J.D., age 45, noticed a red spot on his calf after a day of yard work. It did not bother him at first, and he thought it may have been a spider bite. The next morning, he noticed that the spot had grown to the size of a nickel, and it was hardened and very painful. His wife asked him to get it checked, but he said he could take care of it, and tried to pierce it with a pocketknife he had sterilized with a match in an attempt to drain it. Nothing came out when he tried this, so he put some antibacterial ointment over it and covered it with a bandage. Two days later, he realized that the wound was draining yellowish fluid, and the skin around the wound was red and tender. He decides to see his healthcare provider (HCP), who told J.D. that he had developed cellulitis around the wound, which was infected.

J.D. is sent home with a prescription for doxycycline capsules. Two days later, the results from the cultures are reported to the HCP. J.D. is asked to go to the hospital for treatment for an MRSA infection.

Wound Culture and Sensitivity Report:

$$\begin{array}{ll}\text { Staphylococcus aureus (MRSA) } & \geq \mathbf{1 0 0 , 0 0 0} \text { colonies } \\ \text { Amoxicillin } & \mathrm{R} \\ \text { Ceftriaxone } & \mathrm{R} \\ \text { Ciprofloxacin } & \mathrm{R} \\ \text { Clindamycin } & \mathrm{R} \\ \text { Doxycycline } & \mathrm{R} \\ \text { Levofloxacin } & \mathrm{R} \\ \text { Linezolid } & \mathrm{S} \\ \text { Trimethoprim-sulfa } & \mathrm{R} \\ \text { Vancomycin } & \mathrm{R}\end{array}$$

Anaerobic Culture:

No growth after 2 days

Contact Precautions are implemented. In addition to intravenous linezolid antibiotic treatment, the HCP performs an incision and drainage procedure. Wound care is ordered every 12 hours with sterile normal saline wet-to-dry dressings. Which nursing actions are appropriate to delegate to the UAP? Select all that apply.

a. Taking vital signs b. Assessment of the wound c. Obtaining a wound culture d. Teaching about wound care e. Changing the sterile dressing f. Maintaining contact precautions

In the earlier exercise, what is the probability that exactly 25 students you survey prefer an upgraded model?

J.D., age 45, noticed a red spot on his calf after a day of yard work. It did not bother him at first, and he thought it may have been a spider bite. The next morning, he noticed that the spot had grown to the size of a nickel, and it was hardened and very painful. His wife asked him to get it checked, but he said he could take care of it, and tried to pierce it with a pocketknife he had sterilized with a match in an attempt to drain it. Nothing came out when he tried this, so he put some antibacterial ointment over it and covered it with a bandage. Two days later, he realized that the wound was draining yellowish fluid, and the skin around the wound was red and tender. He decides to see his healthcare provider (HCP), who told J.D. that he had developed cellulitis around the wound, which was infected.

J.D. is sent home with a prescription for doxycycline capsules. Two days later, the results from the cultures are reported to the HCP. J.D. is asked to go to the hospital for treatment for an MRSA infection.

Wound Culture and Sensitivity Report:

$$\begin{array}{ll}\text { Staphylococcus aureus (MRSA) } & \geq \mathbf{1 0 0 , 0 0 0} \text { colonies } \\ \text { Amoxicillin } & \mathrm{R} \\ \text { Ceftriaxone } & \mathrm{R} \\ \text { Ciprofloxacin } & \mathrm{R} \\ \text { Clindamycin } & \mathrm{R} \\ \text { Doxycycline } & \mathrm{R} \\ \text { Levofloxacin } & \mathrm{R} \\ \text { Linezolid } & \mathrm{S} \\ \text { Trimethoprim-sulfa } & \mathrm{R} \\ \text { Vancomycin } & \mathrm{R}\end{array}$$

Anaerobic Culture:

No growth after 2 days

Contact Precautions are implemented. In addition to intravenous linezolid antibiotic treatment, the HCP performs an incision and drainage procedure. Wound care is ordered every 12 hours with sterile normal saline wet-to-dry dressings. You are about to enter J.D.'s room to give the IV linezolid. Which measures are appropriate for Contact Precautions for wound MRSA? Select all that apply.

a. Donning gloves b. Wearing a gown c. Wearing eye protection d. Wear a mask to prevent inhalation of droplets. e. Handwashing before entering and upon leaving the patient's room.

