Archer Basic Comfort and Care/Skills and Procedure/ Medical Admin/ Preoperative Care

The nurse is caring for an 8 year old boy in the pediatric unit. The nurse, when caring for this age group should be aware that: A. The child will do something for another if that person does something for the child. B. The child now follows social standards for the good of all. C. The child wants to follow rules because of a need to be seen as "good." D. The child finds satisfaction in following rules.

Explanation Choice C is correct. The school-age children ages 7-10 find a need to follow the rules as they want to be a "good" person in their eyes, and for others. Choice A is incorrect. This pertains to the pre-conventional stage of moral development. The child will carry out actions to satisfy his needs. If a person does something for the child, the child will do something for the person. This applies to children ages 4-7 years old. Choice B is incorrect. This is the post-conventional stage. It applies to adolescents. The child now follows social standards for the good of all people. Choice D is incorrect. This applies to the 10-12 years old age group. This is where the child finds satisfaction in following rules. Last Updated - 09, Feb 2022

The nurse is providing patient teaching to the mother of a child with a banana allergy. The nurse would be most correct in informing the mother that this child is at an increased risk of developing an allergy to which of the following? A. Penicillin B. Cat dander C. Latex D. Peanuts

Explanation Choice C is correct. Individuals with allergies to bananas are at an increased risk of developing an allergy to latex. Tropical fruit allergies may also indicate an increased risk. Working in a profession with increased exposure to latex, such as a hairdresser or house cleaner, also places a person at an increased risk for developing this allergy. Choices A, B, and D are incorrect. Having an allergy to bananas does not increase a person's risk of developing an allergy to penicillin, cat dander, or peanuts. NCSBN client need Topic: Health Promotion and Maintenance, health promotion Last Updated - 23, Dec 2021

What would the nurse emphasize as an increased risk for an older adult patient? A. Blepharitis and chalazion B. Myopia and strabismus C. Exophthalmos and presbyopia D. Glaucoma and cataracts

Explanation Choice D is correct. Glaucoma, cataracts, and macular degeneration are all more common in the elderly. Choice A is incorrect. Blepharitis is inflammation of the margin of the eyelid. A chalazion is a cyst in the eyelid. Choice B is incorrect. Myopia is nearsightedness. Strabismus is when a person cannot align both eyes simultaneously under normal conditions (cross-eyes). Choice C is incorrect. Exophthalmos is an anterior protrusion of the eyeball out of the socket. Presbyopia is believed to be caused by the loss of elasticity of the crystalline lens. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Age Considerations Last Updated - 07, Oct 2021

The nurse prepares to suction a tracheostomy tube to help clear a patient's secretions. After opening the package, filling the cup with sterile water, and putting on sterile gloves, the nurse uses one hand to connect the catheter to the suction. What action would be most appropriate for the nurse to take next? A. Use the contaminated hand to preoxygenate the patient prior to suction. B. Use the sterile hand to slowly insert the catheter while applying intermittent suction. C. Restart the procedure due to contamination after applying sterile gloves. D. Assess the patient's baseline oxygenation status. Submit Answer

Explanation Choice A is correct. Open suction of a tracheostomy tube requires an aseptic technique. After setting up a sterile field and applying sterile gloves, the nurse would designate one hand as contaminated and ensure the other remains sterile. The contaminated hand should be used to connect/disconnect the catheter tubing, use the resuscitation bag, and operate the suction control. If preoxygenation is indicated, the nurse would use the contaminated hand to administer it. Choice B is incorrect. The sterile hand would be the correct choice for advancing the catheter, but suction should never be applied during insertion. Intermittent suction would only be used while withdrawing the catheter. Choice C is incorrect. The nurse has performed the procedure steps correctly so far and has not taken any action that would compromise the sterile field or require re-starting the procedure. Choice D is incorrect. The nurse should assess the patient's oxygenation status prior to setting up the sterile field and starting the procedure to use as a baseline for monitoring the patient's response to the procedure. Additional Info Last Updated - 10, Feb 2022

The nurse is preparing to suction a client to obtain a sputum sample. Before performing this procedure, the nurse should: A. Hyperoxygenate the client B. Provide the client with a small snack C. Initiate NPO status D. Confirm the order with the physician Submit Answer

Explanation Choice A is correct. Patients about to undergo a suctioning procedure should first be hyper-oxygenated. Suctioning interrupts the patient's breathing, so hyperoxygenation prevents harm. Choice B is incorrect. Providing the patient with a snack is not a necessary action before suctioning. Choice C is incorrect. A patient about to undergo a suctioning procedure does not require NPO status. Choice D is incorrect. There is no reason to confirm this procedure with the physician. Suctioning is a popular way to collect a sputum sample. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential Last Updated - 01, Feb 2022

The nurse is demonstrating the appropriate use of a car seat to a client. The nurse is demonstrating which level of prevention? A. Primary B. Secondary C. Tertiary D. Quaternary Submit Answer

Explanation Choice A is correct. Primary prevention is often referred to as the true level of prevention because it occurs before disease or illness. Demonstrating the appropriate use of a car seat is primary prevention because it happens before an automobile crash, a leading cause of death for those younger than 19. Choices B, C, and D are incorrect. Demonstrating the use of the car seat before an automobile crash is a primary level of prevention. Please see the additional information section for examples of the other levels of prevention. Learning Objective Recognize the levels of prevention Additional Info Last Updated - 10, Jan 2023

Select the domain of pain that is accurately paired with its appropriate nonpharmacological, alternative, complementary pain management intervention. A. The spirit domain of pain: Reiki B. The mind domain of pain: Massage C. The body domain of pain: Self-hypnosis D. The social domain of pain: Music therapy

Explanation Choice A is correct. Reiki is a nonpharmacological, alternative, complementary pain management intervention for the spirit or spiritual, domain of pain. Reiki is performed by the reiki therapist by placing their hands above the person, or lightly on the person, to promote the client's own healing processes including the management and control of pain. Examples of other nonpharmacological, alternative, complementary pain management interventions for the spirit, or spiritual, domain of pain include prayer, meditation, and spiritual healing. Choice B is incorrect. Massage is not a nonpharmacological, alternative, complementary pain management intervention for the mind domain of pain; massage, instead, is a nonpharmacological, alternative, complementary pain management intervention for the body domain of pain. Choice C is incorrect. Self-hypnosis is not a nonpharmacological, alternative, complementary pain management intervention for the body domain of pain; self-hypnosis, instead, is a nonpharmacological, alternative, complementary pain management intervention for the mind domain of pain. Choice D is incorrect. Music therapy is not a nonpharmacological, alternative, complementary pain management intervention for the social domain of pain; music therapy, instead, is a nonpharmacological, alternative, complementary pain management intervention for the mind domain of pain. Last Updated - 09, Feb 2022

When performing a transcultural assessment, the nurse must: A. Determine which questions to ask the client. B. Wait until the nurse-patient relationship is established before asking questions. C. Ask all questions for completeness of the assessment. D. Include all questions as part of an admitting assessment.

