The emergency department nurse receives a client with extensive injuries to the head and upper back

Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma Life Support-qualified health care provider. Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column.

(Option 1) Although use of the backboard is appropriate, the head-tilt chin-lift should not be used as it involves manipulation of the neck without proper stabilization. If the cervical vertebrae are fractured, the spinal cord could be badly damaged.

(Option 2) The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing.

(Option 3) The jaw-thrust maneuver is appropriate, but stabilization of the spine is best performed in the supine position, such as on the flat, hard surface of a backboard.

Educational objective:
If there is any suspicion of spinal injury, the jaw-thrust maneuver should be used for airway assessment to avoid any shifting of unstable vertebrae and subsequent spinal cord damage.

This client's arterial blood gas analysis reveals respiratory acidosis, with a low pH (<7.35), low PaO2, and high PaCO2 (>45 mm Hg [>5.98 kPa]). Any condition that causes a decrease in respiratory rate or tidal volume (eg, chronic obstructive pulmonary disease, chest trauma, over-sedation, sleep apnea) increases the risk of developing respiratory acidosis. This client's breathing is likely shallow due to pain, impairing gas exchange and leading to buildup of acidic carbon dioxide in the blood.

(Option 1) In metabolic acidosis, pH would be decreased (<7.35) and HCO3- would be decreased (<22 mEq/L [<22 mmol/L]).

(Option 2) In metabolic alkalosis, pH would be increased (>7.45) and HCO3- would be increased (>26 mEq/L [>26 mmol/L]).

(Option 4) In respiratory alkalosis, pH would be increased (>7.45) and PaCO2 would be decreased (<35 mm Hg [<4.7 kPa]).

Educational objective:
Buildup of acidic carbon dioxide from hypoventilation causes a decrease in pH, creating a state of respiratory acidosis.

Paracentesis is a procedure that involves removal of excess fluid from the peritoneal cavity (ascites) and is performed to relieve dyspnea and discomfort related to increased intra-abdominal pressure and fluid volume. Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure and also to high volume peritoneal fluid removal (>5 L). The nurse should first validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for manifestations of hypovolemia (eg, orthostatic hypotension, tachycardia, reduced pulse volume, decreased urine output), as decreased circulating volume can lead to hemodynamic instability.

(Option 1) Post-paracentesis vital signs are frequently monitored for the first 4 hours to assess for complications (eg, hypotension, bleeding). The nurse can ask the UAP to take another set of vital signs, but this should not be the nurse's first intervention.

(Option 3) Diuretics (eg, spironolactone, furosemide) are prescribed for clients with ascites. If the client is hypotensive or hypovolemic, the nurse can hold the prescribed diuretics, but this should not be the nurse's first intervention.

(Option 4) The nurse can instruct the UAP to assist the client back to bed if this is an appropriate action after assessing the client, but this should not be the nurse's first intervention.

Educational objective:
A client who is experiencing lightheadedness and unsteady gait following paracentesis requires immediate assessment because these manifestations can signal hypovolemia with hypotension, which can lead to hemodynamic instability and hypovolemic shock.

The nurse has used a nontherapeutic communication technique known as "giving reassurance" or "giving false reassurance." A nurse who does not acknowledge a client's feelings and gives the impression that there is nothing to worry about has devalued the client's concerns. This technique serves to block a therapeutic conversation as the client may feel that the verbalization of additional concerns or feelings will also be devalued.

(Option 1) The nurse has not encouraged exploration of this client's feelings and options. This could have been done by using any one of several therapeutic communication techniques (eg, reflecting, focusing, exploring). An appropriate response by the nurse, such as stating, "Tell me what concerns you have," would have facilitated communication with the client.

(Option 2) The nurse has shown no interest in the client's concerns; instead, the nurse should show interest, be available, and have a conversation with the client (eg, "I will stay and listen to your concerns").

(Option 3) The nurse has not conveyed empathy (attempting to understand and share the feelings behind a client's actions and words). An empathetic nurse might say, "This must be hard for you," or, "I understand you are upset."

