargy — hyponatremia causes osmotic changes that cause brain cells to swell ✓
- Bradycardia and peaked T waves
- No symptoms — this is a normal variant
HYPONATREMIA is defined as serum sodium below 135 mEq/L. Normal: 135-145 mEq/L. A value of 125 mEq/L is SIGNIFICANTLY LOW. PATHOPHYSIOLOGY: sodium is the primary extracellular osmole; when sodium drops, serum osmolality drops; water moves by osmosis from the low-sodium ECF INTO cells (following osmo…
-
A client is receiving IV morphine for pain. Which assessment finding requires the MOST IMMEDIATE intervention?
- Mild drowsiness and report of reduced pain
- Respiratory rate of 8 breaths per minute with deep sedation — signs of opioid overdose requiring immediate intervention including naloxone ✓
- Constipation on day 2 of opioid therapy
- Nausea after the first dose
OPIOID-INDUCED RESPIRATORY DEPRESSION is the most dangerous immediate adverse effect of opioid medications. A respiratory rate of 8 breaths per minute (normal: 12-20) with deep sedation represents an ACUTE LIFE-THREATENING EMERGENCY. MECHANISM: opioids bind to mu receptors in the medullary respirato…
-
A client is scheduled for a fasting blood glucose test in the morning. Which instruction should the nurse give?
- 'Eat a light breakfast before coming in.'
- 'Do not eat or drink anything except water for 8-12 hours before the test; take morning medications with a small sip of water unless instructed otherwise; arrive at the stated time for blood draw' ✓
- 'Drink juice right before the test to ensure accurate results.'
- 'You can eat and drink normally; fasting doesn't affect blood glucose.'
FASTING BLOOD GLUCOSE test measures blood glucose after an adequate fasting period and is used to: SCREEN for diabetes (fasting glucose ≥126 mg/dL on two separate occasions = diabetes); DIAGNOSE impaired fasting glucose (prediabetes: 100-125 mg/dL); MONITOR glycemic control in known diabetics (less …
-
A client with type 1 diabetes is brought to the emergency department unresponsive. The blood glucose is 38 mg/dL. What is the PRIORITY intervention?
- Administer insulin immediately
- Treat the hypoglycemia immediately — if IV access is available, administer 50% dextrose (D50W) 25 grams IV push; if no IV access, administer glucagon IM or intranasally; do NOT give anything by mouth to an unconscious client ✓
- Give orange juice by mouth
- Wait for the client to wake up before treating
SEVERE HYPOGLYCEMIA (blood glucose <54 mg/dL with impaired consciousness) is a MEDICAL EMERGENCY. An unconscious client with a blood glucose of 38 mg/dL requires immediate treatment. PRIORITY TREATMENT: IV ACCESS AVAILABLE: 50% DEXTROSE (D50W) — 25 grams (50 mL) IV push is standard treatment for sev…
-
A client with urinary incontinence requests a urinary catheter for comfort. Which response by the nurse is MOST appropriate?
- Immediately insert an indwelling Foley catheter
- Explore non-catheter approaches first (toileting schedule, absorbent products, skin care); the risks of indwelling urinary catheters (CAUTI — catheter-associated urinary tract infection — is the most common hospital-acquired infection) must be weighed against benefits; catheters are indicated for specific clinical reasons, not convenience ✓
- Deny the request without explanation
- Insert a catheter to prevent skin breakdown, no restrictions
CATHETER-ASSOCIATED URINARY TRACT INFECTION (CAUTI) is the most common healthcare-associated infection (HAI) in hospitals. Every day an indwelling urinary catheter is in place increases infection risk by 3-7%. CAUTI PREVENTION is a major patient safety priority. APPROPRIATE INDICATIONS FOR INDWELLIN…
-
A client prescribed warfarin (Coumadin) reports eating a large amount of leafy green vegetables daily. Why is this significant?
- Leafy greens are irrelevant to warfarin
- Leafy green vegetables are high in Vitamin K, which counteracts warfarin's anticoagulant effect; consistent Vitamin K intake helps maintain stable INR, but LARGE CHANGES in Vitamin K intake can significantly alter warfarin dosing requirements ✓
- Leafy greens increase the risk of bleeding
- All vegetables should be completely avoided on warfarin
WARFARIN (Coumadin) is a VITAMIN K ANTAGONIST anticoagulant — it works by blocking the vitamin K-dependent clotting factors (II, VII, IX, X) and the anticoagulant proteins C and S. VITAMIN K INTERACTION: Vitamin K REVERSES warfarin's anticoagulant effect by providing the substrate for clotting facto…
-
A client's laboratory results show serum calcium of 12.5 mg/dL (normal 8.5-10.5 mg/dL). Which clinical finding is MOST consistent with hypercalcemia?
- Tetany and muscle spasms
- 'Bones, groans, moans, and stones' — bone pain, constipation/nausea, altered mental status/depression, and kidney stones; plus decreased deep tendon reflexes and muscle weakness ✓
- Peaked T waves on ECG
- Positive Chvostek's sign
HYPERCALCEMIA is defined as serum calcium >10.5 mg/dL. Normal: 8.5-10.5 mg/dL. A level of 12.5 mg/dL is significantly elevated. CLINICAL MNEMONIC for hypercalcemia: 'BONES, GROANS, MOANS, AND STONES': BONES: bone pain and pathological fractures — calcium is being leached from bones (especially in ma…
-
A nurse is caring for a client with a new tracheostomy. The client becomes anxious and signals that they cannot breathe. What is the FIRST nursing action?