Explanation Choice A is correct. Since the list of suggested transcultural assessment questions is extensive, nurses are usually not able to conduct a complete assessment for each patient on admission to inpatient or outpatient care. Therefore, the nurse must determine which questions to ask based on the patient's symptoms, learning needs, and potential health effects of culture-based practices. A patient's behavior is influenced in part by his cultural background. Although certain attributes and attitudes are associated with particular cultural groups, not all people from the same cultural background share the same behaviors and views. When caring for a patient from a culture different from their own, nurses need to be aware of and respect the patient's cultural preferences and beliefs. Failure to do so may cause the patient to feel that the nurse is insensitive and indifferent, possibly even incompetent. When performing a transcultural assessment, it is important to not stereotype a patient based on what you believe their cultural beliefs/practices are. The best way to avoid stereotyping is to view each patient as an individual and to find out their cultural preferences. Using a culture assessment tool or questionnaire can help the nurse discover these and document them for other members of the healthcare team. The American Nurses Association, the Joint Commission, the American Psychological Association, and other accrediting agencies direct nurses to acknowledge and address the cultural needs of patients. To facilitate this process, the U.S. Department of Health and Human Services and Office of Minority Health of the U.S. Department of Health and Human Services published the National Standards for Culturally and Linguistically Appropriate Services in Health Care. Choice B is incorrect. The development of the nurse-patient relationship takes time. It is not appropriate to postpone assessment questions until the relationship is developed, since this could cause neglect of immediate needs for care. Choices C and D are incorrect. The transcultural assessment is extensive. Therefore, nurses usually are not able to conduct a complete assessment on admission. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Cultural Assessment Last Updated - 15, Feb 2022

The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 8:30 AM to compare them with the current vital signs at 10:30 AM. What action should the nurse take? See the exhibit. Correct A. Assess the surgical wound [69%] B. Collect blood cultures [5%] C. Administer oxygen at 2 L/minute [15%] D. Encourage by-mouth (PO) fluids [11%]

Explanation Choice A is correct. The client's 10:30 AM vital signs show signs of shock. Considering this client is in the immediate postoperative period, the nurse should assess the surgical wound for signs of hemorrhage. The nurse should reinforce the dressing if this is the source of the bleeding. The nurse should notify the primary healthcare physician (PHCP) of the client's change in condition. Choices B, C, and D are incorrect. Collecting blood cultures is unnecessary as the likely hood of this being a surgical site infection or sepsis is low. This is because the client is immediately postoperative, and infections typically begin in the extended postoperative period. Oxygen administration is not indicated, as oxygen saturation of 95% is optimal. The nurse should not encourage by-mouth fluids - rather, obtain a prescription for intravenous fluids.

Which of the following medication orders for a patient with pulmonary embolism and fever is a priority to clarify with the physician before administration? A. Warfarin 1.0 mg PO B. Morphine sulfate 2 mg IV Push C. Ceftriaxone 1 gram IVPB D. Heparin infusion at 1500 units/hr Submit Answer

Explanation Choice A is correct. The trailing zero in this order could be misread/misinterpreted, resulting in an accidental medication overdose. It is essential to clarify whether the physician meant 1.0 mg or 10 mg of warfarin. Using a zero after a decimal point (trailing zero) is unnecessary. It may sometimes result in administering a drug ten times its prescribed dose if the decimal point is illegible or not seen. Choices B, C, and D are incorrect. All of these answer choices are appropriate based on the client's diagnosis. Morphine (Choice B) is appropriate to address the pain that is often associated with a pulmonary embolism - no additional clarification is needed. Pulmonary embolism clients tend to have tachypnea, not baseline respiratory depression. Some get distracted by this answer choice since some are concerned about opioid safety in dyspnea/respiratory distress cases. Such a thought process is wrong for two reasons. There is no indication of respiratory depression in this case. Many small studies have established the safety of opioids when used in appropriate doses for pain, even in those dyspneic clients with advanced cardiopulmonary disease. The incidence of real respiratory depression in a review of cases where morphine was used for acute moderate to severe pain was 0.5% or less. Low-grade fever can be seen with pulmonary embolism, but it appears like the physician is giving empiric antibiotic coverage with ceftriaxone (Choice C) - no additional clarification is needed. Heparin infusion (Choice D) is appropriate for initial anticoagulation with warfarin. No additional clarification is needed.

The nurse is supervising a student assisting a client with their newly prescribed crutches. Which action by the student requires follow-up by the nurse? The student A. positions the handgrips so that the axillae support the client's body weight. B. demonstrates the proper crutch stance at 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot. C. observes two to three finger widths between the crutch pad and the client's axilla. D. instructs the client to dry crutch tips with a paper towel if they become wet. Submit Answer

Explanation Choice A is correct. This action is incorrect and requires follow-up. This is an incorrect positioning for crutches, as the axillae should not support the client's body weight. The hands should support the client's body weight as weight supported in the axilla may cause nerve injury. Choices B, C, and D are incorrect. These actions are appropriate and do not require follow-up. The basic crutch stance (commonly referred to as the tripod stance) is 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot. Two to three finger widths should be between the crutch pad and the client's axilla. The client should avoid crutches on wet surfaces because of the risk of falling. If the crutch tips become wet, the client should be instructed to dry them promptly with a paper towel. Additional Info Last Updated - 10, Jan 2023

The nurse is precepting a newly hired nurse administer an intramuscular injection to an adult. Which action by the newly hired nurse requires follow-up? A. Prepares to administer the medication in the dorsogluteal. B. Prepares to insert the needle at a 90-degree angle. C. Uses isopropyl alcohol to clean the area prior to injection. D. Washes their hands before and after the procedure. Submit Answer

Explanation Choice A is correct. This action requires follow-up as the dorsogluteal site is not recommended. The dorsogluteal site is not recommended because of potential damage to nearby nerves and blood vessels. Choices B, C, and D are incorrect. These are correct actions and do not require follow-up. Intramuscular injections should be given at a 90-degree angle. Prior to injecting the medication, the nurse should appropriately clean the skin with isopropyl alcohol. Standard precautions are utilized for an injection which requires the use of thorough hand hygiene. Additional Info For adults, potential intramuscular sites include the ventrogluteal, vastus lateralis, and deltoid. The dorsogluteal site is not recommended because of potential damage to nearby nerves and blood vessels. A normal, well-developed adult patient tolerates 3 mL of medication into a larger muscle without severe muscle discomfort. Larger volumes of medication (4-5 mL) are unlikely to be absorbed properly. Children, older adults, and patients who are thin tolerate only 2 mL of an IM injection. Do not give more than 1 mL to small children and older infants, and do not give more than 0.5 mL to smaller infants

The nurse is reviewing clinical data for a client. Which of the following actions should the nurse take? See the exhibit. A. Initiate a client referral to a registered dietician. B. Inform the client that the results are within normal limits. C. Request a prescription for occupational therapy. D. Review the client's family history.

Explanation Choice A is correct. This client is showing evidence of metabolic syndrome and needs prompt intervention to mitigate the risk of diabetes mellitus. Nutritional intervention is necessary because this client needs to modify their diet and reduce their intake of sodium, fats, and simple carbohydrates. Thus, it would be appropriate for the nurse to initiate a referral to a registered dietician. Choices B, C, and D are incorrect. The results are not within normal limits. The client has an elevated BMI, cholesterol, and blood pressure. The hemoglobin A1C is also elevated, showing prediabetes. The client's family history is not pertinent based on this data as it will not guide the treatment plan. The most appropriate action is for the nurse to refer the client to a dietician for nutritional counseling (not occupational therapy). Additional Info Metabolic syndrome is when the client has three out of the five abnormalities - Hypercholesterolemia (> 200 mg/dl) High triglycerides (> 150 mg/dl) High fasting blood glucose (>100 mg/dl) Abdominal obesity (> 40 inches in men; > 35 inches in females) Elevated blood pressure (> 130/85 mmHg) Low High-Density Lipoproteins (<50 mg/dl) Last Updated - 04, Jun 2022

The nurse is preparing to administer the prescribed mannitol. The nurse plans to administer the infusion using A. microdrip intravenous tubing. B. filtered intravenous tubing. C. vented intravenous tubing. D. non-vented intravenous tubing. Submit Answer

Explanation Choice B is correct. Mannitol is an osmotic diuretic indicated for cerebral edema. Mannitol may crystallize when exposed to low temperatures. Because of this, mannitol is always administered intravenously through intravenous tubing with a filter. Choices A, C, and D are incorrect. These tubing choices are incorrect and should not be used for mannitol administration. Micro drip tubing is utilized when precise amounts of fluid need to be administered. For this tubing, 60/gtts = 1 mL of fluid. Vented tubing is helpful to progress the infusion of fluids (or medication). The vent allows air to enter the container and displace the medication or solution as it's infused. Non-vented tubing creates a vacuum that allows the container to shrink or collapse as the fluid drains from the container. Additional Info Mannitol is used in the treatment of patients in the early oliguric phase of acute renal failure. For it to be effective in this setting, however, enough renal blood flow and glomerular filtration must still remain to enable the drug to reach the renal tubules. Mannitol can also be used to promote the excretion of toxic substances, reduce intracranial pressure, and treat cerebral edema. Last Updated - 12, Dec 2022