Educational objective:
The nurse must learn to use effective therapeutic communication skills to enhance the development of a trusting and therapeutic nurse-client relationship.

Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia. Oral KCl is available in extended-release tablets, capsules, dissolvable packets, and effervescent tablets, and as an oral liquid. If a client has difficulty swallowing large pills, the nurse should consult the pharmacist to see if other forms of KCl are currently available and to determine if the medication is safe to crush. If a more appropriate form (eg, liquid) is available, the nurse would then discuss that change in route with the health care provider and obtain an updated prescription.

(Option 2) Some pills or capsules are sustained-release formulations, and crushing may alter the release of the drug and cause an overdose of the medication. The nurse should consult the pharmacist before altering the form of the drug.

(Option 3) The use of a loop diuretic, such as furosemide, is a common cause of potassium depletion. Holding the KCl dose may cause the client's potassium level to fall below normal (<3.5 mEq/L [3.5 mmol/L]), which can potentiate digoxin toxicity (eg, cardiac dysrhythmias, gastrointestinal upset).

(Option 4) Tucking the chin to the chest during swallowing is a technique used to prevent aspiration. This most likely will not help the client swallow the large pill.

Educational objective:
Oral potassium chloride comes in multiple forms: tablet or capsule, oral liquid, dissolving packets, and effervescent tablets. If a client has difficulty swallowing large pills, the pharmacist can determine availability of other medication forms, which can then be prescribed by the health care provider.

Clinical features of opioid withdrawal
Clinical presentation
Acute opioid cessation/dose reduction after prolonged use
Gastrointestinal: nausea, vomiting, diarrhea, cramping, ↑ bowel sounds
Cardiac:↑ pulse, ↑ blood pressure, diaphoresis
Psychological: insomnia, yawning, dysphoric mood
Other: myalgias, arthralgias, lacrimation, rhinorrhea, piloerection, mydriasis
Management
Opioid agonist: methadone (preferred) or buprenorphine
Nonopioid: clonidine or adjunctive medications (antiemetics, antidiarrheals, benzodiazepines)

Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone [Narcan]) is administered. Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity as the depressant effect of the opioid wanes (Option 4).

Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given medications, such as methadone, to alleviate discomfort. The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or maintenance interventions.

(Options 1, 2, and 3) Opioid use typically causes constipation, constricted pupils, and drowsiness due to its central nervous system depressant effects.

Educational objective:
Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped or dosage is reduced. Symptoms of opioid withdrawal (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity.

Additional Information
Psychosocial Integrity
NCSBN Client Need

Postpartum endometritis
Risk factors
Cesarean delivery
Chorioamnionitis
Group B Streptococcus colonization
Prolonged rupture of membranes
Operative vaginal delivery
Clinical
features
Fever >24 hours postpartum
Uterine fundal tenderness
Purulent lochia
Etiology
Polymicrobial infection
Treatment
Clindamycin & gentamicin

Postpartum endometritis occurs when the endometrium (uterine lining) becomes infected after birth, often beginning at the placental site. Endometritis is characterized by uterine tenderness and subinvolution, foul-smelling or purulent lochia, fever, tachycardia, and chills. Cesarean birth is a primary risk factor, particularly if performed emergently or after prolonged labor.

The infection is usually polymicrobial and requires treatment with broad-spectrum antibiotics (eg, IV clindamycin plus IV gentamicin). Antibiotic administration is a priority because it treats the primary cause of endometritis and prevents complications related to the spread of infection (eg, abscess, peritonitis) (Option 2). Antibiotics are required until approximately 24 hours after symptoms resolve.

(Option 1) Antipyretics (eg, acetaminophen) and other comfort measures (eg, repositioning, oral hydration, pain medication) can be provided after antibiotic therapy is initiated.

(Option 3) IV fluid administration (eg, Lactated Ringer IV bolus) is a supportive measure used to help resolve tachycardia and promote adequate hydration, but it does not take priority over antibiotic administration.

