💊 A change in mood

💊 Isotretinoin is associated with serious psychiatric adverse effects, including depression, mood changes, anxiety, irritability, and suicidal thoughts.

💊 Adolescents taking isotretinoin should immediately report sadness, withdrawal, crying spells, hopelessness, aggressive behavior, or thoughts of self-harm.

💊 Mental health monitoring is important because emotional changes may occur even in clients without a prior psychiatric history.

💊 Family members should also observe for unusual behavior or personality changes during therapy.

💊 Because this adolescent already reports low self-esteem related to severe acne, careful emotional assessment is especially important during treatment.

💊 Mood changes are considered a serious adverse effect requiring immediate provider notification.

💊 Engagement in sexual activity

💊 Isotretinoin is highly teratogenic, meaning it can cause severe fetal abnormalities if pregnancy occurs during treatment.

💊 Even though the adolescent currently reports not being sexually active, the nurse must teach them to notify the provider immediately if sexual activity begins.

💊 Pregnancy prevention is a critical safety concern during isotretinoin therapy.

💊 Clients capable of pregnancy typically require regular pregnancy testing and strict contraceptive counseling while taking the medication.

💊 The provider may need to discuss birth control methods and additional pregnancy-prevention measures if sexual activity begins.

💊 Preventing fetal exposure to isotretinoin is one of the highest-priority teaching points for this medication.

❌ Dry mouth

❌ Dry mouth is a common expected side effect of isotretinoin therapy.

❌ Clients may also experience dry lips, dry skin, and skin flaking because the medication reduces sebaceous gland activity.

❌ Moisturizers, lip balm, and hydration are usually recommended to manage these effects.

❌ Although uncomfortable, dry mouth alone does not usually require immediate provider notification.

❌ The development of dry eyes

❌ Dry eyes commonly occur during isotretinoin treatment due to reduced oil production.

❌ Clients who wear contact lenses may experience increased irritation or discomfort.

❌ Artificial tears and eye lubrication may help relieve symptoms.

❌ This side effect is expected and does not typically require urgent reporting unless severe.

❌ Nausea

❌ Mild nausea may occur with many oral medications, including isotretinoin.

❌ Taking the medication with food may help decrease stomach upset.

❌ Severe abdominal pain or persistent vomiting would be more concerning for pancreatitis or liver complications.

❌ Mild nausea alone is not the highest-priority symptom requiring immediate notification.

❌ Sunburn

❌ Isotretinoin increases photosensitivity, making the skin more sensitive to sunlight.

❌ Clients should avoid excessive sun exposure and use sunscreen and protective clothing outdoors.

❌ Sunburn risk is expected during therapy and is managed through prevention teaching.

❌ While important, sunburn is not as urgent as mood changes or pregnancy risk.

❌ Decreased night vision

❌ Isotretinoin may affect night vision in some clients.

❌ Clients should use caution when driving or performing activities in low light.

❌ The nurse should reinforce safety precautions and monitoring of vision changes.

❌ However, pregnancy risk and psychiatric symptoms are the highest-priority immediate reporting concerns in this scenario.

❌ Worsening of acne

❌ Temporary worsening of acne can occur early in isotretinoin treatment before improvement begins.

❌ Clients should be taught that improvement may take several weeks to months.

❌ Skin dryness, peeling, and irritation are also expected during therapy.

❌ This finding alone does not require urgent provider notification unless severe.

❤️ A 1 kg (2.2 lb) weight gain in 24 hours is a significant finding in a client with heart failure because it usually indicates fluid retention.

❤️ In heart failure, the heart is unable to pump blood effectively, causing fluid to accumulate in the tissues and vascular system.

❤️ Rapid weight gain is one of the earliest and most reliable indicators of worsening fluid overload.

❤️ Excess fluid can lead to worsening edema, pulmonary congestion, shortness of breath, crackles, and decreased oxygenation.

❤️ The nurse should report this finding promptly because it may indicate worsening heart failure and the need for medication adjustment, such as increased diuretics.

❤️ Daily weights are more accurate than intake and output alone when monitoring fluid balance in heart failure clients.

❌ Oral intake of 300 mL in 8 hr

❌ A fluid intake of 300 mL over 8 hours is within the client’s prescribed fluid restriction limits.

❌ A 2,000 mL/day restriction allows approximately 666 mL every 8 hours.

❌ This intake does not indicate excessive fluid consumption.