A nurse is preparing a client for computed tomography (CT) scan with intravenous (IV) iodinated contrast. The nurse should take which action? A. Ask the client if they are allergic to shellfish B. Insert a 20-gauge peripheral vascular access device C. Obtain capillary blood glucose (CBG) D. Instruct the client to decrease their fluids after the procedure Submit Answer

Explanation Choice B is correct. Patent vascular access of at least a 20-gauge catheter is necessary before the infusion of intravenous contrast. Extravasation of contrast media can be severe, and treatment involves stopping the infusion, removing the catheter, and elevating the extremity above the heart. This can be avoided by establishing IV patency before the infusion of contrast. Warm or cold compresses may also be helpful. Choice A is incorrect. Shellfish allergies are to tropomyosin (a muscle protein), not iodine. Thus, asking questions regarding shellfish allergy before giving an intravenous contrast agent is unnecessary and has been disproven by the American College of Radiology for quite some time. The cause of contrast reactions is unclear, and previous reactions specific to iodine contrast should be inquired upon before the exam. Choices C and D are incorrect. Capillary blood glucose should be obtained before a PET scan - not CT. The client should be instructed to increase their fluid intake - not decrease, as contrast may be nephrotoxic. Learning Objective Recognize and follow the updated evidence-based guidelines that indicate shellfish allergy is no longer a contraindication to receiving IV contrast. Additional Info Computed tomography scans may be performed with or without contrast. This procedure uses radiation and is commonly indicated for abdominal pain, stroke, and spinal cord injuries. If contrast is administered, a baseline creatinine and eGFR should be obtained. The client should be instructed to increase their fluid intake following a contrast procedure to facilitate its passing.

The client with a communicable disease just expired. Which information should the nurse provide to the mortuary staff? A. The nurse cannot release information to the mortuary staff. B. The nurse should inform them of the client's diagnosis. C. Inform the mortuary staff that the nurse will first obtain permission from the client's family. D. Instruct the mortuary personnel to call the physician. Submit Answer

Explanation Choice B is correct. The mortuary team should be informed of the client's diagnosis since they are also part of the health care team. Choice A is incorrect. The mortuary team should be informed of the client's diagnosis since they are also part of the health care team. Choice C is incorrect. The nurse does not need permission from the client's family to inform the mortuary personnel of the client's diagnosis. Choice D is incorrect. The nurse is the one that releases the body into the mortuary, not the physician. Last Updated - 04, Feb 2022

The nurse receives an order to give the patient 125 mg of the medication each day. The drug on hand is 250 mg in each tablet. The nurse should administer: A. ¼ tablet B. ½ tablet C. 1 tablet D. 2 tablets Submit Answer

Explanation Choice B is correct. The nurse should administer ½ tablet. Use the formula: Amount ordered/Amount on hand = number of tablets. 125 mg/250 mg = ½ tablet. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-topic: Dosage Calculation; Medication administration Last Updated - 19, Nov 2021

The nurse has received the following prescriptions for newly admitted clients. The nurse should first administer which of the following? A. Enoxaparin to a patient with a platelet count of 165,000 mm3 B. Warfarin to a patient with an international normalized ratio of 2.4 C. Packed red blood cells to a patient with a hemoglobin of 6.8 g/dL D. Regular insulin to a patient with a blood glucose of 285 mg/dL Submit Answer

Explanation Choice C is correct. A hemoglobin of 6.8 g/dL is critical and requires the nurse to immediately initiate the prescribed transfusion of packed red blood cells. This circulation problem under the airway, breathing, and circulation strategy requires prompt intervention. Choices A, B, and D are incorrect. A platelet count of 165,000 mm3 is normal (the therapeutic range is 150,000 to 400,000), and administering enoxaparin would not be contraindicated but is not a priority compared to the critical hemoglobin. While a client is receiving a heparin product, the platelet count should be monitored. Although unlikely because enoxaparin is a low molecular weight-based heparin, the platelet count should be observed. An INR of 2.4 (therapeutic range while on warfarin 2-3) is within range and is safe to administer. The client's hyperglycemia (any blood glucose greater than 250 mg/dl) is concerning but not prioritized over the critical hemoglobin. Additional Info The normal hemoglobin is 14-18 g/dL for males and 12-16 g/dL for females. A transfusion of packed red blood cells (PRBCs) is typically prescribed once the hemoglobin drops below 7 g/dL. One unit of packed red blood cells will raise the hemoglobin by 1 g/dL. Last Updated - 11, Apr 2022

When communicating with a client who speaks a different language, the nurse should do which of the following? A. Speak loudly and slowly B. Stand close to the client and speak in an exaggerated volume C. Arrange for a trained health care interpreter when communicating with the client D. Speak to the client and family together to promote comprehension

Explanation Choice C is correct. A nurse should arrange for a trained health care interpreter during each encounter with a client who speaks a different language. Additionally, the use of the interpreter should be documented within the subsequent documentation of the encounter. Choice A is incorrect. The issue is not that the client cannot hear and comprehend the words being spoken; the problem is that the client does not understand the language. Speaking at a louder volume and slower pace will not make the client comprehend the language. Choice B is incorrect. Similar to the above answer, the issue is not that the client cannot hear the words spoken; the problem is that the client does not understand the language. The volume or distance from the client is not the issue, and speaking in an exaggerated voice will not remedy this issue. Choice D is incorrect. Prior to understanding the issue at hand, having the family present potentially violates the patient's right to privacy. Additionally, in the event the nurse is utilizing the family members of this client to translate for this encounter with this client, this practice would be incorrect, as the use of family members for translation purposes does not ensure correct or unbiased translation. Learning Objective Identify the need to utilize a trained health care interpreter when communicating with a client who speaks a different language. Additional Info Trained health care interpreters can reduce liability, help ensure appropriate utilization, and increase client adherence and satisfaction with services. Trained health care interpreters help to assure effective communication between the client and provider, support effective use of time during the clinical encounter, and improve outcomes. Source : Archer Review Last Updated - 12, Sep 2022

What is the process with which members of another culture adopt the culture of the host, predominant culture? A. Immigration B. Emigration C. Acculturation D. Assimilation

Explanation Choice C is correct. Acculturation is the process with which members of another culture adopt the culture of the host, predominant religion. This adaptation allows the members of the non-dominant culture to survive and thrive in the new environment. Although acculturation and assimilation are similar, adaptation is the process with which a person develops a new cultural identity, rather than assimilating and adopting a new culture while retaining their own. Immigration is the process by which citizens of one country enter another country, whereas emigration is the process by which individuals of a nation leave it. Both immigration and emigration can lead to cultural dissonance. Choice A is incorrect. Immigration is the process by which citizens of one country enter another country. Choice B is incorrect. Emigration is the process by which individuals of a country leave it. Choice D is incorrect. Assimilation is the process with which a person develops a new cultural identity process. Last Updated - 09, Jan 2022

The nurse is caring for a patient who has recently had a femoral vein catheter placed. The nurse would be most correct in advising the patient to do which of the following? A. Refrain from drinking more than 500 mL per day B. Perform toe touch stretches in bed every morning C. Refrain from sitting up more than 45 degrees D. Remove the dressing if it becomes itchy Submit Answer

Explanation Choice C is correct. Patients who have undergone a femoral vein catheter should refrain from sitting up more than 45 degrees because this could kink the catheter, thus interfering with treatment. Choice A is incorrect. This patient does not need to be on a fluid restriction unless specifically indicated by the physician. Choice B is incorrect. Toe touches require that the patient bend more than 45 degrees and may damage or kink the femoral vein catheter. Choice D is incorrect. The patient should leave their occlusive dressing on while the femoral vein catheter is inserted. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential Last Updated - 15, Nov 2022

Select the age group that is accurately paired with a physiological characteristic that places them at risk for adverse effects, contraindications, side effects, and/or interactions related to medications. A. Neonates: Acidic gastric acids that affect absorption B. Toddler: Immature hepatic functioning that affects distribution C. The elderly: Decreased renal perfusion that affects excretion D. Adolescents: An underdeveloped blood-brain barrier