(Option 4) To promote uterine involution, uterotonics (eg, PO methylergonovine) may be prescribed. Although uterine involution can promote drainage of purulent lochia, methylergonovine does not take priority over antibiotics, which are needed to treat the cause of infection.

Educational objective:
Postpartum endometritis is an infection of the endometrium (uterine lining) and is characterized by fever, chills, tachycardia, uterine tenderness, and foul-smelling or purulent lochia. The nurse's priority intervention is initiation of broad-spectrum antibiotics to treat the infection and reduce the risk of complications (eg, abscess, peritonitis). Subsequent interventions include antipyretics, IV fluids, and (possibly) uterotonics for uterine subinvolution.

Postpartum depression (PPD) is a perinatal mood disorder that affects women following childbirth. Symptoms may include crying, irritability, difficulty sleeping (or sleeping more than usual), anxiety, and feelings of guilt. Symptoms typically arise within 4 weeks of delivery and can affect the mother's ability to care for herself and the newborn. The nurse should ask specific questions about depression or hopelessness to assess for PPD (Option 4). It is also important to ask about thoughts of self-harm or harm to the newborn.

(Option 1) Women who do not have strong support systems are at a higher risk for PPD. However, it is most important to assess for the presence of PPD.

(Option 2) Mothers may have feelings of inadequacy or guilt as they experience challenges in caring for their infant (eg, breastfeeding difficulties, infant colic). The nurse should assess the need for client teaching, which can help to alleviate anxiety and improve outcomes; however, this is not the priority.

(Option 3) Sleep disturbances are common when caring for a newborn and may worsen depression or anxiety. However, it is most important to directly ask the client about depression.

Educational objective:
Postpartum depression (PPD) is a perinatal mood disorder characterized by crying, irritability, sleep disturbances, anxiety, or feelings of guilt. Nurses should assess for PPD by asking specific questions about feelings of depression and hopelessness as well as thoughts about self-harm or harm to the newborn.

In placenta previa, the placenta is implanted over or very near the cervix. This causes placental blood vessels to be disrupted during cervical dilation and effacement, which may result in massive blood loss and maternal/fetal compromise. Because of the increased risk of hemorrhage if contractions result in cervical change, a cesarean birth is planned for after 36 weeks gestation and prior to the onset of labor (Option 4). A stable client with no active bleeding and reassuring fetal status may be discharged home and managed in an outpatient setting (Option 3). However, the client must be closely monitored and instructed to return to the hospital immediately if bleeding recurs.

As pregnancy progresses, the placenta grows in size and can potentially migrate away from the cervical opening, resulting in complete resolution of the previa. Therefore, an additional ultrasound is usually performed around 36 weeks gestation to assess placental location (Option 1).

(Options 2 and 5) Clients with placenta previa should be instructed to remain on pelvic rest. Vaginal examinations, douching, and vaginal intercourse are contraindicated due to the risk of disruption of the placental vessels and subsequent hemorrhage. Modified bed rest (ie, decreasing any physical activity that could cause contractions) is also recommended.

Educational objective:
Clients with placenta previa are at risk for hemorrhage. Vaginal examinations are contraindicated, and pelvic rest is recommended to prevent disruption of placental vessels. A cesarean birth is planned prior to onset of labor.

Surgical debridement of an unstageable pressure injury involves using a scalpel to remove necrotic (eschar) or infected tissue from the wound to promote healing. The most appropriate room assignment for this client is Room C, as the client with a gastrointestinal bleed and nasogastric tube is the least susceptible to infection compared with the clients in Rooms A and B (Option 3).

(Option 1) Multiple myeloma is a cancer that involves proliferation of malignant plasma cells (monoclonal antibodies), which are ineffective in providing protection against infection and suppress normal bone marrow cell production (eg, erythrocytes, platelets, leukocytes). This client in Room A is especially vulnerable to infection due to immunosuppression related to the disease process and to drug therapy with corticosteroids.