❌ Urinary output of 420 mL in 8 hr

❌ A urinary output of 420 mL in 8 hours is generally considered adequate.

❌ Normal urine output is about 30 mL/hr or greater in adults.

❌ This finding does not suggest worsening fluid retention or kidney compromise.

❌ Intravenous intake of 240 mL in 8 hr

❌ IV intake of 240 mL in 8 hours is not excessive for a client on a 2,000 mL/day restriction.

❌ The nurse would still include IV fluids in the total intake calculation.

❌ This amount alone does not require immediate provider notification.

💊 Correct Answer: Lithium toxicity

💊 The client’s lithium level is 2.5 mEq/L, which is above the therapeutic range of 0.6 to 1.2 mEq/L.

💊 This level indicates toxicity, especially because the client is showing neurologic symptoms such as blurred vision and clonic jerking of the upper extremities.

💊 Lithium toxicity can occur when serum lithium rises due to dehydration, sodium imbalance, renal changes, or medication interactions.

💊 The client has very low fluid intake with high urine output, which can worsen dehydration and increase lithium concentration in the blood.

💊 Lisinopril can also increase lithium levels by reducing lithium clearance, making toxicity more likely.

💊 Lithium toxicity is dangerous because it can progress to confusion, severe tremors, seizures, coma, dysrhythmias, and kidney complications.

⚡ Blank 2: Seizure activity

⚡ Correct Answer: Seizure activity

⚡ The client should be monitored closely for seizure activity because severe lithium toxicity affects the central nervous system.

⚡ The presence of clonic jerking is already a warning sign of neuromuscular irritability and possible progression toward seizures.

⚡ A lithium level of 2.5 mEq/L is significantly elevated and can cause worsening neurologic impairment if not treated quickly.

⚡ The nurse should institute seizure precautions, maintain safety, monitor neurologic status, and notify the provider immediately of worsening symptoms.

⚡ Safety measures include padding side rails, keeping suction and oxygen available, lowering the bed, and reducing environmental stimulation.

⚡ Monitoring for seizures is the priority because neurologic complications from lithium toxicity can become life-threatening.

❌ Neuroleptic malignant syndrome

❌ Neuroleptic malignant syndrome is usually associated with antipsychotic medications and presents with high fever, severe muscle rigidity, altered mental status, and autonomic instability.

❌ This client is taking lithium, not a neuroleptic medication in the provided prescriptions.

❌ The warm, dry skin without rash and absence of extreme fever do not support this diagnosis.

❌ Urinary tract infection

❌ A urinary tract infection would more likely cause dysuria, frequency, urgency, fever, cloudy urine, positive nitrites, or leukocytes.

❌ The urinalysis shows clear urine and no nitrites, which does not support infection.

❌ The neurologic symptoms and elevated lithium level point strongly to lithium toxicity.

❌ Metabolic syndrome

❌ Metabolic syndrome is associated with obesity, insulin resistance, hypertension, dyslipidemia, and elevated blood glucose.

❌ The client’s fasting blood glucose is 80 mg/dL, which is within the expected range.

❌ Metabolic syndrome does not explain the acute blurred vision, clonic jerking, and elevated lithium level.

🚰 Review the need for the indwelling urinary catheter daily

🚰 Indwelling urinary catheters significantly increase the risk for catheter-associated urinary tract infections (CAUTIs) because they provide a direct pathway for microorganisms to enter the bladder.

🚰 The longer a catheter remains in place, the greater the risk that bacteria will travel through or around the catheter into the urinary tract.

🚰 This client has heart failure and requires accurate intake and output monitoring, which may justify temporary catheter use.

🚰 However, the nurse should reassess the need for the catheter every day and collaborate with the provider to remove it as soon as possible.

🚰 Early catheter removal is one of the most effective evidence-based strategies for reducing UTI risk.

🚰 The nurse should also monitor for signs of infection such as fever, cloudy urine, foul odor, suprapubic pain, or changes in mental status.

🚰 Use soap and water to provide perineal care

🚰 Daily perineal hygiene with soap and water helps reduce bacterial growth around the urethral opening and catheter insertion site.

🚰 Proper cleansing decreases the number of microorganisms that could potentially enter the bladder through the catheter.

🚰 Perineal care should be performed routinely and after bowel movements or episodes of incontinence.

🚰 The nurse should clean gently from front to back and avoid aggressive scrubbing, which may irritate tissue.

🚰 Antiseptic solutions are not routinely necessary and may increase irritation or tissue damage.