Explanation Choice C is correct. The elderly population, as the result of the regular changes occurring in the aging process, is at a higher risk for adverse medication effects, contraindications, side effects, and interactions. Among these frequent changes of the aging process include decreased renal perfusion and functioning, decreased hepatic perfusion and functioning, lowered bodily water, reduced gastric acid production, increased adipose tissue, and polypharmacy as the result of multiple chronic diseases and disorders. This also increases the elderly's risk for adverse effects, contraindications, side effects, and/or interactions. Choice A is incorrect. Neonates can be affected by adverse effects, contraindications, side effects, and interactions with medications because their gastric acid is more alkaline (not more acidic). Choice B is incorrect. Neonates and infants less than one year of age have immature hepatic functioning that affects distribution (not toddlers). Choice D is incorrect. Neonates and infants less than one year of age have an underdeveloped blood-brain barrier (not adolescents). Last Updated - 12, Feb 2022

The nurse provides discharge teaching to a client prescribed a cane for left-sided weakness. Which instruction should the nurse provide? A. Advance the cane, then your stronger leg B. Remove the rubber tip when going upstairs C. Measure the height of the cane to your elbow D. Secure the cane in your right hand Submit Answer

Explanation Choice D is correct. A client with left-sided weakness should have the cane secured in their right hand. The point of having a cane as an ambulation device is to ensure that two points of sturdy contact are on the ground at all times. Choices A, B, and C are incorrect. These instructions are incorrect. The cane should be advanced at the same time as the affected (weaker) leg, followed by the unaffected (stronger) leg. A rubber tip should always be applied to the crutch to ensure appropriate traction with the ground. The cane's height should be measured to the client's greater trochanter or wrist crease. Additional Info Source : Archer Review When a client ambulates with a cane, the nurse should ensure that a gait belt is applied before getting out of bed. The nurse is positioned on the client's affected (weaker) side, slightly behind the client. Measure the height of the cane from the wrist crease or greater trochanter The cane should be held on the unaffected (stronger) side The elbow should be flexed 15-30 degrees The cane should be advanced (6-10 inches), along with the affected (weaker) leg Then, the unaffected (stronger) leg should be advanced just past the cane A rubber tip should always be applied to a cane to ensure appropriate traction with the ground. Last Updated - 04, Dec 2022

The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside? A. One liter of 0.9% saline B. Sterile gloves C. Portable ultrasound D. Suction equipment Submit Answer

Explanation Choice D is correct. A client with severe pre-eclampsia should be monitored closely for seizures which are the hallmark manifestation of eclampsia. The nurse should plan care involving seizure precautions at the bedside, including suction equipment, padded side rails, and oxygen. Choices A, B, and C are incorrect. Sterile gloves, portable ultrasound, and a liter of 0.9% saline would not be necessary to manage a client having a seizure directly related to pre-eclampsia. These tools would be helpful for other obstetric procedures but not for a severely pre-eclamptic client at risk of having a seizure. Additional Info Severe pre-eclampsia may require intensive care monitoring, depending on other factors. Nursing care for a client with severe pre-eclampsia includes: ➢ Appropriate safety equipment at the bedside, which includes seizure precautions. ➢ Frequent vital signs and blood pressure must be closely monitored as a hypertensive emergency may develop. ➢ Prescribed medication administration such as magnesium sulfate. ➢ Frequent fetal well-being assessment that includes continuous fetal heart rate monitoring. Source : Archer Review Last Updated - 18, Nov 2022

The nurse manager is working on a unit where his nursing staff is not comfortable taking care of patients from other cultural backgrounds. What is the most appropriate action for the manager? A. Let the staff research different articles regarding various cultures so they become more familiar with them. B. Transfer the nurses to another unit where they can't be assigned to patients from other cultures. C. Rotate the nurses' assignments so they can all have the opportunity to take care of patients from other cultures. D. Organize an activity that offers opportunities for the staff to learn about the cultures they might encounter at work. Submit Answer

Explanation Choice D is correct. An activity like a workshop is an excellent opportunity for staff to learn about new cultures and to identify their feelings towards other religions. They also have a chance to ask questions. Choice A is incorrect. This strategy only provides information about cultures. It does not promote an open discussion regarding the situation. Choice B is incorrect. All units have clients coming from different cultures. This initiative is not feasible. Choice C is incorrect. Rotating assignments do not address the primary issue. Instead, this will likely create more tension in the unit. Last Updated - 16, Oct 2021

Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic? A. "Autologous donations require a health care provider's (HCP) order." B. "There is no age limitation for autologous blood donations." C. "I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery." D. "My autologous blood donation will be screened for infectious diseases." Submit Answer

Explanation Choice D is correct. Autologous donations are not screened for infectious diseases. According to the Food and Drug Administration (FDA), autologous donations are not screened because autologous donors are not exposed to new transfusion-transmitted infections in receiving their own blood. Choice A is incorrect. Each autologous donation requires an order or prescription by a health care provider (HCP). Choice B is incorrect. Although certain ages are preferable to others, there is no age limit for autologous donations. Active infections, specific cardiac conditions, and decreased hemoglobin levels are the primary methods of disqualification from autologous blood donation. Choice C is incorrect. Unless the client's health care provider (HCP) specifies otherwise, the traditional window for autologous blood donation begins five weeks before the scheduled surgery date, with the donation cutoff occurring 72 hours before the surgery. Learning Objective Recognize that autologous donors are not screened for infections because they are not exposed to new transfusion-related diseases in receiving their own blood. Additional Info Depending on the surgical procedure and any unanticipated needs arising during surgery, the autologous units previously stored may be insufficient for the client's needs. If so, the client may receive additional units of blood from the community blood bank. To help maintain the client's blood hemoglobin at an acceptable level, the HCP will often recommend iron supplements for clients who choose to provide autologous blood donations. Although infectious disease testing is not traditionally performed on autologous blood donations, these donations receive ABO/Rh and antibody screenings. Approximately half of all autologous blood collected in the United States is not utilized. Severe transfusion reactions, including fluid overload causing heart failure, are not prevented by autologous donation. Last Updated - 02, Oct 2022

The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care? A. Apply sequential compression devices B. Apply an extra sheet to the bed C. Position the client on a donut pillow D. Encourage the consumption of high-protein foods

Explanation Choice D is correct. High-protein foods are encouraged because they promote wound healing and prevent fluid shifting, which may lead to a pressure ulcer. The prevention of fluid shifting (edema) contributes to a pressure ulcer. Optimal protein intake is key to preventing (and healing) a pressure ulcer. Choices A, B, and C are incorrect. Sequential compression devices would be a helpful way to prevent venous thromboembolism, not pressure ulcers. Extra linens are not an effective way to prevent pressure ulcers. The least amount of linen on the bed should be used as it traps moisture which leads to the development of a pressure ulcer. Positioning the client on a donut pillow would be inappropriate because this applies direct pressure to the client's buttocks. Additional Info Recommended interventions for a client at risk for developing a pressure ulcer include the following: ▪ Utilize standardized assessments to evaluate a client's risk for a pressure ulcer. ▪ Ensure that nutritional goals are being met by providing adequate fluid and protein in the diet. ▪ Keep the head of the bed at 30 degrees or less to prevent shearing. ▪ Offload bony prominences using foam or pillows. Reposition the client at least every two hours. ▪ Do not use any products comprised of plastic and avoid using donut pillows. ▪ Moisturize the skin with products containing zinc oxide. ▪ Do not massage reddened areas. Last Updated - 25, Sep 2022

The nurse is caring for a 5-year-old client whose family is of Orthodox Jewish faith. The mother requests that the client remains kosher while in the hospital. Which of the following actions while assisting the child with lunch would best respect the mother's request? A. Finding metal utensils instead of plastic B. Placing the food on plastic plates instead of paper C. Helping the child unwrap the plastic utensils from their packaging D. Allowing the child and his mother to unwrap the eating utensils