(Option 2) The postoperative client should not be assigned to Room B with a client who has osteomyelitis, an infection of bone.

(Option 4) The client with influenza requires droplet precautions and would likely require a private room (Room D). Clients with severe disease (ie, requiring hospitalization) should receive antiviral medication (eg, zanamivir, oseltamivir) as they are at high risk for complications.

Educational objective:
A client undergoing an extensive surgical debridement for an infected pressure injury should not be assigned to a room with a client who is vulnerable to infection (eg, immunocompromised) or who has an active infection.

Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation.

Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death.

(Option 1) Avoiding high-sodium foods is important for blood pressure control but is not the most important advice for this client as consumption of these is not immediately life-threatening.

(Option 2) Dizziness is a side effect of clonidine. The nurse should teach the client to change positions slowly and sit for a few minutes before rising to prevent falls. Drowsiness is also quite common with clonidine. Clients should not use it with alcohol or central nervous system depressants. However, dizziness and drowsiness should diminish with continued use of the medication.

(Option 4) Dry mouth is a side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may be helpful for clients with dry mouth.

Educational objective:
Clonidine is a very potent antihypertensive. Abrupt discontinuation can result in serious rebound hypertensive crisis. Other common side effects of clonidine include dizziness, drowsiness, and dry mouth (the 3 Ds). Beta blockers, another class of blood pressure medications, can result in withdrawal symptoms if discontinued suddenly.

Mononucleosis is caused by the Epstein-Barr virus. It is typically seen in adolescence from the sharing of drinks, kissing, or other direct exposure to saliva. Symptoms may include fatigue, fever, sore throat, splenomegaly, hepatomegaly, and swollen lymph nodes. Antibiotic treatment is inappropriate for a viral infection. Inadvertent intake of antibiotics (amoxicillin) can cause a rash. Treatment for mononucleosis is management of symptoms and includes hydration, rest, control of pain, and reducing fever as necessary. Sore throat is treated with saline gargles or anesthetic troches.

Complications include airway obstruction (eg, stridor, difficult breathing) from swollen lymph nodes around the neck and severe abdominal pain (splenic rupture). These should be reported to the health care provider (HCP) immediately.

(Option 2) Ibuprofen or acetaminophen is appropriate treatment to control pain and manage fever in the child with mononucleosis. Aspirin should be avoided in children due to the risk of Reye syndrome.

(Option 3) Fatigue is a symptom of mononucleosis. Rest is very important in the care of a client with mononucleosis.

(Option 4) Mononucleosis may cause splenomegaly or hepatomegaly. Contact sports such as soccer should be avoided to prevent injury to the spleen or liver.

Educational objective:
Treatment for mononucleosis is largely symptomatic. It includes rest, hydration, pain control for sore throat, and fever reduction. Clients should avoid contact sports such as soccer to prevent injury to the spleen or liver. Breathing difficulty or abdominal pain should be reported to the HCP.

The concerns presented by this child's parent are suggestive of a developmental delay and very possibly autism spectrum disorder (ASD).

ASD is a complex neurodevelopmental disorder characterized by the onset of abnormal functioning before age 3. The 2 core symptoms of ASD are abnormalities in social interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. Social skills, especially communication, are delayed more significantly than other developmental functioning and are the focus during client assessment.

The vast majority of children diagnosed with ASD lack the acquisition of communication skills during the first 2 years of life. A healthy 2-year-old should have a vocabulary of about 300 words and should be able to string 2 or more words together in a meaningful phrase. Assessing this child's language abilities would be the priority.

(Option 2) Assessing any 2-year-old's progress in toilet training is appropriate. However, it is not the priority assessment given the parent's concerns.

(Option 3) A nutrition assessment is part of every well-child visit, but it is not the priority in this situation.

(Option 4) Although not the priority assessment, it would be important to ask the parent about the child's play activities. Children with ASD often have a restricted interest in and preoccupation with a single toy, exhibit repetitive behaviors when playing with the toy, and insist on the same play routine.