- Leave to get the doctor
- Stay with the client, call for help, assess for obstruction (mucus plug, dislodged tube), attempt suctioning first, have emergency supplies available (extra tracheostomy tube set, bag-valve mask) — be prepared for emergency tube change if tube is dislodged ✓
- Reassure the client verbally and wait
- Increase the oxygen flow rate only
A CLIENT WITH TRACHEOSTOMY reporting inability to breathe is a RESPIRATORY EMERGENCY. Never leave the client alone during a tracheostomy emergency. IMMEDIATE ASSESSMENT AND ACTIONS: STAY WITH CLIENT and CALL FOR HELP (call code/emergency team, call RN and provider); ASSESS AIRWAY: look-listen-feel a…
-
A nurse is caring for a client with chronic pain. Which non-pharmacological pain management approach is MOST supported by evidence?
- Ignoring the pain
- Cognitive-behavioral therapy (CBT) for pain — along with other evidence-based approaches including heat/cold therapy, TENS, massage, mindfulness-based stress reduction, and physical therapy/exercise therapy; multimodal pain management is the standard of care ✓
- Prescribing maximum opioid doses immediately
- Telling the client pain is not real
CHRONIC PAIN management has evolved significantly with recognition that pain is complex — involving biological, psychological, and social factors (the biopsychosocial model). EVIDENCE-BASED NON-PHARMACOLOGICAL APPROACHES: COGNITIVE-BEHAVIORAL THERAPY (CBT) for pain: most evidence-based psychological…
-
A client is prescribed furosemide (Lasix) for fluid volume excess. Which electrolyte must the nurse monitor most closely?
- Calcium
- Potassium — furosemide is a loop diuretic that causes significant renal potassium wasting; hypokalemia (K+ below 3.5 mEq/L) is the most common adverse effect and can cause dangerous cardiac dysrhythmias ✓
- Phosphorus
- Chloride only
FUROSEMIDE (LASIX) is a LOOP DIURETIC — it inhibits sodium and chloride reabsorption in the Loop of Henle, resulting in increased excretion of: water (the desired diuretic effect); sodium; chloride; POTASSIUM (the most clinically important side effect); magnesium; calcium; hydrogen ions. HYPOKALEMIA…
-
A client with type 2 diabetes has a hemoglobin A1c (HbA1c) of 9.8%. What does this value tell the nurse?
- The client's blood glucose was 9.8 mg/dL today
- The client's average blood glucose over the past 2-3 months has been significantly elevated (approximately 235 mg/dL average, well above the ADA target of less than 7% A1c), indicating poor long-term glycemic control ✓
- The client has type 1 diabetes
- The client's A1c is within normal range
HEMOGLOBIN A1c (HbA1c or glycated hemoglobin) reflects average blood glucose over the PRECEDING 2-3 MONTHS because: glucose binds irreversibly to hemoglobin in red blood cells (RBCs); RBCs have a lifespan of approximately 90-120 days; the percentage of HbA1c reflects average glucose exposure during …
-
A client receives 2 liters of 0.9% normal saline in 4 hours. The nurse should monitor for which complication?
- Dehydration from the saline
- Fluid volume excess — signs include increasing blood pressure, peripheral edema, crackles in lung bases, weight gain, and dyspnea; 2 liters in 4 hours is a significant fluid bolus that can cause overload, especially in clients with cardiac or renal compromise ✓
- Hyperglycemia
- Hyperthermia
FLUID VOLUME EXCESS RISK from IV fluid administration is a significant clinical concern, especially with rapid infusion rates. 2 LITERS IN 4 HOURS = 500 mL/hour — a moderately rapid rate; this is often appropriate in acute resuscitation but requires monitoring for fluid overload. HIGH-RISK POPULATIO…
-
A client is scheduled for a thyroidectomy. What post-operative complication requires most urgent assessment in the first 24-48 hours?
- Hair loss
- Hypocalcemia (tetany) from inadvertent removal or damage to the parathyroid glands, and hemorrhage/hematoma that can compress the airway — both are potentially life-threatening and require immediate recognition ✓
- Mild hoarseness only
- Weight changes
POST-THYROIDECTOMY COMPLICATIONS require vigilant monitoring in the immediate post-operative period. TWO PRIORITY CONCERNS: (1) HYPOCALCEMIA / HYPOPARATHYROIDISM: The parathyroid glands (4 tiny glands on the posterior thyroid) are at risk of damage or inadvertent removal during thyroidectomy; if par…
-
A client is immobile after hip replacement surgery. Which position is contraindicated and must be AVOIDED to prevent hip dislocation?