Explanation Choice D is correct. It is appropriate to allow the child and the mother to unwrap the eating utensils. This is the only action listed that allows the child and the mother to remain kosher as requested. Choice A is incorrect. It is not appropriate for the nurse to replace the utensils that come with the tray with metal utensils. Kosher meals will arrive on the unit on paper plates with sealed plastic utensils which the nurse should not open. Choice B is incorrect. It is not appropriate for the nurse to transfer the food to another dish. The nurse should deliver the tray to the client on the paper plate that it arrives on. Choice C is incorrect. It is not appropriate to help the child unwrap the plastic utensils from their packaging. The nurse should deliver the paper plate and sealed plastic utensils directly to the client and the mother. The mother can assist in the unwrapping, but the nurse should not do it for the client unless otherwise instructed. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Culture & Spirituality Last Updated - 15, Sep 2021

Which of the following practices does the nurse recognize as typical in the Amish community? Select all that apply. A. Health is viewed as a gift from God. B. They commonly use alternative healthcare. C. Women and men are equal and can both make healthcare decisions. D. Most of the Amish community choose to have health insurance. Submit Answer

Explanation Choices A and B are correct. The belief that health is a gift from God is prevalent in Amish society. While they believe that their health is a gift, they also believe that clean living and a healthy diet are essential to maintain their health (Choice A). Members of the Amish society commonly use alternative healthcare in addition to traditional healthcare. Healers, herbs, and massage are all widely used in their alternative medicine practices (Choice B). Choice C is incorrect. Women and men do not have equal authority in the Amish community. Their society is patriarchal, so men typically have power when making healthcare decisions. Choice D is incorrect. Most of the Amish community chooses not to have health insurance. Instead, they may want to save the money they would have spent on health insurance to maintain a mutual aid fund amongst the community for members who need help with medical costs. NCSBN Client Need: Topic: Psychosocial Integrity, Subject: Fundamentals of care; Culture/Spirituality Last Updated - 15, Feb 2022

Which of the following falls under the right dose of the 8 rights of medication administration? Select all that apply. A. Using a drug reference to verify that the dose ordered is appropriate. B. Identify the patient using 2 separate identifiers. C. Have a second nurse independently calculate the medication dosage. D. Double-check the last time that the medication was administered. Submit Answer

Explanation Choices A and C are correct. A is correct. Using a drug reference to verify the dose ordered is appropriate is a part of the right dose check in the 8 rights of medication administration. The nurse should always verify that the dose is appropriate by checking a current drug reference for the medication and verifying that what is ordered is in the safe range. C is correct. Having a second nurse independently calculate the medication dosage is an important part of verifying the right dose. This check ensures that two nurses both calculate the dosages and come up with the same answer, decreasing the chance of an error in calculation. Choice B is incorrect. Identifying the patient using 2 separate identifiers falls under the right patient in the 8 rights of medication administration, not the right dose. The nurse should always verify the correct patient by using 2 separate identifiers, such as name and medical record number, but this is a part of verifying the right patient, not the right dose. Choice D is incorrect. Double-checking the last time that the medication was administered is a part of the right time step in the 8 rights of medication administration. This is important because the nurse needs to verify that she is giving the dose at the correct time and that it is not being administered too frequently based upon the previous administration. This is not a part of the right dose step, however. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological adaptation, Fundamentals - Medication Administration Additional Info Last Updated - 08, Dec 2021

Select the complication of intravenous therapy that is accurately paired with one of its preventive measures. Select all that apply. A. Catheter embolus: Never reinserting the stylet into the catheter B. Hematoma: Start the infusion prior to releasing the tourniquet C. Infiltration: Insuring that the catheter is securely stabilized D. Site ecchymosis: Changing the intravenous site every 48 hours E. Fluid overload: Ensuring that the client's arm is not swollen Submit Answer

Explanation Choices A and C are correct. Catheter embolus can be prevented by never reinserting the stylet into the catheter during insertion. Infiltration can be restricted by ensuring that the catheter is securely stabilized. Choice B is incorrect. Hematomas are a complication of intravenous therapy that can be prevented by a variety of interventions, which do not include starting the infusion before releasing the tourniquet. Hematomas can be avoided by releasing the tourniquet before initiating the intravenous flow. Other preventive measures include maintaining pressure over the intravenous insertion site when the intravenous therapy is discontinued and minimizing the duration of time that a tourniquet is in place during the intravenous therapy initiation process. Choice D is incorrect. Site ecchymosis is a complication of intravenous therapy that can be prevented by starting the infusion before releasing the tourniquet. Hematomas can be restricted by releasing the tourniquet before initiating the intravenous flow. Other preventive measures include maintaining pressure over the intravenous insertion site when the intravenous therapy is discontinued and minimizing the duration of time that a tourniquet is in place during the intravenous therapy initiation process. Site ecchymosis is not prevented by changing the intravenous site every 48 hours. Choice E is incorrect. Fluid overload is a complication of intravenous therapy that can be prevented by monitoring the rate of administration, checking the client's vital signs, monitoring the client's intake and output, assessing the client for the signs and symptoms of fluid overload, and ensuring that the client (particularly a confused client) cannot reach and manipulate the intravenous flow rate. Observing the client's arm for swelling is not a way to prevent fluid overload. Last Updated - 24, Oct 2022

Select the pharmacological terms that are accurately paired with their definition/description. Select all that apply. A. Adverse effects: highly serious, sometimes life-threatening, and rare side effects of a particular medication. B. Therapeutic index: The relationship of the therapeutic, desired effect of a drug to its onset, peak, trough, and duration. C. Peak plasma level: The steady and maintained level of the medication in the body with several doses of the medication. D. The plateau of a medication: The highest possible concentration of a medication that is achieved with a dose of a medication. E. Potentiating effect: The ability of a medication to produce its desired effect by the addition of one or more kappa receptor medications. F. First pass effect: The inactivation of a medication as it is inactivated by the metabolic role of the liver. G. Inhibiting effect: The ability of a medication to reduce its side effects with the addition of one or more agonist medications.

Explanation Choices A and F are correct. Adverse effects are highly severe, sometimes life-threatening, and rare side effects of a particular medication. Medications are most often discontinued when a client is adversely affected. A first-pass effect is the inactivation of a medication as it is inactivated by the metabolic role of the liver; this sometimes occurs with oral medications. Choice B is incorrect. The therapeutic index is not the relationship of the therapeutic, desired effect of a drug to its onset, peak, trough, and duration; instead, the therapeutic index is the narrow margin of the medication dosage between its optimal effect and drug toxicity. Choice C is incorrect. The peak plasma level is not the steady and maintained level of the medication in the body with several doses of the drug; instead, this process is the plateau of a medication. Choice D is incorrect. The plateau of a medication is not the highest possible concentration of a drug that is achieved with a dose of drugs; instead, this process is the peak plasma level. Choice E is incorrect. The potentiating effect is not the ability of a medication to produce its desired result by the addition of a nonsteroidal anti-inflammatory medication; medications are potentiated when the addition of a drug to another one increases the effect(s) of one or both of the medications. Choice G is incorrect. An Inhibiting effect of a medication is not the ability of a drug to reduce its side effects with the addition of one or more agonist medications. An inhibiting effect is when a drug binds to a receptor and decreases its activity. Last Updated - 16, Oct 2021

The nurse provides oral care to clients in the ICU. What are the benefits of providing oral care to a client in critical care? Select all that apply. A. It promotes the patient's sense of well-being. B. It prevents deterioration of the oral cavity. C. It decreases the incidence of aspiration pneumonia. D. It eliminates the need for regular flossing. E. It decreases oropharyngeal secretions. F. It compensates for an inadequate diet. Submit Answer