Educational objective:
The 2 core symptoms of autism spectrum disorder are abnormalities in social interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. Social skills, especially communication, are delayed more significantly than other developmental functioning.

Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet high in fiber-rich foods (eg, fruits, vegetables, legumes, whole grains) improves stool elimination, which helps prevent constipation and decreases the risk of colorectal cancer (Options 1 and 5).

Fiber-rich foods tend to have a low glycemic load (less sugar per serving) and are nutrient dense, yet they have lower caloric density. Clients may also experience increased satiety as fiber absorbs water and produces fullness. This may help reduce caloric intake, improve blood glucose control, and promote weight loss (Options 2 and 3).

Fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of dietary cholesterol that enters the bloodstream. Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis. A high intake of fiber-rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery disease and stroke (Option 4).

Educational objective:
Dietary fiber increases stool bulk and makes stool softer and easier to pass. A fiber-rich diet helps prevent constipation; decreases risk of colorectal cancer; promotes weight loss; improves blood glucose control; and decreases serum cholesterol levels, which reduces the risk of coronary artery disease and stroke.

Separation or stranger anxiety occurs when the primary caregivers leave the child in the care of others who are not familiar to the child. This behavior starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. Separation anxiety produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. However, this reaction is normal and resolves as the child approaches age 3 years.

A 3-month-old can be soothed by any comforting voice (Option 1).

(Option 2) A 3-month-old is not developmentally capable of fearing abandonment.

(Option 3) A 3-month-old might sense a parent's anxiety but is cognitively unable to process it.

(Option 4) A 3-month-old cannot tell time and would not understand the concept of returning later in the day.

Educational objective:
Separation anxiety starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. It produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. However, separation anxiety is normal and resolves by age 3 years.

Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (eg, St. John's wort), placing clients at risk for serotonin syndrome.

Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). The nurse should call this client back to investigate the symptoms further.

(Option 1) Panic attacks can be frightening but typically last less than 10 minutes. A panic attack following a stressful event does not pose an immediate risk; the request for a refill of alprazolam (benzodiazepine for acute anxiety relief) can wait.

(Option 3) Phenelzine is a monoamine oxidase inhibitor that has multiple food interactions (eg, foods containing tyramine), which can cause hypertensive crisis. This client needs further education to prevent this condition, but is asymptomatic and not in immediate danger.

(Option 4) Stimulants (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are commonly used for attention-deficit hyperactivity disorder (in both children and adults) and are commonly associated with insomnia, irritability, diminished appetite, weight loss, and headaches.

Educational objective:
Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (eg, St. John's wort), placing clients at risk for serotonin syndrome.

Additional Information
Management of Care
NCSBN Client Need

Pulmonary embolism (PE) is usually caused by a dislodged thrombus that travels through the pulmonary circulation, becomes lodged in a pulmonary vessel, and causes an obstruction to blood flow in the lung.

The nursing diagnosis of impaired gas exchange involves an alteration in the normal exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, resulting in inadequate oxygenation and hypoxemia (respiratory alkalosis, pO2 <80 mm Hg, restlessness, dyspnea, and tachycardia).

Impaired gas exchange related to a ventilation-perfusion (V/Q) imbalance is the highest priority nursing diagnosis. It addresses the most basic physiologic need—oxygen. Clients will not survive without adequate oxygenation.

(Options 1, 2, and 3) Activity intolerance, acute pain, and anxiety elicit autonomic responses (exertional discomfort, dyspnea, tachycardia) and are all appropriate nursing diagnoses. However, none are the highest priority or pose the greatest threat to survival.

Educational objective:
Activity intolerance, anxiety, acute pain, and impaired gas exchange are all appropriate nursing diagnoses to include in the plan of care for a client with PE. The highest priority nursing diagnosis is the one that poses the greatest threat to the client's survival.