J.D., age 45, noticed a red spot on his calf after a day of yard work. It did not bother him at first, and he thought it may have been a spider bite. The next morning, he noticed that the spot had grown to the size of a nickel, and it was hardened and very painful. His wife asked him to get it checked, but he said he could take care of it, and tried to pierce it with a pocketknife he had sterilized with a match in an attempt to drain it. Nothing came out when he tried this, so he put some antibacterial ointment over it and covered it with a bandage. Two days later, he realized that the wound was draining yellowish fluid, and the skin around the wound was red and tender. He decides to see his health care provider (HCP), who told J.D. that he had developed cellulitis around the wound, which was infected. What is cellulitis? What contributed to the development of cellulitis in J.D.'s situation?

J.D., age 45, noticed a red spot on his calf after a day of yard work. It did not bother him at first, and he thought it may have been a spider bite. The next morning, he noticed that the spot had grown to the size of a nickel, and it was hardened and very painful. His wife asked him to get it checked, but he said he could take care of it, and tried to pierce it with a pocketknife he had sterilized with a match in an attempt to drain it. Nothing came out when he tried this, so he put some antibacterial ointment over it and covered it with a bandage. Two days later, he realized that the wound was draining yellowish fluid, and the skin around the wound was red and tender. He decides to see his healthcare provider (HCP), who told J.D. that he had developed cellulitis around the wound, which was infected.

J.D. is sent home with a prescription for doxycycline capsules. Two days later, the results from the cultures are reported to the HCP. J.D. is asked to go to the hospital for treatment for an MRSA infection.

Wound Culture and Sensitivity Report:

$$\begin{array}{ll}\text { Staphylococcus aureus (MRSA) } & \geq \mathbf{1 0 0 , 0 0 0} \text { colonies } \\ \text { Amoxicillin } & \mathrm{R} \\ \text { Ceftriaxone } & \mathrm{R} \\ \text { Ciprofloxacin } & \mathrm{R} \\ \text { Clindamycin } & \mathrm{R} \\ \text { Doxycycline } & \mathrm{R} \\ \text { Levofloxacin } & \mathrm{R} \\ \text { Linezolid } & \mathrm{S} \\ \text { Trimethoprim-sulfa } & \mathrm{R} \\ \text { Vancomycin } & \mathrm{R}\end{array}$$

Anaerobic Culture:

No growth after 2 days

Explain the "R" and the "S" results on the culture report. Which drug will be chosen to treat J.D.'s infection, based on the report?

Will $24.7\times10^{-3}$ be greater than or less than zero? Explain.

Identify which value represents the sample mean and which value represents the claimed population mean.

(a) American households spent an average of about $\$ 52$ in 2007 on Halloween merchandise such as costumes, decorations and candy. To see if this number had changed, researchers conducted a new survey in 2008 before industry numbers were reported. The survey included 1,500 households and found that average Halloween spending was $\$ 58$ per household.

(b) The average GPA of students in 2001 at a private university was 3.37. A survey on a sample of 203 students from this university yielded an average GPA of $3.59$ in Spring semester of 2012.

J.D., age 45, noticed a red spot on his calf after a day of yard work. It did not bother him at first, and he thought it may have been a spider bite. The next morning, he noticed that the spot had grown to the size of a nickel, and it was hardened and very painful. His wife asked him to get it checked, but he said he could take care of it, and tried to pierce it with a pocketknife he had sterilized with a match in an attempt to drain it. Nothing came out when he tried this, so he put some antibacterial ointment over it and covered it with a bandage. Two days later, he realized that the wound was draining yellowish fluid, and the skin around the wound was red and tender. He decides to see his healthcare provider (HCP), who told J.D. that he had developed cellulitis around the wound, which was infected.

J.D. is sent home with a prescription for doxycycline capsules. Two days later, the results from the cultures are reported to the HCP. J.D. is asked to go to the hospital for treatment for an MRSA infection.