- Supine with legs slightly abducted
- Hip flexion greater than 90 degrees, adduction (crossing legs), and internal rotation — these movements can dislocate the new prosthetic hip joint; the hip must be kept in a neutral or slightly abducted position ✓
- Elevating the head of the bed to 30 degrees
- Ambulating with weight-bearing on the operative side
TOTAL HIP REPLACEMENT (THR) PRECAUTIONS are critical for preventing prosthetic hip dislocation — a serious complication requiring surgical revision. HIP PRECAUTIONS — THE THREE PROHIBITIONS: (1) NO HIP FLEXION GREATER THAN 90 DEGREES: Do not bend the hip past a right angle; no leaning forward in a c…
-
A client is prescribed metformin for type 2 diabetes. Which instruction is MOST important to include in patient teaching?
- Take it only when your blood sugar is high
- Take with meals to reduce gastrointestinal side effects; report any unusual muscle pain or weakness (possible lactic acidosis); hold before and 48 hours after IV contrast procedures or major surgery ✓
- Never take it if you feel ill
- Take double the dose if you miss one
METFORMIN PATIENT TEACHING PRIORITIES: WITH FOOD: Taking with meals significantly reduces GI side effects (nausea, diarrhea, abdominal discomfort) that cause many patients to discontinue; LACTIC ACIDOSIS: Rare but serious adverse effect; early symptoms: unusual muscle pain, weakness, difficulty brea…
-
A post-operative client is 6 hours after abdominal surgery and has not urinated. What is the nurse's FIRST action?
- Insert a urinary catheter immediately
- Assess for bladder distension by palpating the suprapubic area and assessing for patient's urge to void; check the IV fluid intake and output record; ambulate the patient if able — urinary retention after abdominal surgery is common from anesthesia effects, opioid medications, and positional factors ✓
- Restrict fluids until the patient voids
- Document and wait 2 more hours before taking action
POST-OPERATIVE URINARY RETENTION ASSESSMENT: NORMAL: Most patients void within 6-8 hours after surgery; ASSESSMENT FIRST: Before inserting a catheter (invasive procedure), assess: palpate suprapubic area for distension and firmness; ask if patient feels urge to void; review total fluid intake (IV + …
-
A client with a nasogastric (NG) tube is about to receive a tube feeding. Which verification is ESSENTIAL before starting?
- Check that the tube looks clean
- Verify tube placement by checking gastric pH (acidic pH <5.5 suggests gastric placement) and confirming measurement marking at the naris matches the documented insertion length — do NOT rely on auscultation alone (whoosh test) ✓
- Simply ask the client if the tube feels okay
- Only verify if the client reports discomfort
NG TUBE PLACEMENT VERIFICATION — CRITICAL SAFETY ISSUE: Feeding through a misplaced NG tube (especially one accidentally in the lung) can cause aspiration pneumonia and death. VERIFICATION METHODS (from most to least reliable): ASPIRATION AND PH TESTING: Aspirate stomach contents; pH of 5.5 or below…
-
A client with heart failure has gained 4 lbs in 2 days and reports increased ankle swelling. How should the nurse interpret this?
- Normal fluctuation requiring no action
- Significant fluid retention — 1 kg of weight gain = approximately 1 liter of fluid retention; 4 lbs ≈ 2 liters of fluid; in a heart failure patient, this indicates worsening fluid volume excess requiring prompt assessment and notification of the provider for medication adjustment ✓
- The client is gaining muscle mass
- Only concerning if the client reports difficulty breathing
FLUID WEIGHT MONITORING IN HEART FAILURE: CALCULATION: 1 kg = 1,000 mL of fluid; 1 lb ≈ 0.45 kg; 4 lbs ≈ 1.8 kg ≈ 1.8 liters of additional fluid; HEART FAILURE ALERT WEIGHT: Standard patient teaching: notify provider for weight gain of 2+ lbs in a day or 5+ lbs in a week; this patient has gained 4 l…
-
A client is receiving IV vancomycin. The infusion has been running for 20 minutes and the nurse notices facial flushing and hypotension. What is the likely cause and nursing action?
- An allergic reaction requiring epinephrine
- Red Man Syndrome — a rate-related (non-allergic) infusion reaction caused by rapid vancomycin infusion; treated by stopping or slowing the infusion and administering antihistamines (diphenhydramine); NOT a true allergic reaction ✓
- Normal expected effects of vancomycin
- The client needs more vancomycin
RED MAN SYNDROME (vancomycin-related): MECHANISM: NOT an allergic reaction — it is a direct mast cell degranulation triggered by too-rapid infusion; the faster the infusion, the more histamine release; PRESENTATION: Facial flushing/erythema; neck and chest redness ('red man' distribution); hypotensi…
-
When positioning a client who had a left-sided stroke resulting in right-sided hemiplegia (weakness/paralysis), which position is contraindicated?
- Semi-Fowler's with right arm supported
- Lying on the affected (right) side without adequate protection — the hemiplegic side has reduced sensation and reduced ability to reposition; lying directly on the affected extremities without padding and correct alignment can cause pressure injuries, joint damage, shoulder subluxation, and skin breakdown ✓
- Supine with foot board
- Supported side-lying on the unaffected (left) side
HEMIPLEGIA POSITIONING: The AFFECTED SIDE requires special protection because: reduced or absent sensation (cannot feel pain from poor positioning); reduced motor function (cannot shift weight normally); increased muscle tone in abnormal patterns (spasticity); RISKS OF IMPROPER POSITIONING ON AFFECT…
-
A client is receiving heparin infusion and the aPTT comes back at 120 seconds (therapeutic range 60-100 seconds for anticoagulation, normal 25-35 seconds). What is the appropriate nursing action?