Explanation Choices A, B, and C are correct. Adequate oral hygiene is essential for promoting a client's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of both aspiration pneumonia and ventilator associate pneumonia (VAP). Choices D, E, and F are incorrect. Oral care does not eliminate the need for flossing. It can increase saliva production and would not be expected to decrease oropharyngeal secretions. Mouth care has been found to improve appetite but does not compensate for poor nutrition. Additional Info Adequate oral hygiene helps clear the airway, reduces infection risk, and supports client comfort and self-esteem. When performing oral care, it is important to use a sponge cleaner or soft-bristled toothbrush with water. Glycerin swabs and alcohol-containing mouthwash products can alter the mouth's pH and dry out the mucous membranes, leading to increased bacterial growth. If ordered, diluted hydrogen peroxide solutions can help address crusted areas. Last Updated - 15, Dec 2022

The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? Select all that apply. The student A. applies clean gloves to clean the perineal area with soap and water. B. asks the client to bear down gently and slowly insert the catheter through the urethral meatus. C. separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution. D. secures the catheter tubing to the inner thigh. E. attaches the drainage bag to the side rails of bed. Submit Answer

Explanation Choices C and E are correct. These actions by the student are incorrect and require follow-up by the nurse. When cleaning the labia with the antiseptic solution, the student should wear sterile gloves to clean the labia with their dominant hand while separating the labia with the fingers of the nondominant hand (now contaminated) to fully expose the urethral meatus. Acting correctly will greatly decrease the risk of contamination. The drainage bag of the urinary catheter should not be secured to the bed's side rails as it will move and cause tension on the tubing that may cause urinary trauma. Choices A, B, and D are incorrect. These actions by the student are correct and do not require follow-up by the nurse. Clean gloves are worn to clean the perineal area with soap and water (sterile gloves are used to apply the povidone iodine or other antiseptic solution). Asking the client to bear down gently and slowly insert the catheter through the urethral meatus is appropriate because it relaxes the external urinary sphincter, which facilitates the passage of the tubing. The urinary catheter tubing should be secured to the inner thigh of a female. The device is then secured to the bed's frame below the bladder. Additional Info ✓ An RN or LPN may insert, manage, and remove an indwelling urinary catheter. ✓ A UAP may assist with gathering supplies, sending appropriate specimens to the lab, and recording urinary output from the device. ✓ Pretesting the indwelling catheter balloon by injecting fluid from the saline syringe is no longer recommended. This distorts the balloon and may cause urinary tract trauma during the insertion. ✓ When securing the tubing for an indwelling urinary catheter for a male, it is secured to the upper thigh or lower abdomen (with the penis directed toward the chest). For a female, it is secured to the inner thigh. ✓ It is critical to stop the procedure for any contamination and restart the procedure with new supplies. Last Updated - 07, Feb 2023

Which interventions are appropriate for venous thromboembolism prophylaxis when caring for a non-ambulatory client? Select all that apply. A. Floating both of the heels using a pillow B. Apply sequential compression devices to the lower extremities C. Encourage range of motion exercises in the lower extremities D. Apply compression hose to the lower extremities E. Administer enoxaparin subcutaneously, as prescribed Submit Answer

Explanation Choices B, C, D, and E are correct. Sequential compression devices (SCDs) provide DVT prophylaxis by applying intermittent external pressure, pushing blood into deep veins, reducing stasis, and improving venous return. Range of motion exercises should be encouraged for a non-ambulatory client to encourage venous return. Thromboembolic deterrent (TED) hose promotes venous blood flow, prevents venous dilation, improves venous valve function, and stimulates endothelial fibrinolytic activity. Enoxaparin is a low molecular weight-based heparin given subcutaneously in the abdomen. This is a form of chemical VTE (venous thromboembolism) prophylaxis. Choice A is incorrect. Floating the heels is a measure to prevent a pressure ulcer. The heels may be floated using pillows or a specialty mattress that relieves the pressure. This would not be a measure to prevent a VTE. NCLEX Category: Reduction of Risk Potential Related Content: Potential for Alteration in Body Systems Question Type: Application Additional Info Prophylaxis for VTE includes mechanical and chemical agents. Mechanical prophylaxis involves SCDs and TED hose. Chemical prophylaxis includes medications such as enoxaparin or heparin. Risk factors for VTE include • Active cancer • Previous VTE (excluding superficial vein thrombosis) • Reduced mobility • Known thrombophilic condition • Recent (≤1 month) trauma and/or surgery • Older adult (≥70 years) • Cardiac and/or respiratory failure • Acute MI and/or ischemic stroke • Acute infection and/or rheumatologic disorder • Obesity (body mass index [BMI] ≥30) • Ongoing hormonal treatment Last Updated - 10, Apr 2022

A nurse is caring for a client following the surgical repair of a detached retina in the client's right eye. Which nursing action(s) should the nurse include in the client's plan of care? Select all that apply. A. Position the client in a prone position B. Approach the client from the left side C. Instruct the client to perform deep breathing and coughing exercises D. Instruct client to avoid bending down E. Orientate the client to the environment F. Obtain a prescription for a stool softener

Explanation Choices B, D, E, and F are correct. Choice B is correct. The nurse should always approach the client from the unaffected side. Here, the nurse would approach this client from the client's left side to avoid startling the client. Choice D is correct. Activities that increase intraocular pressure, such as bending down, should be avoided. Choice E is correct. In order to prevent unwarranted injury, the client should always be oriented to his or her environment. Choice F is correct. A prescription for a stool softener is provided for multiple reasons. First, activities that increase intraocular pressure should be avoided. Since constipation and straining during defecation often increase intraocular pressure, stool softeners are administered to prevent constipation prophylactically. Second, any use of opioid pain medication during the surgical or postoperative procedure would likely inhibit gastrointestinal and colonic motility. A stool softener would assist in alleviating this medication side effect. Choice A is incorrect. During the postoperative period, activities that increase intraocular pressure should be avoided. Increased intraocular pressure can lead to postoperative vision loss and recurrent retinal detachment. When a client is placed in a prone position, the client's intraocular pressure increases significantly due to the position change. If the client remains in the prone position, the client's intraocular pressure will continue to rise over the next ten minutes while the client remains in this position. To avoid this increase in intraocular pressure, the client should lie down on their back (supine) or on the unaffected side (i.e., here, the client's left side would be the client's unaffected side) to reduce the intraocular pressure in the affected eye. Choice C is incorrect. As discussed above, activities that increase intraocular pressure should be avoided during the postoperative period, as increased intraocular pressure can lead to postoperative vision loss and recurrent retinal detachment. Clients should not be instructed to perform deep breathing and coughing exercises, as coughing causes increased intraocular pressure and should therefore be avoided. Learning Objective When caring for a client following the surgical repair of the client's detached retina, identify the need to include the following in the client's care plan: approaching the client from the unaffected side, instructing the client to avoid bending down, orientating the client to the environment, and obtaining a stool softener prescription. Additional Info Intraocular pressure (IOP) occurs when a measurement is greater than 21 mm Hg. Retinal detachment is painless. Clients experiencing retinal detachment usually see an increase in floaters (i.e., objects that appear to move through a client's field of vision) or many flashes of bright light that last less than a second (photopsia) and have blurred vision. Peripheral vision is typically lost first, and vision loss spreads as the detachment progresses, causing grayness in the field of vision or resembling a curtain or veil falling across the line of sight. Most retinal detachments can be repaired via surgery, although the type of surgery is dependent upon the severity of the retinal tear. Last Updated - 28, Nov 2022

The nurse is preparing to obtain a wound culture on an infected leg ulcer. Before swabbing the wound to obtain the culture, the nurse should A. clean the wound with normal saline. B. pat dry the wound with gauze. C. irrigate the wound with hydrogen peroxide. D. don sterile gloves Submit Answer

Explanation Choice A is correct. Cleansing the wound with normal saline immediately before obtaining a wound culture is appropriate. This action will ensure that no residual skin flora will be sent with the sample, potentially making the result inaccurate. The nurse should never collect a wound culture sample from old drainage. Choices B, C, and D are incorrect. Disinfecting the wound with alcohol or hydrogen peroxide with skew the quality of the sample. The nurse should only use sterile saline before collecting the culture. Drying the wound with gauze is not indicated when collecting a wound culture. Clean gloves are used for this procedure, as sterile gloves are not necessary. Additional Info When collecting a wound culture, the nurse should take into consideration the following - ➢ The procedure requires the nurse to perform hand hygiene and wear clean gloves. ➢ Before culturing the wound, the wound bed should be irrigated with sterile saline. This will remove any residual skin flora that may contaminate the sample. ➢ Never collect a wound culture sample from old drainage or eschar tissue. ➢ For a review of the procedure, please visit: https://journals.lww.com/nursing/Citation/2007/11000/Obtaining_a_wound_culture_specimen.12.aspx