Additional Information
Management of Care
NCSBN Client Need

Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components. Bowel sounds are normally intermittent (every 5-15 seconds), high-pitched, gurgling sounds that can be auscultated with the diaphragm of the stethoscope in all 4 quadrants. Cardiovascular bruits (swishing, humming, buzzing) are rarely benign and usually indicate arterial narrowing or dilation.

Procedures that require bowel manipulation cause a temporary halting of peristalsis (paralytic ileus) for the first 24-48 hours, resulting in absent bowel sounds (Option 1). For bowel sounds to be considered absent, the nurse must auscultate for 2-5 minutes in each quadrant. Peristalsis will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days. Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause absent bowel sounds.

(Option 2) Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting in borborygmi include gastroenteritis, diarrhea, and the early phases of mechanical obstruction.

(Option 3) High-pitched, gurgling sounds signify normal bowel sounds and are unlikely to be heard immediately following abdominal surgery.

(Option 4) A swishing, humming, or buzzing sound (bruit) may be cardiovascular in origin; a bruit indicates turbulent blood flow as with artery dilation (aneurysm) or narrowing (obstruction). A bruit can best be auscultated with the bell of the stethoscope.

Educational objective:
Bowel sounds following abdominal manipulation may be absent for 24-48 hours. Any disease process that causes an increase in peristalsis may cause borborygmi (loud, gurgling sounds). Swishing and humming sounds heard best with the bell of the stethoscope may be indicative of turbulent blood flow.

Latex allergy is an exaggerated immune-mediated reaction when one is exposed to products or dusts containing latex, a natural rubber used in many medical devices (eg, gloves, catheters, tape). Many people, particularly health care workers and individuals requiring chronic invasive procedures (eg, self-catheterization), develop latex allergy from repeated exposures.

When assessing for potential latex allergies, the nurse should inquire about the client's reactions to common latex-containing objects and potentially cross-allergenic products. Balloons commonly contain latex, and reports of lip swelling, itching, or hives after contact indicate a high risk for anaphylactic reactions with continued exposure (Option 5). Many food allergies (eg, avocado, banana, tomato) also increase the risk for latex allergy because the food proteins are similar to those found in latex (Option 3).

(Option 1) There is no documented cross-sensitivity reaction between ACE inhibitors (eg, lisinopril) and latex.

(Option 2) Epilepsy is not associated with an increased risk for latex allergy. However, clients who have spina bifida or who have undergone multiple surgeries are at increased risk.

(Option 4) Shellfish allergy was previously believed to be associated with allergy to iodine (CT contrast material), which has now been disproved. Shellfish allergy has no relationship to latex allergy.

Educational objective:
Latex allergy is an exaggerated immune reaction to exposure to latex-containing products (eg, gloves, catheters, tape). Risk factors include swelling, hives, or itching after exposure to common latex-containing products (eg, balloons); certain food allergies (eg, banana, avocado, tomato); and a history of multiple latex exposures (eg, self-catheterization, multiple surgeries).

Clozapine (Clozaril) is an atypical antipsychotic medication used to manage schizophrenia in clients who have not improved with other antipsychotic medications. Clozapine is highly effective at controlling schizophrenia; however, it has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease (myocarditis), and seizures.

Agranulocytosis (decreased neutrophils) increases the risk for infection. Clients require serial monitoring of white blood cell counts and frequent assessment for signs of infection (eg, sore throat, fever, flulike symptoms), which should be reported immediately to the health care provider (Option 2).

(Option 1) Weight gain is a common side effect. Clients should be educated about weight management.

(Option 3) Hypersalivation and drooling are common side effects. When excessive, they can occasionally pose risk for aspiration, especially while the client is sleeping. This is important but not an immediate priority. The side effect can be reduced by lowering the dose. The client should chew sugarless gum to promote swallowing and reduce drooling.

(Option 4) Many clients experience significant sedation when the medication is started. Most will develop tolerance to this and eventually improve.