- Increase the heparin rate
- Hold or reduce the heparin infusion per protocol and notify the provider — an aPTT of 120 seconds is above the therapeutic anticoagulation range, indicating excessive anticoagulant effect and increased bleeding risk ✓
- Continue at the same rate
- Document and reassess in 4 hours without action
HEPARIN MONITORING with aPTT: THERAPEUTIC RANGE: For anticoagulation (treatment of VTE, PE, atrial fibrillation), aPTT target is typically 60-100 seconds (1.5-2.5× normal); this range varies by indication and institution protocol; SUPRATHERAPEUTIC (>100 seconds): Excessive anticoagulation — HIGH BLE…
-
A client who has been on bedrest for 5 days reports sudden onset of unilateral calf pain, warmth, and swelling. What should the nurse do FIRST?
- Massage the calf to reduce the pain
- Stop any activity or calf manipulation; notify the RN immediately — these are classic symptoms of deep vein thrombosis (DVT); the risk with DVT is pulmonary embolism if the clot dislodges; massaging a DVT can cause embolisation ✓
- Apply a warm compress to the calf
- Complete the physical assessment before notifying anyone
DVT RECOGNITION AND INITIAL RESPONSE: CLASSIC DVT SIGNS: Unilateral (one leg) calf pain; warmth; swelling (may see difference in leg circumference); redness; may be accompanied by low-grade fever; HOMAN'S SIGN (calf pain on dorsiflexion): historically taught but is UNRELIABLE and NOT recommended for…
-
A client on a loop diuretic (furosemide) reports muscle cramps and fatigue. Blood work shows potassium 3.1 mEq/L. Which intervention should the nurse prioritize?
- Encourage rest only
- Report the potassium level to the provider and implement ordered potassium replacement; educate the client on dietary potassium sources; hold the next furosemide dose if ordered until potassium level is addressed — K+ 3.1 is below normal (3.5-5.0) and symptomatic ✓
- Give the scheduled furosemide and monitor
- Increase the furosemide dose
HYPOKALEMIA from loop diuretics: NORMAL POTASSIUM: 3.5-5.0 mEq/L; MILD HYPOKALEMIA: 3.0-3.4 mEq/L (client's 3.1 mEq/L is mild); SYMPTOMS: Muscle weakness, cramps, fatigue (matching this client's complaints); SEVERE (<3.0): Potentially fatal cardiac dysrhythmias (PVCs, ventricular fibrillation), seve…
-
A client 2 days post abdominal surgery develops a fever of 101.8°F (38.8°C). What is the most common cause of post-operative fever within the first 24-48 hours?
- Wound infection (surgical site infection)
- Atelectasis — collapse of small lung segments from shallow breathing after surgery and anesthesia; this is the classic cause of post-op fever in the first 24-48 hours; treated with incentive spirometry, deep breathing exercises, and ambulation ✓
- Blood clot
- IV line infection
POST-OPERATIVE FEVER — TIMING-BASED APPROACH: DAY 1 (within 24 hours): ATELECTASIS (collapsed lung segments) is the most common cause; wound infections at this stage are nearly impossible (too early for bacteria to proliferate); TREATMENT: Incentive spirometry (10 deep breaths every hour); early amb…
-
A client with dysphagia (difficulty swallowing) is at risk for aspiration. Which nursing action is highest priority at mealtimes?
- Keep the bed flat during feeding
- Position the client upright at 90 degrees and keep upright for at least 30 minutes after meals; ensure thin liquids are thickened as ordered; feed slowly with small bites; have suction available ✓
- Feed quickly to minimise choking time
- Only provide liquid meals
ASPIRATION PRECAUTIONS: POSITIONING: 90° upright (not just slightly elevated) during and 30-45 min after meals — gravity assists swallowing and reduces reflux/aspiration risk; THICKENED LIQUIDS: Thin liquids are the most dangerous for dysphagia — thickening agents (nectar, honey, pudding consistency…
-
A post-surgical client has a urine output of 20 mL over the past hour. Normal minimum is 30 mL/hr. What is the LPN's priority action?
- Document and recheck in two hours
- Notify the RN immediately — urine output below 30 mL/hr (oliguria) is a critical finding that may indicate inadequate renal perfusion, hypovolaemia, or acute kidney injury requiring prompt assessment and intervention ✓
- Encourage the client to drink more fluids
- Reassure the client this is normal after surgery
OLIGURIA (<30 mL/hr or <0.5 mL/kg/hr): This is a critical assessment finding. CAUSES: Hypovolaemia (most common post-surgical — inadequate fluid replacement, haemorrhage); cardiac output reduction (heart failure, MI); renal causes (ATN, contrast nephropathy); obstruction (kinked catheter — check fir…
-
A client taking warfarin has an INR of 4.8 (therapeutic range 2.0–3.0). The nurse assesses for which priority finding?