Wound Culture and Sensitivity Report:

$$\begin{array}{ll}\text { Staphylococcus aureus (MRSA) } & \geq \mathbf{1 0 0 , 0 0 0} \text { colonies } \\ \text { Amoxicillin } & \mathrm{R} \\ \text { Ceftriaxone } & \mathrm{R} \\ \text { Ciprofloxacin } & \mathrm{R} \\ \text { Clindamycin } & \mathrm{R} \\ \text { Doxycycline } & \mathrm{R} \\ \text { Levofloxacin } & \mathrm{R} \\ \text { Linezolid } & \mathrm{S} \\ \text { Trimethoprim-sulfa } & \mathrm{R} \\ \text { Vancomycin } & \mathrm{R}\end{array}$$

Anaerobic Culture:

No growth after 2 days

Contact Precautions are implemented. In addition to intravenous linezolid antibiotic treatment, the HCP performs an incision and drainage procedure. Wound care is ordered every 12 hours with sterile normal saline wet-to-dry dressings.

After 7 days of IV antibiotic therapy, the wound shows signs of healing, and J.D. is prescribed an oral antibiotic for the next 14 days. You are providing teaching about oral antibiotic therapy and wound care. Which statement by J.D. reflects a correct understanding of antibiotic therapy?

a. "I will finish this prescription of antibiotics." b. "I will stop the antibiotic when the wound is healed." c. "If I have bad side effects, I will stop taking the antibiotic and let the doctor know at my next visit." d. "I will stop taking the antibiotic when the wound is healed, but start again if the infection returns."

Which neurotransmitter is selectively blocked by the antidepressant effect of citalopram?

Three-year-old C.E. is admitted to the emergency department fast-track clinic. Her mother tells the nurse that C.E. has had a low-grade fever for 2 days and is complaining frequently of ear pain and a sore throat. C.E.'s mother also notes that C.E. has been coughing and is a little hoarse. C.E.'s mother states that C.E.'s appetite has been "off," but she has been drinking and using the bathroom as usual. As you get C.E. settled in the exam room, you suspect C.E. may have otitis media (OM).

You continue to obtain a history from C.E.'s mother and learn C.E. has had "ear problems" and throat infections since she was a baby. She is in daycare each weekday, the father smokes outside of the house, and there is a family history of seasonal allergies. C.E. is allergic to penicillin. Her weight is $14 \mathrm{~kg}$ (31 lbs).

The primary care provider (PCP) diagnoses C.E. with bilateral AOM and strep pharyngitis. C.E. is given a prescription for Augmentin $600 \mathrm{mg}$ twice daily $P O \times 7$ days and her mother is instructed to give acetaminophen $240 \mathrm{mg}$ every 4 hours as needed for pain. She is to be discharged to home with instructions to follow up with the ear, nose, and throat (ENT) specialist. C.E.s mother is given a new prescription for azithromycin (Zithromax) PO $160 \mathrm{mg} /$ day $\times 5$ days. Azithromycin is dispensed as $200 \mathrm{mg} / 5 \mathrm{~mL}$.

C.E.'s mother takes C.E. to an ENT specialist. It is determined that her enlarged tonsils might be contributing to the frequent throat and ear infections, and a tonsillectomy and adenoidectomy (T&A) is scheduled. She is admitted postoperatively for 24-hour observation. After the surgery, the postoperative nurse receives C.E. in the short-stay unit from the postanesthesia care unit (PACU). C.E. is awake and alert, bilateral breath sounds are clear, and her $\mathrm{O}_2$ saturation is 98% on room air. She has tolerated sips of clear fluids, and her parents are with her. You are reviewing discharge instructions with C.E.'s mother. She asks, "How would I know if we need to come back?" Discuss common findings and when C.E.'s mother would need to seek immediate medical attention for C.E.

J.J., a 79-year-old woman with a history of COPD and renal insufficiency, was hospitalized for pneumonia for over a month. While hospitalized, she received intravenous clindamycin and steroids. She was discharged a week ago on oral antibiotics and steroids. This morning, she developed severe, watery diarrhea that has a strong odor and abdominal pain. This evening, her daughter took her to the emergency department because J.J. had become extremely weak and drowsy, with some confusion. Her vital signs are BP 100/68, P 118, R 24, T 100.5 F $\left(38.1^{\circ} \mathrm{C}\right)$. Her daughter stated, "All of a sudden she had terrible diarrhea, about 8 or 9 times, and she said her belly hurt. She hasn't eaten a thing all day, and I could not get her to drink anything." An IV of 0.9% normal saline at 125 mL/hr was started.