🚰 Maintaining skin cleanliness and dryness is especially important in clients with urinary incontinence because moisture promotes bacterial growth and skin breakdown.

🚰 Empty the drainage bag when it is half-full

🚰 The drainage bag should be emptied regularly before it becomes overly full or heavy.

🚰 A half-full bag helps maintain unobstructed urine flow and reduces the risk of urine backing up into the bladder.

🚰 Urinary stasis and reflux increase the chance that bacteria will enter the urinary tract and cause infection.

🚰 Overfilled drainage bags may also pull on the catheter tubing, causing urethral irritation or trauma.

🚰 The nurse should use a clean collection container and avoid touching the drainage spout to contaminated surfaces during emptying.

🚰 Hand hygiene before and after handling the drainage system is essential for infection prevention.

❌ Change the indwelling urinary catheter tubing every 3 days

❌ Routine scheduled tubing changes are not recommended because they interrupt the closed sterile drainage system.

❌ Every time the system is disconnected, bacteria can enter the tubing or catheter and increase infection risk.

❌ The catheter and tubing should only be changed when clinically indicated, such as leakage, obstruction, contamination, or system damage.

❌ Maintaining a continuously closed drainage system is one of the most important methods of preventing CAUTIs.

❌ The nurse should instead focus on keeping the tubing free of kinks and ensuring continuous urine drainage.

❌ Place the drainage bag on the bed when transporting the client

❌ The drainage bag should always remain below the level of the bladder to prevent urine reflux.

❌ Placing the drainage bag on the bed increases the risk that urine will flow backward into the bladder, carrying bacteria with it.

❌ Backflow of contaminated urine significantly increases UTI risk.

❌ The drainage bag should also never touch the floor because the floor is considered contaminated.

❌ During transport, the nurse should secure the drainage bag below bladder level while maintaining gravity drainage.

❌ Encourage the client to drink 3000 mL of fluid daily

❌ This client has a prescribed fluid restriction of 1000 mL/day because of heart failure.

❌ Excessive fluid intake would worsen fluid overload, pulmonary congestion, edema, and cardiac workload.

❌ Although increased hydration may help prevent UTIs in some clients, it is not appropriate when fluid restriction is ordered.

❌ The client already demonstrates signs of volume overload, including bilateral crackles and 3+ pitting edema.

❌ The nurse must balance urinary health with the more urgent need to manage heart failure safely.

💧 A paracentesis is a procedure used to remove fluid from the peritoneal cavity, commonly for ascites related to liver disease, cancer, or abdominal conditions.

💧 The nurse should weigh the client before the procedure because comparing pre- and post-procedure weights helps evaluate the amount of fluid removed and the effectiveness of treatment.

💧 Baseline abdominal girth measurements and vital signs are also important because large-volume fluid removal can affect hemodynamic stability.

💧 The nurse should monitor for complications such as hypotension, bleeding, hypovolemia, electrolyte imbalance, and infection after the procedure.

💧 Accurate intake and output monitoring may also be required, especially if large amounts of fluid are removed.

💧 Daily weight is one of the most reliable indicators of fluid status changes in clients with ascites.

❌ Place the client in supine position.

❌ The client is usually positioned in high Fowler’s or upright position during paracentesis.

❌ Upright positioning allows fluid to collect in the lower abdomen, making drainage easier and safer.

❌ A supine position does not promote optimal fluid pooling for the procedure.

❌ Ensure the client has a full bladder.

❌ The client should empty the bladder before the procedure to reduce the risk of accidental bladder puncture.

❌ A full bladder increases the risk of injury during needle insertion.

❌ The nurse may assist the client to void immediately before the procedure.

❌ Obtain a creatinine level.

❌ Creatinine monitoring may be useful in some conditions, but it is not the primary nursing preparation action listed for paracentesis.

❌ The priority nursing preparation includes weighing the client, obtaining baseline abdominal girth, assisting with positioning, and ensuring bladder emptying.

❌ Creatinine does not directly guide routine preparation for fluid removal.

🧤 Gloves are considered the most contaminated piece of personal protective equipment because they come into direct contact with body fluids, secretions, contaminated surfaces, and microorganisms.

🧤 Removing the gloves first helps prevent the spread of pathogens to the face, clothing, or clean body areas during PPE removal.

🧤 The nurse should remove gloves carefully by grasping the outside edge near the wrist and turning them inside out while removing them.