- Tachycardia
- Bleeding — assess for haematuria (pink/red urine), haematochezia (blood in stool), unusual bruising, prolonged bleeding from cuts, gum bleeding, and any headache or neurological change (intracranial bleed) ✓
- Hyperglycaemia
- Muscle cramps
SUPRATHERAPEUTIC INR (4.8 vs target 2-3): This represents excessive anticoagulation — significantly increased bleeding risk. ASSESSMENT PRIORITIES: Urine colour (haematuria); stool colour/occult blood (GI bleed); skin for excessive bruising or haematomas; neurological status (headache, confusion, fo…
-
Following a lumbar puncture (spinal tap), which position should the client be placed in and for how long?
- Sit upright for 2 hours
- Lie flat (supine) for 4-8 hours as directed — this reduces the risk of post-lumbar puncture headache (spinal headache) by allowing the puncture site to seal before CSF pressure is restored by being upright ✓
- Elevate the head of bed 45 degrees
- Lie on their side only
POST-LUMBAR PUNCTURE CARE: POSITIONING: Flat (supine or prone) 4-8 hours per order — the evidence for preventing post-LP headache with positioning has evolved (some studies suggest not clearly beneficial) but most institutions still recommend flat positioning; the rationale: CSF leaks through the du…
-
A client has a stage 2 pressure injury on the sacrum. Which dressing is most appropriate?
- Dry gauze dressing
- Hydrocolloid dressing — maintains a moist wound environment that promotes epithelial migration, is self-adhesive, requires less frequent changing, and protects the wound from contamination; appropriate for stage 2 wounds (partial-thickness skin loss) ✓
- Wet-to-dry dressing
- Leave open to air
PRESSURE INJURY STAGING AND DRESSING SELECTION: STAGE 2: Partial thickness skin loss — epidermis and part of dermis; wound appears as shallow open ulcer with red-pink wound bed; MOIST WOUND HEALING: Evidence consistently shows moist wound healing accelerates epithelialisation compared to dry; DRY GA…
-
A client is receiving an IV antibiotic infusion and reports pain, redness, and swelling at the IV site. What does this indicate and what should the nurse do first?
- This is a normal infusion reaction — continue the infusion
- This indicates phlebitis or infiltration — stop the infusion immediately, remove the IV catheter, elevate the extremity, apply warm/cool compress per facility policy, document, and notify the RN; establish a new IV site in a different location ✓
- Slow the infusion rate
- Add a warm pack without stopping the infusion
IV SITE COMPLICATIONS: PHLEBITIS: Inflammation of the vein wall — redness, warmth, pain, and a palpable cord along the vein; can be caused by mechanical trauma, chemical irritation from medications, or infection; INFILTRATION: IV catheter has displaced from the vein — fluid infusing into surrounding…
-
A client with a chest tube is being transferred between units. During transport, the chest tube drainage system accidentally tips over. What is the priority action?
- Leave it tipped until arriving at the destination
- Immediately return the drainage system to the upright position — a tipped drainage system allows fluid to block the water seal, which could create a pressure imbalance; ensure all connections are intact and the system continues to drain properly; notify the RN ✓
- Clamp the chest tube
- Remove the chest tube
CHEST TUBE MANAGEMENT DURING TRANSPORT: DRAINAGE SYSTEM POSITIONING: Must remain upright to maintain the water seal; the water seal prevents air from entering the pleural space; SYSTEM TIPPED: Priority is to return to upright position quickly; if water seal is disrupted (water spilled), notify RN im…
-
A client is being discharged on oral iron supplements. Which instruction is most important to prevent the most common adverse effect?
- Take on a completely empty stomach at all times
- Take with orange juice (vitamin C) to enhance absorption and take with food if GI upset occurs — GI distress (nausea, constipation, dark/black stools) is the most common reason patients discontinue iron; stool will be dark green or black (expected, not blood) ✓
- Only take at night
- Crush tablets for faster absorption
ORAL IRON SUPPLEMENTATION TEACHING: MOST COMMON ADVERSE EFFECT: GI distress — nausea, constipation, stomach cramps; dark/black stools (expected, not a sign of GI bleeding unless bright red); MANAGING GI EFFECTS: Take with small amount of food to reduce nausea (reduces absorption slightly but improve…
-
A client's serum sodium is 128 mEq/L (normal 135-145). They appear confused and report nausea and headache. What condition does this represent and what is the nursing priority?
- Hypernatraemia — restrict fluids
- Hyponatraemia — notify the RN urgently; severe hyponatraemia causes neurological symptoms from cerebral oedema; the nurse should NOT encourage the client to drink free water (worsens the condition) and should await medical orders for IV sodium replacement ✓
- Hypokalaemia — check the ECG
- Dehydration — give oral fluids freely
HYPONATRAEMIA (Na <135 mEq/L): SEVERE (<125 mEq/L): Neurological symptoms — confusion, nausea, headache, seizures, and if untreated, cerebral oedema, herniation, and death; 128 mEq/L with symptoms = URGENT; CAUSES: SIADH (syndrome of inappropriate ADH secretion); heart failure; cirrhosis; excessive …
-
During a tracheostomy care procedure, the client begins coughing vigorously. What is the nurse's immediate action?