Educational objective:
Clozapine, an atypical antipsychotic, is used to manage schizophrenia in clients who have not improved with other medications. Clozapine may cause agranulocytosis, which increases the risk of life-threatening infection. Clients receiving clozapine should be monitored for signs of infection (eg, fever, flulike symptoms).

Peripheral artery disease (PAD [previously called peripheral vascular disease]) refers to arteries that have thickened, have lost elasticity due to calcification of the artery walls, and are narrowed by atherosclerotic plaques (made up of fat and fibrin). Pain due to decreased blood flow is the most common symptom of PAD. Cramping pain in the muscles of the legs during exercise, known as intermittent claudication, is usually relieved with rest. However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that is worsened by elevating the legs and improved when the legs are dependent. Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen). Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. Clients should be advised that a progressive walking program will aid the development of collateral circulation.

(Options 1, 2, and 3) Chronic venous insufficiency refers to inadequate venous blood return to the heart. Too much venous blood remains in the lower legs, and venous pressure increases. This increased venous pressure inhibits arterial blood flow to the area, resulting in inadequate supply of oxygen and nutrients to area cells and the development of stasis ulcers, which are typically found around the medial side of the ankle. By the end of the day or after prolonged standing, the legs become edematous with dull pain due to venous engorgement. The skin of the lower leg becomes thick with a brown pigmentation.

Educational objective:
The pain of peripheral artery disease is arterial in nature and results from decreased blood flow to the legs. It is made worse with leg elevation. Arterial ulcers are formed at the most distal end of the body. Venous ulcers form over the medial malleolus, and compression bandaging is needed to reduce the pressure.

The charge nurse must know the UAP's level of knowledge and competency in relation to the task and be familiar with institutional policy and procedures before delegating the task. Routine tasks, such as taking vital signs, supervising ambulation, bed making, assisting with hygiene, and activities of daily living, can be delegated to an experienced UAP.

The charge nurse appropriately delegates the routine task of feeding to the UAP. The general procedure and safety principles associated with feeding (positioning, observations about swallowing, recording intake) do not change because of the client's diagnosis of dementia. Normal fasting blood glucose levels are 70-110 mg/dL (3.9-6.1 mmol/L).

(Option 1) It is not appropriate for the UAP to independently assist a client in ambulating for the first time following surgery as it requires assessment of potential postoperative complications and evaluation of ability to ambulate.

(Option 2) Initial teaching/explaining about the use of incentive spirometer is the sole responsibility of the registered nurse (RN).

(Option 4) Taking vital signs in an unstable newly postoperative client requires assessment of potential postoperative complications and is not appropriate to delegate to the UAP.

Educational objective:
The RN can delegate routine tasks such as taking vital signs, supervising ambulation, making beds, assisting with hygiene, and activities of daily living to the experienced UAP. Assessment, analysis of data, planning, teaching, and evaluation are the responsibilities of the RN.

Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy.

A teaching plan for a client prescribed INH includes the following:

Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity (Option 1)
Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy
Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH
Report changes in vision (eg, blurred vision, vision loss)
Report signs/symptoms of severe adverse effects such as:
Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) (Option 3)
Peripheral neuropathy (eg, numbness, tingling of extremities) (Options 4)
(Option 2) Rifampin, another antitubercular drug, often causes a red-orange discoloration of body fluids (ie, urine, sweat, saliva, tears). However, this effect is not associated with INH use.

(Option 5) Concurrent use of antacids containing aluminum decreases INH absorption. The medication may be taken with food if gastric irritation is a concern.

Educational objective:
Common potential side effects of INH include hepatotoxicity (eg, jaundice, vomiting, dark urine, fatigue) and peripheral neuropathy (eg, numbness, tingling of extremities). Clients should avoid alcohol use and aluminum-containing antacids, and report any experienced side effects to the health care provider immediately.