🧤 Proper glove removal reduces contamination of the hands and decreases the risk of healthcare-associated infections.

🧤 After glove removal, the nurse should continue removing the remaining PPE in the correct order and perform hand hygiene immediately after all equipment is removed.

🧤 Correct doffing technique is essential because improper PPE removal is a common cause of self-contamination in healthcare settings.

❌ Remove mask first.

❌ The mask should not be removed first because the gloves are still contaminated.

❌ Touching the face or mask with contaminated gloves can transfer microorganisms to the mucous membranes.

❌ Masks are generally removed later in the PPE removal process after contaminated items are removed.

❌ Remove protective eyewear first.

❌ Protective eyewear should remain in place while heavily contaminated items such as gloves are removed.

❌ Removing eyewear first increases the risk of contamination to the eyes and face.

❌ Eye protection is typically removed after gloves and gown have been removed safely.

❌ Remove gown first.

❌ Although the gown is contaminated, the gloves are usually considered more heavily contaminated.

❌ Gloves are removed first to decrease the spread of pathogens while handling the gown.

❌ PPE removal should follow a sequence that minimizes contamination risk.

🟢 Meconium aspiration syndrome

🟢 The infant is post-term at 42 weeks, which increases the risk for fetal stress and passage of meconium before birth.

🟢 The record shows late decelerations, progressing from occasional late decelerations to late decelerations with each contraction, which suggests possible uteroplacental insufficiency and fetal hypoxia.

🟢 At 0945, the provider performs an amniotomy and notes thick green amniotic fluid, which indicates meconium-stained fluid.

🟢 If the newborn gasps before or during birth, meconium can be inhaled into the lungs and cause airway obstruction, inflammation, and respiratory distress.

🟢 This places the newborn at risk for meconium aspiration syndrome, especially with thick meconium and fetal stress.

🟢 Macrosomia

🟢 A post-term infant is at increased risk for being larger than expected, especially when pregnancy continues beyond 40 weeks.

🟢 Macrosomia means the newborn has an excessive birth weight, commonly greater than 4,000 g to 4,500 g, depending on the definition used.

🟢 A larger infant increases the risk for delivery complications such as shoulder dystocia, birth trauma, prolonged labor, and neonatal hypoglycemia.

🟢 Even though the record does not provide estimated fetal weight, the post-term status makes macrosomia one of the risk concerns from the available choices.

🟢 The nurse should anticipate careful newborn assessment for size, birth injury, glucose instability, and respiratory status.

❌ Bronchopulmonary dysplasia

❌ Bronchopulmonary dysplasia is most commonly associated with prematurity, prolonged oxygen therapy, and mechanical ventilation.

❌ This infant is post-term, not premature.

❌ The record does not indicate prolonged ventilator support or chronic lung injury risk.

❌ Intraventricular hemorrhage

❌ Intraventricular hemorrhage is most commonly associated with very preterm infants due to fragile cerebral blood vessels.

❌ This infant is 42 weeks gestation, so this is not the expected risk from the given findings.

❌ The key risks in this scenario are related to post-term status and meconium-stained fluid.

⚠️ Potential Condition: Compartment syndrome

⚠️ Compartment syndrome occurs when swelling or bleeding increases pressure inside a closed muscle compartment.

⚠️ This pressure compresses nerves and blood vessels, reducing circulation and oxygen delivery to the affected limb.

⚠️ The client’s findings strongly support compartment syndrome: numbness, tingling, increased pain from 4/10 to 9/10, cool hard skin, edema, and decreased right pedal pulse.

⚠️ Pain that is severe and worsening after a fracture repair is a major warning sign.

⚠️ This is an emergency because untreated compartment syndrome can lead to nerve damage, tissue death, and loss of limb function.

✅ Action: Prepare the client for a fasciotomy

⚠️ A fasciotomy is the definitive treatment for severe compartment syndrome.

⚠️ During this procedure, the provider surgically opens the fascia to relieve pressure inside the muscle compartment.

⚠️ Releasing the pressure restores blood flow and prevents permanent muscle and nerve damage.

⚠️ The nurse should prepare the client for urgent intervention because delaying treatment can cause irreversible ischemia.

⚠️ This action directly addresses the underlying problem of increasing compartment pressure.

✅ Action: Loosen surgical dressings

⚠️ Loosening the surgical dressing helps reduce external pressure on the affected extremity.

⚠️ A tight dressing can worsen swelling and further restrict circulation.