- Stop the procedure and leave the room
- Pause the procedure; allow the client to cough; hold the tracheostomy tube securely in place during coughing — vigorous coughing can dislodge a new or unsecured tracheostomy tube; suction secretions if they are visible in the airway after coughing stops; then resume care ✓
- Apply the inner cannula immediately
- Continue the procedure without stopping
TRACHEOSTOMY TUBE SAFETY DURING COUGHING: TUBE DISPLACEMENT RISK: Coughing generates significant intrathoracic pressure — a tracheostomy tube, especially one within the first 7-10 days of placement (before the stoma tract is established), can be expelled from the stoma; if this happens, the airway m…
-
A client prescribed furosemide (Lasix) 40 mg IV is a nursing priority to assess which parameter BEFORE administration?
- Blood glucose
- Serum potassium and recent urine output — furosemide is a loop diuretic that causes significant potassium wasting; administering to a hypokalaemic client can cause dangerous cardiac dysrhythmias; also assess: BP (diuretic in hypotensive client causes further drop), renal function (contraindicated in anuria) ✓
- INR level
- Liver enzymes
PRE-FUROSEMIDE ASSESSMENT: POTASSIUM: Most critical — loop diuretics (furosemide, torsemide, bumetanide) block Na-K-Cl co-transporter in the loop of Henle; significant potassium loss with every dose; hold and notify if K+ < 3.0-3.5 mEq/L (facility-specific threshold); BLOOD PRESSURE: Hold if hypoten…
-
A client returns from a thyroidectomy. During the first 24 hours, which assessment finding requires the MOST immediate response?
- Mild sore throat
- Positive Chvostek's sign (tapping the facial nerve causes facial twitching) — this indicates hypocalcaemia, which is a known complication of thyroid surgery when the parathyroid glands are inadvertently removed or traumatised; severe hypocalcaemia can cause tetany, laryngospasm, and cardiac dysrhythmias ✓
- Slight hoarseness
- Temperature of 99.2°F
POST-THYROIDECTOMY COMPLICATIONS: HYPOCALCAEMIA: Parathyroid glands (regulate calcium) may be inadvertently removed or devascularised during thyroid surgery; EARLIEST SIGNS: Perioral tingling, finger and toe numbness/tingling; CHVOSTEK'S SIGN: Tap the facial nerve at the cheek — positive if facial m…
-
When providing oral care for an unconscious client, which position should the nurse use to prevent aspiration?
- Flat supine with head turned to the side
- Lateral position (side-lying) or supine with head turned to one side — gravity allows secretions and excess water to drain from the mouth rather than pooling at the back of the throat; suction must be available during oral care for unconscious clients ✓
- Upright at 90 degrees
- Prone position
ORAL CARE FOR UNCONSCIOUS CLIENTS: ASPIRATION RISK: Unconscious clients have no protective gag reflex — fluid, secretions, or debris can enter the airway; POSITIONING: Side-lying is ideal — gravity drains secretions away from the airway; if patient cannot be turned, turn the head to the side; TECHNI…
-
A client with a history of COPD is prescribed oxygen therapy at 2 L/min via nasal cannula. The nurse finds the client has increased their own flow rate to 6 L/min because they felt short of breath. What should the nurse do?
- Leave it at 6 L/min since the client was uncomfortable
- Return the oxygen to 2 L/min as prescribed, assess the client thoroughly for the cause of dyspnoea, and notify the RN — in COPD clients with chronic CO2 retention, high-flow oxygen can suppress the hypoxic respiratory drive and cause respiratory depression ✓
- Increase it further to 10 L/min
- Tell the client they cannot change their own oxygen and leave it at 2 L/min without assessment
OXYGEN THERAPY IN COPD — RATIONALE: Clients with chronic CO2 retention (type 2 respiratory failure) may rely partly on hypoxaemia to drive respiration (hypoxic drive); high-flow O2 can blunt this drive, causing hypoventilation and CO2 retention; TARGET SpO2 in COPD: 88-92% (NOT 95-100% as in normal …
-
A client receiving total parenteral nutrition (TPN) develops sudden onset of shortness of breath, chest pain, and a decrease in SpO2. The central line was just changed. What complication should the nurse suspect and what is the priority action?
- Fluid overload — slow the TPN
- Air embolism — clamp the central line immediately, position the client in left lateral Trendelenburg (left side down, head down), call for emergency assistance, and administer oxygen ✓
- Pneumothorax — help the client sit up
- Hypoglycaemia — check blood glucose
AIR EMBOLISM: CAUSE: Air enters the central venous system through the central line during tubing changes, disconnections, or catheter removal; SIGNS: Sudden onset dyspnoea, chest pain, decreased SpO2, tachycardia, 'millwheel' murmur (churning sound from air in heart); EMERGENCY RESPONSE: CLAMP the l…
-
A client is prescribed warfarin (Coumadin). Which laboratory value monitors the therapeutic effect of this medication?
- aPTT
- INR (International Normalized Ratio) — the standardized measure of prothrombin time used to monitor warfarin; therapeutic range is typically 2.0-3.0 for most indications (2.5-3.5 for mechanical heart valves) ✓
- Platelet count
- Serum potassium
WARFARIN MONITORING: INR (International Normalized Ratio) is the standardized PT measurement for warfarin. THERAPEUTIC RANGES: Most indications (atrial fibrillation, DVT/PE treatment): 2.0-3.0; Mechanical heart valves: 2.5-3.5; INR ABOVE RANGE: Excessive anticoagulation, bleeding risk — hold warfari…
-
A client returns from surgery with a urinary catheter. Which nursing action best prevents catheter-associated urinary tract infection (CAUTI)?