The nurse reviews obtaining blood pressure with unlicensed assistive personnel (UAP). It would indicate effective teaching if the UAP states which client finding would not be appropriate for an electronic blood pressure measurement? The client A. having coarse tremors. B. wearing a watch. C. who has excessive tattoos. D. requiring a chest radiograph. Submit Answer

Explanation Choice A is correct. Coarse tremors would cause the blood pressure reading to be inaccurate. The nurse should not use electronic blood pressure monitoring if the client has these tremors. Choices B, C, and D are incorrect. These client findings would not alter blood pressure measurement. Wearing a watch is not advised if the client has a fistula for dialysis. Tattooing would not alter blood pressure results, and a chest radiograph would not alter the results. Additional Info Client Conditions Not Appropriate for Electronic Blood Pressure Measurement • Irregular heart rate • Known hypertension • Peripheral vascular obstruction (e.g., clots, narrowed vessels) • Shivering • Seizures • Excessive tremors • Inability to cooperate • Blood pressure less than 90 mm Hg systolic Last Updated - 02, Dec 2022

The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury? A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor. B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor. C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position. D. Hold the gait belt, and lower the client to the floor by using a narrow base of support. Submit Answer

Explanation Choice A is correct. For a client who is ambulating, the nurse should always be slightly behind the client and positioned on the affected (weaker) side. If a client starts to fall, the nurse should hold the gait belt, try to extend one leg, let the client slide against the leg, and gently lower the client to the floor, protecting the head. The nurse can help prevent client injury by maintaining a wide base of support. Choices B, C, and D are incorrect. These actions place the nurse at risk for injury. The nurse should never let go of the gait belt. Additionally, instructing the client to fall to the floor in a side-lying position will not mitigate injury. To prevent injury, whenever the nurse is engaged in physical care with a client, the nurse should maintain a broad base of support and engage their thigh muscles. Additional Info Trying to stop or minimize a fall can cause the nurse injury. An approach that may be used to minimize injury during a fall is where the nurse assumes a wide base of support with one foot in front of the other, thus supporting the client's body weight. Allowing the client to slide down one leg can reduce injury to the client. Last Updated - 08, Jun 2022

Which of the following is an example of an inspection? A. Skin is pink B. Lungs are clear C. Heart rate and rhythm are regular D. Abdomen is tympanic Submit Answer

Explanation Choice A is correct. Inspection refers to visual examination. Inspection is the first technique of the overall general survey for each body part/ system. The purpose of gathering data during this initial phase of the inspection is to obtain an overall impression of the patient and assess the clinical presentation's severity. Nurses should learn to observe for cues that may indicate the need for immediate intervention. For example, an inspection finding of pink skin is a healthy finding. In contrast, a finding of cyanosis ( bluish discoloration of skin, lips, and nail beds) may indicate decreased oxygenation from respiratory failure or reduced perfusion from heart failure. Such inspection findings may need urgent intervention. Choices B and C are incorrect. These options are examples of auscultation, not inspection. Auscultation is a technique that is often used to listen to the lungs ( breath sounds), heart ( heart sounds), and abdomen ( bowel sounds). Upon auscultation, the character of these sounds is defined. "Lungs are clear" indicates no adventitious sounds upon lung auscultation ( Choice B). "Heart rhythm and rate regular" refers to the normal description of the heart rate and rhythm upon cardiac auscultation. Choice D is incorrect. Tympany is a finding noted on percussion, not inspection. The three common sounds that are heard with percussion include resonance, tympany, and dullness. Tympany is a hollow sound heard upon percussion over an air-containing cavity. Physiologically, the tympanic note can be heard over the lungs and the air-filled bowel loops. Examples of pathological conditions where a tympanic note can be heard upon percussion include pneumothorax or an obstructed bowel distended with gas. Learning Objective Understand the proper description of inspection, palpation, percussion, and auscultation findings. Last Updated - 08, Nov 2021

The nurse is providing sensitivity training to new members of the health care team about the best ways to manage and care for families after a miscarriage. The nurse explains that when it comes to telling children about a woman's pregnancy or pregnancy loss, it is the health care team's job to: A. Provide available resources and ultimately support the mother's decision. B. Inform the children of the parents so that they don't have to worry over the task. C. Encourage the parent's not to inform the children of the status of their mother's pregnancy. D. Use a hands-off approach and let the family come up with a solution alone. Submit Answer

Explanation Choice A is correct. It is the health care team's job to provide resources and support to the mother and her family when it comes time to discuss pregnancy and pregnancy loss. Choice B is incorrect. It is not the job of the health care team to inform the children of a woman about her pregnancy or pregnancy loss. Choice C is incorrect. There is no reason that the best option is to withhold information from the children at this point. This is a decision for the parents to make. Choice D is incorrect. A hands-off approach may be tempting, but the health care team should provide resources that are available and provide as much support as possible. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care Last Updated - 26, Oct 2021

The nurse understands that a portion of the pain "assessment" entails the client's subjective, sensory, and emotional comments that indicate the quality or intensity of their pain. The client describes their pain as "crushing and sharp." Select the type of pain a client is experiencing based on this sensory description of their pain. A. Somatic pain B. Visceral pain C. Hurt D. Neuropathic pain Submit Answer

Explanation Choice A is correct. Somatic pain arises from skin and musculoskeletal structures. This type of pain is often reported as sharp, easily localized, gnawing, crushing or throbbing. Sources of acute somatic pain include (and are not limited to) incisional pain, pain at insertion sites of tubes, orthopedic injuries, and wound complications. Choice B is incorrect. "Crushing and sharp" are sensory descriptors of another type of pain, not visceral pain. Visceral pain typically arises from organs and linings of the body cavities. This type of pain is poorly localized, and reported as diffuse, deep cramping or pressure. Choice C is incorrect. The term "hurt" is a word the client uses to inform the health care provider that they are experiencing pain but does not give a sensory description to what type of pain they are experiencing. The nurse should further ask clarification questions to try to get to the type of pain the pain is experiencing when they report they are "hurt". Choice D is incorrect. Neuropathic pain happens when the peripheral nervous system or the central nervous system has abnormal pain processing. This pain may be described as poorly localized, shooting, burning, numbness, tingling or shock-like. Learning Objective Apply knowledge of anatomy and physiology to perform an evidence-based assessment for a client with pain Additional Info Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is the most common reason people seek medical care and the number one reason client's take medication. Pain is a universal, complex, and personal experience that everyone has at some point in their life. Unrelieved pain can diminished quality of life more than any other single health-related problem. The single most reliable indicator that a patient is in pain is their self-report. Pain is whatever the client says it is. Unrelieved pain may prolong a stress response, increase a client's heart rate, blood pressure and oxygen demand. Poorly managed acute pain increases a patients risk for development of chronic pain. Last Updated - 18, Jun 2022

What complication should the nurse monitor for during the immediate postoperative time following a thoracentesis? A. Pneumothorax B. Infection C. Dyspnea D. Aspiration

Explanation Choice A is correct. The most immediate postoperative risk factor is pneumothorax. Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove pleural effusion (excess fluid) from the pleural space to help ease breathing. Some conditions, such as lung disease/infections, heart failure, and tumors may cause pleural effusion. All procedures have some risks. The risks of this procedure may include: air in the space between the lung covering (pleural space) that causes the lung to collapse (pneumothorax), bleeding, infection, and liver or spleen injury (rare). Symptoms of pneumothorax include dyspnea, chest pain, shortness of breath, and pain. Choice B is incorrect. Infection would not be evident during the immediate postoperative period. Choice C is incorrect. Dyspnea is a sign of pneumothorax. Choice D is incorrect. Aspiration is not a complication related to Thoracentesis. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential Last Updated - 23, Jan 2022