⚠️ The nurse should not remove surgical dressings completely unless directed, but loosening restrictive dressings is an appropriate immediate action.

⚠️ This can temporarily improve perfusion while preparing for provider evaluation or fasciotomy.

⚠️ The nurse should continue frequent neurovascular checks after loosening the dressing.

✅ Parameter to Monitor: Increasing pain level

⚠️ Increasing pain level is one of the earliest and most important signs of compartment syndrome.

⚠️ Pain is often severe, progressive, and not relieved by usual pain medication or repositioning.

⚠️ The client’s pain increased from 4/10 to 9/10, which is a major change from baseline.

⚠️ Worsening pain suggests increasing pressure and reduced tissue oxygenation.

⚠️ Monitoring pain trends helps determine whether the condition is worsening or improving after interventions.

✅ Parameter to Monitor: Capillary refill

⚠️ Capillary refill helps assess peripheral circulation in the affected extremity.

⚠️ Delayed capillary refill can indicate decreased blood flow due to swelling and compartment pressure.

⚠️ The nurse should compare capillary refill between both lower extremities.

⚠️ Capillary refill should be monitored along with pulses, temperature, color, sensation, and movement.

⚠️ Worsening capillary refill suggests impaired perfusion and requires urgent follow-up.

❌ Osteomyelitis

❌ Osteomyelitis is a bone infection and usually develops over more time.

❌ Expected findings include fever, elevated WBC count, localized warmth, drainage, and persistent bone pain.

❌ This client’s sudden neurovascular changes and severe pain are more consistent with compartment syndrome.

❌ Cellulitis

❌ Cellulitis is a skin and soft tissue infection.

❌ It usually causes redness, warmth, tenderness, swelling, and sometimes fever.

❌ The client’s limb is cool, hard, numb, and painful, which points more toward impaired circulation than infection.

❌ Deep vein thrombosis

❌ Deep vein thrombosis can cause calf pain, swelling, warmth, and tenderness.

❌ DVT does not usually cause severe neurovascular compromise with numbness, tingling, cool hard skin, and decreased pulses.

❌ The rapid increase in pain and circulation changes after fracture repair are more concerning for compartment syndrome.

❌ Other actions

❌ Prepare for administration of corticosteroids

❌ Corticosteroids do not relieve the pressure inside the muscle compartment.

❌ They are not the priority treatment for compartment syndrome.

❌ Prepare to insert a peripherally inserted central catheter

❌ A PICC line is not needed to treat acute compartment syndrome.

❌ This action delays urgent limb-saving care.

❌ Draw blood for PT and PTT

❌ PT and PTT assess clotting status, but they do not treat the immediate problem.

❌ The priority is relieving pressure and restoring perfusion.

❌ Other parameters

❌ WBC count

❌ WBC count is useful for infection monitoring, not the best indicator of compartment syndrome progression.

❌ Fever

❌ Fever supports infection, but this client’s problem is acute neurovascular compromise.

❌ Level of consciousness

❌ Level of consciousness is important generally, but it is not the most direct parameter for limb compartment pressure.

🌙 A light bedtime snack may promote sleep by preventing nighttime hunger and stabilizing blood glucose during the night.

🌙 Foods containing tryptophan or complex carbohydrates, such as milk, crackers, or toast, may help support relaxation and sleep onset.

🌙 Older adults commonly experience changes in sleep patterns, including lighter sleep and more frequent awakenings.

🌙 Establishing healthy sleep hygiene practices can improve sleep quality and nighttime rest.

🌙 The nurse should also encourage a consistent sleep schedule, limiting caffeine late in the day, and creating a quiet sleep environment.

❌ Take a 1-hr nap during the day.

❌ Long daytime naps can interfere with nighttime sleep and make falling asleep more difficult.

❌ If naps are needed, they should usually be short and earlier in the day.

❌ Excessive daytime sleeping may worsen insomnia patterns.

❌ Perform exercises prior to bedtime.

❌ Vigorous exercise immediately before bed can increase stimulation and delay sleep onset.

❌ Exercise is beneficial earlier in the day but may interfere with relaxation if done too close to bedtime.

❌ Increased heart rate and alertness can make sleep more difficult.

❌ Stay in bed at least 1 hr if unable to fall asleep.

❌ Remaining awake in bed for long periods can increase frustration and anxiety about sleep.

❌ If unable to sleep, the client should get up briefly and perform a relaxing activity until drowsy.

❌ The bed should be associated with sleep rather than wakefulness.