- Irrigate the catheter every shift
- Keep the drainage bag below the level of the bladder, maintain a closed drainage system, and perform daily perineal hygiene — and advocate for catheter removal as soon as it is no longer needed ✓
- Clamp the catheter intermittently
- Change the catheter daily
CAUTI PREVENTION (one of the most common healthcare-associated infections): KEY MEASURES: Keep drainage bag BELOW bladder level (prevents backflow of contaminated urine); maintain a CLOSED drainage system (don't disconnect unnecessarily); secure the catheter to prevent movement and urethral trauma; …
-
A client with dysphagia (difficulty swallowing) following a stroke is at risk for aspiration. Which feeding position is safest?
- Lying flat (supine)
- High Fowler's position (sitting upright at 90 degrees) with the chin slightly tucked toward the chest — and remaining upright for 30-60 minutes after eating ✓
- Side-lying
- Trendelenburg (head down)
DYSPHAGIA ASPIRATION PREVENTION: POSITIONING: High Fowler's (90 degrees upright) during meals; CHIN TUCK: Slightly tucking the chin toward the chest narrows the airway entrance and directs food toward the esophagus — reduces aspiration; REMAIN UPRIGHT: 30-60 minutes after eating prevents reflux and …
-
A client is receiving digoxin. Before administering the morning dose, the nurse should assess which vital sign?
- Respiratory rate
- Apical heart rate for one full minute — hold digoxin and notify the provider if the apical pulse is below 60 beats per minute in an adult (digoxin slows heart rate and can cause dangerous bradycardia) ✓
- Temperature
- Oxygen saturation
DIGOXIN ADMINISTRATION SAFETY: ASSESS APICAL PULSE: Count the apical heart rate for ONE FULL MINUTE before each dose; HOLD AND NOTIFY: If apical HR < 60 bpm in adults (< 70 in children, < 90-110 in infants depending on protocol); WHY: Digoxin has negative chronotropic effect (slows heart rate) — giv…
-
A client has a serum sodium level of 122 mEq/L (normal 135-145). Which assessment finding would the nurse expect with this level of hyponatremia?
- Extreme thirst and dry mucous membranes
- Neurological changes — confusion, headache, lethargy, muscle weakness, and in severe cases seizures; severe hyponatremia causes cerebral edema as water shifts into brain cells ✓
- Flushed dry skin
- Increased urine output with high specific gravity
HYPONATREMIA (low sodium, <135 mEq/L): 122 mEq/L is significantly low. NEUROLOGICAL EFFECTS DOMINATE: Sodium imbalances primarily affect the brain because water shifts based on sodium concentration; LOW SODIUM = water moves INTO cells (including brain cells) = cerebral edema; SYMPTOMS by severity: M…
-
A diabetic client's morning fasting blood glucose is 52 mg/dL and the client is alert and able to swallow. What is the appropriate nursing intervention?
- Administer the scheduled insulin dose
- Give 15 grams of fast-acting carbohydrate (4 oz juice, glucose tablets, or regular soda), wait 15 minutes, and recheck blood glucose — the '15-15 rule' for treating conscious hypoglycemia ✓
- Call a code
- Withhold all food until the provider rounds
HYPOGLYCEMIA TREATMENT — THE 15-15 RULE: For a CONSCIOUS client able to swallow with blood glucose < 70 mg/dL: GIVE 15g fast-acting carbohydrate: 4 oz (1/2 cup) fruit juice or regular soda; 3-4 glucose tablets; 1 tablespoon honey or sugar; 8 oz milk; WAIT 15 minutes; RECHECK blood glucose; REPEAT if…
-
A client with a new colostomy is concerned about odor and appliance care. Which statement indicates the client needs more teaching?
- 'I should empty the pouch when it is one-third to one-half full.'
- 'I can apply the skin barrier even if the surrounding skin is moist or weepy' — this is incorrect; the skin must be clean and DRY for the barrier to adhere properly and protect the peristomal skin ✓
- 'I should check the stoma color regularly — it should be pink or red and moist.'
- 'Certain foods like eggs and fish can increase odor.'
COLOSTOMY CARE TEACHING: CORRECT statements (no further teaching needed): Empty pouch at 1/3 to 1/2 full (prevents weight pulling appliance off and leakage); Stoma should be PINK/RED and MOIST (healthy perfusion — report pale, dusky, purple, or black stoma immediately = ischemia); Odor management wi…
-
A client is prescribed an opioid for post-operative pain. Which assessment is the highest priority before and after administration?
- Blood pressure
- Respiratory rate and sedation level — opioids cause respiratory depression, the most dangerous adverse effect; assess RR (hold if below 12/min) and level of sedation before and after administration ✓
- Temperature
- Bowel sounds
OPIOID SAFETY — RESPIRATORY DEPRESSION: The most dangerous opioid adverse effect is respiratory depression — opioids suppress the brainstem respiratory drive. PRIORITY ASSESSMENTS: Respiratory rate (hold and notify if < 12/min in adults); Sedation level (use a sedation scale — increasing sedation pr…
-
A client is on contact precautions for Clostridioides difficile (C. diff). Which hand hygiene method is required?