Physician's Orders:

Normal saline IV at $125 \mathrm{~mL} / \mathrm{hr}$ Obtain stool specimen for culture, O&P and C, Diff PCR assay $\mathrm{CBC}$, basic metabolic panel Admit to the medical-surgical department Clear liquids as tolerated BRP with assistance only

The Clostridium difficile PCR results are positive. The hospitalist visits J.J. and tells her daughter that JJ. has an antibiotic-associated C. difficile infection (CDI). The hospitalist orders vancomycin, $250 \mathrm{mg}$ PO 4 times a day. When the nurse comes in to give J.J. the first dose, her daughter asks, "If this was caused by an antibiotic, why is she getting another antibiotic now?" J.J.'s daughter asks, "Can you give her some medicine to stop diarrhea?" What is your response?

M.R., who is 81 years old, lives alone in a senior citizens' apartment complex. After she missed several planned holiday activities, and a neighbor knocked on her door to check on her. M.R. answered the door and said that she has had a cold for 4 days and did not want to spread it to others. She said, "It happened so fast, and it just won't go away. It seems to be getting worse no matter what I do." She said she felt very achy and weak, with a headache, and has had no appetite, but did not want to bother her son, who is very busy with his job. M.R.'s neighbor convinced her to call her healthcare provider (HCP), whose office is in the same building. The nurse at the office asked M.R. to come immediately for a visit. When she arrived at the office, the HCP called for an ambulance to take M.R. to the hospital. You place a mask on M.R. in anticipation that she may have influenza. M.R. has a history of hyperlipidemia and osteoarthritis in her knees.

M.R. is admitted to a general medical unit and placed on droplet precautions. She is instructed to remain on bed rest with bathroom privileges, and "Fall Risk" measures are posted because of her weakness. An IV of $\mathrm{D}_5 1 / 2 \mathrm{NS}$ at $75 \mathrm{~mL} / \mathrm{hr}$ is started. In addition to her home medication for hyperlipidemia, other orders include acetaminophen, $650 \mathrm{mg}$ PO every 4 hours as needed for pain or for temperature over $101^{\circ} \mathrm{F}\left(38.3^{\circ} \mathrm{C}\right)$. Her vital signs are BP 110/72, P 110, R 13, T 102.4 $4^{\circ} \mathrm{F}\left(39.1^{\circ} \mathrm{C}\right)$. She is told by the admitting HCP that she most likely has the flu.

The HCP also orders oseltamivir (Tamiflu), $75 \mathrm{mg} \mathrm{PO}$ twice daily for 5 days. M.R. expresses relief that she is receiving this drug because "it will cure the flu." Specify the potential complications that may occur in a person with influenza.

Three-year-old C.E. is admitted to the emergency department fast-track clinic. Her mother tells the nurse that C.E. has had a low-grade fever for 2 days and is complaining frequently of ear pain and a sore throat. C.E.'s mother also notes that C.E. has been coughing and is a little hoarse. C.E.'s mother states that C.E.'s appetite has been "off," but she has been drinking and using the bathroom as usual. As you get C.E. settled in the exam room, you suspect C.E. may have otitis media (OM).

You continue to obtain a history from C.E.'s mother and learn C.E. has had "ear problems" and throat infections since she was a baby. She is in daycare each weekday, the father smokes outside of the house, and there is a family history of seasonal allergies. C.E. is allergic to penicillin. Her weight is $14 \mathrm{~kg}$ (31 lbs).

The primary care provider (PCP) diagnoses C.E. with bilateral AOM and strep pharyngitis. C.E. is given a prescription for Augmentin $600 \mathrm{mg}$ twice daily $P O \times 7$ days and her mother is instructed to give acetaminophen $240 \mathrm{mg}$ every 4 hours as needed for pain. She is to be discharged to home with instructions to follow up with the ear, nose, and throat (ENT) specialist. C.E.s mother is given a new prescription for azithromycin (Zithromax) PO $160 \mathrm{mg} /$ day $\times 5$ days. Azithromycin is dispensed as $200 \mathrm{mg} / 5 \mathrm{~mL}$.