Asthma is a chronic inflammatory disease of the lungs in genetically susceptible children. Frequent cough, especially at night, is the warning signal that the child's airway is very sensitive to stimuli; it may be the only sign in "silent" asthma. Common triggers include indoor contaminants (eg, tobacco smoke, pet dander, cockroach feces), outdoor contaminants (eg, air pollution), and allergic disease (eg, hay fever, food allergies).

(Option 2) A red or pink butterfly rash across the cheeks and bridge of the nose is classic for systemic lupus erythematosus (SLE), an autoimmune disease that affects connective tissue. The child has no symptoms of SLE. Manifestations are acute (eg, nephritis, arthritis, vasculitis) or involve a gradual onset of nonspecific symptoms.

(Option 3) Celiac, or gluten-sensitive, enteropathy is a chronic malabsorption syndrome. There is intolerance for gluten, a protein found in wheat, barley, rye, and oats. This condition affects absorption of nutrients; it does not cause nausea.

(Option 4) Pyloric stenosis is a hypertrophy of the pylorus that results in stenosis of the passage between the stomach and the duodenum. Symptoms become evident 2-8 weeks after birth. It starts with occasional vomiting that eventually becomes forceful/projectile vomiting as the obstruction becomes complete. Dehydration and electrolyte imbalance result. The thickened pyloric muscle can sometimes be palpated and can be confirmed with ultrasound. This child is too old for this complication.

Educational objective:
Pediatric asthma can present as night coughing until the child vomits.

A once-in-a-lifetime pneumococcal vaccination is ineffective for preventing community-acquired pneumonia (CAP). The current guidelines for pneumococcal vaccination state that all adults age ≥65 should receive 2 pneumococcal vaccinations: PCV13, or 13-valent pneumococcal conjugate vaccine (Prevnar 13) followed by PPSV23, or 23-valent pneumococcal polysaccharide vaccine (Pneumovax 23) ≥1 year apart. In addition, pneumococcal pneumonia revaccination (PPSV23) is recommended after 5 years for clients who are immunocompromised, those with a splenectomy, and those who are ≥65 years old if the first dose was given before this age.

(Option 1) CAP often follows a viral illness; therefore, an annual influenza vaccination is an effective prevention strategy for CAP.

(Option 3) Smoking cessation is an effective prevention strategy for CAP. Smoking or exposure to secondhand smoke is a significant risk factor associated with pneumococcal infections, especially in individuals age ≥65.

(Option 4) Effective prevention strategies for CAP include using proper cough etiquette, practicing respiratory and hand hygiene, and avoiding crowds and contact with individuals with viral respiratory illnesses.

Educational objective:
Effective prevention strategies for CAP include smoking cessation, vaccination for influenza and pneumococcal pneumonia, avoidance of contact with individuals with viral respiratory illnesses, respiratory and hand hygiene practices, and use of proper cough etiquette.

Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic, inhaled medication used to control chronic obstructive pulmonary disease (COPD). It is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole.

Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client proper administration prior to the first dose, emphasizing that the capsule should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future appointments, the nurse should assess/reassess the client's ability to use this medication correctly.

(Option 2) Clients should rinse the mouth after using tiotropium and inhaled steroids (eg, beclomethasone, budesonide, fluticasone) to remove any medication remaining in the mouth, which decreases the risk of developing thrush.

(Option 3) Tiotropium is a controller medication for COPD with a peak effect of approximately 1 week; therefore, it should not be used as a rescue medication. Instead, short-acting bronchodilators (eg, albuterol and/or ipratropium) should be used for symptom rescue. Clients must discontinue ipratropium before taking tiotropium as both are anticholinergic.

(Option 4) Anticholinergic inhaled medications (eg, ipratropium, tiotropium, umeclidinium) do not reduce inflammation in the airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help dry up airway secretions.

Educational objective:
Tiotropium and umeclidinium are long-acting, 24-hour, anticholinergic medications. Ipratropium is a short-acting anticholinergic used as a rescue medication for COPD and asthma. Tiotropium is typically administered as a powder via a special inhaler.

Additional Information
Pharmacological and Parenteral Therapies
NCSBN Client Need