- Alcohol-based hand sanitizer is sufficient
- Soap and water handwashing — alcohol-based sanitizers do NOT kill C. diff spores; mechanical removal by washing with soap and water is required after caring for a C. diff patient ✓
- No hand hygiene needed if gloves were worn
- Hand sanitizer followed by lotion
C. DIFF HAND HYGIENE — A CLASSIC NCLEX POINT: C. difficile forms SPORES that are resistant to alcohol — alcohol-based hand sanitizers do NOT kill C. diff spores; SOAP AND WATER required — the mechanical action of washing physically removes spores from hands; ALWAYS wash with soap and water before an…
-
A client receiving IV potassium chloride (KCl) reports burning at the IV site. What should the nurse do first?
- Increase the infusion rate to flush it through faster
- Slow or stop the infusion and assess the site — KCl is irritating to veins; burning may indicate the rate is too fast or infiltration; KCl is NEVER given IV push (causes fatal cardiac arrest) and must be diluted and infused slowly via pump ✓
- Apply heat to the site
- Document and continue the infusion
IV POTASSIUM SAFETY — A HIGH-ALERT MEDICATION: KCl is irritating to veins and dangerous if administered incorrectly. BURNING at the site: Slow or stop the infusion; assess for infiltration; KCl is a vein irritant — slower rates and greater dilution reduce burning; consider a central line for higher …
-
An immobile client is at risk for pressure injury. How often should the nurse reposition a bedbound client to prevent skin breakdown?
- Every 8 hours
- At least every 2 hours — repositioning relieves pressure over bony prominences before tissue ischemia and breakdown occur; more frequent repositioning may be needed for high-risk clients ✓
- Once per shift
- Only when the client requests it
PRESSURE INJURY PREVENTION — REPOSITIONING: Reposition bedbound clients at least every 2 hours (chair-bound: every 1 hour or teach weight shifts every 15 minutes); WHY: Pressure over bony prominences (sacrum, heels, hips, elbows, occiput) compresses capillaries, causing tissue ischemia; unrelieved p…
-
A client is taking an ACE inhibitor (lisinopril) for hypertension. Which side effect should the nurse teach the client to report?
- Increased appetite
- A persistent dry cough (and rarely, angioedema — swelling of the face, lips, tongue, or throat, which is a medical emergency) ✓
- Weight gain
- Improved vision
ACE INHIBITOR SIDE EFFECTS (drugs ending in '-pril': lisinopril, enalapril, ramipril): DRY COUGH: Persistent, non-productive cough occurs in 5-20% of patients due to bradykinin accumulation; often requires switching to an ARB (angiotensin receptor blocker, '-sartan' drugs) which doesn't cause cough;…
-
A client at risk for falls is being discharged home. Which home safety instruction is most important for fall prevention?
- Keep all rooms brightly decorated
- Remove throw rugs, ensure adequate lighting (especially night lights on the path to the bathroom), install grab bars in the bathroom, and keep walkways clear of clutter and cords ✓
- Keep the home temperature warm
- Use a softer mattress
HOME FALL PREVENTION: ENVIRONMENTAL MODIFICATIONS: Remove throw rugs (major trip hazard) or secure with non-slip backing; Adequate lighting throughout, especially night lights from bed to bathroom (most home falls happen at night going to the bathroom); Install grab bars in bathroom (near toilet and…
-
A client is prescribed a 1,500 mL fluid restriction over 24 hours. The day shift (7a-3p) and evening shift (3p-11p) typically use more of the allotment than night shift. How should the nurse distribute the fluid?
- Give all 1,500 mL during the day shift
- Distribute proportionally with more during waking hours — commonly day shift 800 mL, evening shift 500 mL, night shift 200 mL — to accommodate meals, medications, and the client's preference while staying within the total limit ✓
- Let the client drink freely until the limit is reached
- Give equal amounts each shift regardless of activity
FLUID RESTRICTION MANAGEMENT: Distribute the daily allotment to match the client's activity and needs — more during waking/meal hours, less at night. TYPICAL DISTRIBUTION (1,500 mL example): Day (7a-3p): ~800 mL (breakfast, lunch, morning/noon meds, most active); Evening (3p-11p): ~500 mL (dinner, e…
-
A client is to receive an intramuscular (IM) injection in the ventrogluteal site. Why is the ventrogluteal site preferred over the dorsogluteal site for IM injections?
- It is easier to reach
- The ventrogluteal site is free of major nerves and blood vessels (away from the sciatic nerve), has a thick muscle mass, and is considered the safest IM injection site for adults and children ✓
- It allows larger injection volumes
- It is less painful only because it is smaller
VENTROGLUTEAL SITE — THE PREFERRED IM SITE: LOCATION: Place the palm on the greater trochanter, index finger on the anterior superior iliac spine, middle finger toward the iliac crest, inject in the V between fingers; ADVANTAGES: Free of major nerves and blood vessels — notably AWAY from the SCIATIC…