C.E.'s mother takes C.E. to an ENT specialist. It is determined that her enlarged tonsils might be contributing to the frequent throat and ear infections, and a tonsillectomy and adenoidectomy (T&A) is scheduled. She is admitted postoperatively for 24-hour observation. After the surgery, the postoperative nurse receives C.E. in the short-stay unit from the postanesthesia care unit (PACU). C.E. is awake and alert, bilateral breath sounds are clear, and her $\mathrm{O}_2$ saturation is 98% on room air. She has tolerated sips of clear fluids, and her parents are with her. C.E. is able to verbalize discomfort to you and her mother. Which pain rating scales would be most appropriate? Explain your answer.

a. 1 to 10 scale b. Neonatal Infant Pain Scale (NIPS) c. Oucher or Wong-Baker FACES Pain Rating Scale d. Face, Legs, Activity, Cry, Consolability (FLACC) scale

T.B. is a 65 -year-old retiree who is admitted to your unit from the emergency department (ED). On arrival, you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid back as a deep, sharp, boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but "none as bad as this." He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fried fish and chips at a fast-food restaurant earlier today. He is not happy to be in the hospital and is grumpy that his daughter insisted on taking him to the ED for evaluation.

After orienting him to the room, you perform your physical assessment. The findings are as follows: He is awake, alert, and oriented $\times 3$, and he moves all extremities well. He is restless, constantly shifting his position, and complains of fatigue. Breath sounds are clear to auscultation. Heart sounds are clear with no murmur or rub noted and with a regular rhythm. His abdomen is flat, slightly rigid, and very tender to palpation throughout, especially in the RUQ; bowel sounds are present. He reports having light-colored stools for 1 week. The patient voids dark amber urine but denies dysuria. Skin and sclera are jaundiced. Admission vital signs are blood pressure 164/100, pulse of 132, respiration of 26, the temperature of $100^{\circ} \mathrm{F}$ (37.8 $\left.{ }^{\circ} \mathrm{C}\right), \mathrm{Spo}_2$ 96% on 2 L of oxygen by nasal cannula.

T.B.'s abdominal ultrasound demonstrates several retained stones in the common bile duct and a stone filled gallbladder. T.B. is admitted to your floor, placed on nothing by mouth (NPO) status, and scheduled to undergo endoscopic retrograde cholangiopancreatography (ERCP) that afternoon. T.B.'s other lab results are posted, and you review them.

Preoperative Laboratory Test Results:

$$\begin{array}{ll}\text { WBC } & 11,900 / \mathrm{mm}^3\left(11.9 \times 10^9 / \mathrm{L}\right) \\ \text { Hgb } & 14.3 \mathrm{~g} / \mathrm{dL}(143 \mathrm{~g} / \mathrm{L}) \\ \text { Hct } & 43 \% \\ \text { Platelets } & 250,000 / \mathrm{mm}^3\left(250 \times 10^9 / \mathrm{L}\right) \\ \text { ALT } & 200 \mathrm{units} / \mathrm{L} \\ \text { AST } & 260 \mathrm{units} / \mathrm{L} \\ \text { ALP } & 450 \mathrm{units} / \mathrm{L} \\ \text { Total bilirubin } & 4.8 \mathrm{mg} / \mathrm{dL}(82 \mathrm{mcmol} / \mathrm{L}) \\ \text { PT/INR } & 11.5 \mathrm{sec} / 1.0 \\ \text { Amylase } & 50 \text { units } / \mathrm{L} \\ \text { Lipase } & 23 \text { units } / \mathrm{L} \\ \text { Urinalysis } & \text { Negative }\end{array}$$

T.B. undergoes the ERCP, and stones and bile are released; however, imaging reveals that a stone is still retained within the cystic duct and multiple stones remain within the gallbladder itself. Surgical consultation is obtained, and laparoscopic cholecystectomy ("lap choley") is planned.

T.B. undergoes a successful laparoscopic cholecystectomy the next morning. An intraoperative cholangiogram shows that the ducts are finally cleared of stones at the conclusion of the surgery. When he returns to the nursing unit, his stomach is soft but quite distended. His wife asks you whether anything is wrong.

The next day, you prepare for the first dressing change as ordered by the surgeon. When you remove the tape the next day to change the dressing, you note that the skin is red and blistered underneath. Otherwise, he is doing well; his VS are $128 / 72,80,16,99.8^{\circ} \mathrm{F}\left(37.7^{\circ} \mathrm{C}\right)$, and $\mathrm{Spo}_2$ of $96 \%$ on room air. He even tolerated a light breakfast. To protect the blistered area from further damage, you apply a hydrocolloid dressing to the damaged skin. What has T.B. experienced, and what are the benefits of using a hydrocolloid dressing?