The nurse is caring for assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, it would be essential to follow up with which of the following clients? A. P: 109; R: 26; BP: 110/70 mmHg B. P: 90; R: 12; BP: 99/54 mmHg C. P: 100; R: 18; BP: 161/98 mmHg D. P: 88; R: 14; BP: 166/52 mmHg Submit Answer

Explanation Choice A is correct. The pulse and respiration rate of this client is quite concerning. Tachycardia is the earliest sign of shock, and intervention is necessary before the client further deteriorates. Choices B, C, and D are incorrect. Each client has an altered vital sign. However, none of the vital signs are life-threatening compared to the correct response. The nurse should always attend to the unstable client; part of that determination is assessing vital signs. Learning Objective Recognize the normal vital signs in an adult, deviations from the normal, and those that need urgent attention. Additional Info Vital signs are essential in determining a client's clinical stability. Tachycardia (heart rate greater than 100 beats per minute) may be a warning sign for shock. This also could be found in a client experiencing pain, hyperglycemia, hypoglycemia, or anxiety. Tachycardia is the earliest sign of a client developing shock. Tachypnea (respiratory rate greater than 20) may be an expected finding in some pathologies (asthma exacerbation, COPD), but when combined with tachycardia, this is quite concerning. Last Updated - 03, Nov 2022

The nurse has instructed a client who is being discharged with crutches about using stairs. Which statement by the client would indicate a correct understanding of the teaching? A. "I should hold the handrail for support with one hand." B. "Going up the stairs, I should lead with my crutch and weaker leg." C. "Going down the stairs, I should lead with my crutch and strong leg." D. "I should remove the rubber tip when going up and down the stairs." Submit Answer

Explanation Choice A is correct. This statement is correct and indicates an understanding of using crutches. The client should place both crutches on the side away from the handrail and then hold the handrail for support with one hand. The client should lead with their affected leg and crutch as they descend the stairs. Choices B, C, and D are incorrect. These statements are incorrect and require follow-up. When a client is ascending stairs, the client leads with the stronger leg. When the client is descending the stairs, the client should lead with the affected leg. The client must always have a rubber tip on the crutch to ensure appropriate traction. Additional Info When a client is using crutches and has to use stairs, the nurse should emphasize the following points: Have the client hold the handrail for support with one hand, and their strong leg should be next to the railing. The client places a crutch under the axilla of the affected side. Have the client transfer body weight to the crutch while holding the handrail with one hand. Then, have the client support the weight evenly between the handrail and crutch. Next, the client places some weight on the crutch and then steps up the first step with an unaffected leg. Have the client balance by leaning forward with the weight on the unaffected leg. Then ask the client to straighten the good knee, push down on crutches and lift body weight, bringing the affected leg and then the crutch up the stair. The crutch tip is entirely on the stair.

Which of the following indicators would most likely signify to the nurse that a patient with dementia is in pain? A. Rubbing a body part B. Facial droop C. Falling asleep D. A relaxed body position

Explanation Choice A is correct. Vocalizations, facial grimaces, bracing, rubbing, restlessness, and vocal complaints are behaviors in patients with dementia who cannot accurately express their pain. A critical component in evaluating pain is the knowledge of the person's normal behavior and interactions with others. This information is often best provided by family, who can answer questions about typical mood and behavior, body posture, life-long history of pain, and response to pain medications. Nurses should be aware that the following challenging behaviors can all be signs of pain in a patient with dementia: Cursing Combativeness Apathy and withdrawal from activities/interactions Being high maintenance (seemingly challenging to please) Wandering Restlessness Repeating behaviors or words Choice B is incorrect. A facial droop may be associated with a stroke. Choice C is incorrect. Sleep is interrupted when a patient is in pain and the patient may be anxious or restless. Choice D is incorrect. The patient is likely to exhibit bracing or tension of the affected body part, rather than showing a relaxed body position. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort; Barriers to Pain Assessment Last Updated - 13, Feb 2022

The nurse reviews the vital signs of a client admitted to the medical-surgical unit. The unlicensed assistive personnel (UAP) indicates that the client's blood pressure was obtained in the client's leg. The nurse should expect which change in the blood pressure when taken in the leg? A. Systolic pressure in the legs is usually higher by 10 to 40 mm Hg B. Systolic pressure in the legs is decreased by 10 to 40 mm Hg C. Diastolic pressure is the decreased by 10 to 40 mm Hg D. Diastolic pressure is higher by 10 to 40 mm Hg Submit Answer

Explanation Choice A is correct. When blood pressure is obtained in the leg, the systolic blood pressure is increased by up to 10 to 40 mm Hg compared to blood pressure obtained over the brachial artery. The higher SBP is due to the calcification in the distal arteries, which raises the SBP. DBP in the lower extremities is usually the same when compared to the upper extremities. Choices B, C, and D are incorrect. SBP is increased when it is obtained in the lower extremities; it is not decreased. DBP is unaffected when obtained in the lower extremities Additional Info Dressings, casts, IV catheters, arteriovenous fistulas or shunts can make the upper extremities inaccessible for BP measurement. If this is the case, obtain the BP in a lower extremity. Systolic pressure in the legs is usually higher by 10 to 40 mm Hg than in the brachial artery, but the diastolic pressure is the same. Last Updated - 13, Jun 2022

The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. What is the next step to do with the urine specimen? A. Place it in a separate container and later add to the collection. B. Discard it, then the collection process begins C. Test it, then discard D. Save as part of the 24-hour collection

Explanation Choice B is correct. A 24-hour urine collection may be ordered to evaluate the type and severity of certain renal disorders. The nurse is responsible for providing the collection container and educating the patient on the correct process of collecting the specimen. At the beginning of the 24-hour urine procedure, the patient should not collect or save the first urine specimen. This first void is considered "old urine" or urine in the bladder before the test began. This specimen should be flushed and the time at which its discarded is noted. After the first discarded specimen, urine is collected for the next 24 hours. Choices A, C, and D are incorrect. The first urine is not saved or tested but discarded. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential Last Updated - 19, Jan 2022

Which statement about palliative care at the end of life is most accurate? A. Palliative care at the end of life is conducted in hospice centers. B. Palliative care at the end of life can occur in all care settings. C. Narcotic pain medications can be used in palliative care, but not in curative care. D. Narcotic pain medications can be used in curative care, but not in palliative care. Submit Answer

Explanation Choice B is correct. Palliative care at the end of life can occur in all care settings. Palliative care is also referred to as hospice care. It is a philosophy of care that can, and is, carried out in all healthcare settings, including in the client's home. Narcotic pain medications can be used at the end of life using the palliative/hospice care philosophy as well as with curative care. Choice A is incorrect. Palliative care at the end of life can be conducted in hospice centers as well as in other settings and environments. Choice C is incorrect. Narcotic pain medications are not restricted, and they can be used in curative care. Choice D is incorrect. Narcotic pain medications are not restricted, and they can be used in palliative care. Last Updated - 26, Jan 2022

The nurse is assisting a client using a fracture bedpan. Which action should the nurse take? A. Position the client prone while applying the bed pan B. Raise the head-of-bed to 30 degrees C. Place the open rim of the bedpan facing toward the head of the bed D. Lower all of the side rails Submit Answer

Explanation Choice B is correct. Placing the head-of-bed at 30 to 60 degrees will facilitate comfort by preventing strain on the lumbar spinal column. Choices A, C, and D are incorrect. When applying the bedpan, the client should be supine, not prone. The open rim of the bedpan should be facing toward the foot of the bed. This will prevent spillage and promote comfort. All of the side rails should not be lowered. The nurse should raise the side rail on the opposite side of the bed. This will allow the client to turn so the nurse may place the bedpan. Additional Info Two types of bedpans are available The regular bedpan, made of plastic, has a curved smooth upper end and a sharper-edged lower end and is about 5 cm (2 inches) deep. The smaller fracture pan, designed for clients with lower-extremity fractures, has a shallow upper end about 2.5 cm (1 inch) deep. The shallow end of the pan fits under the buttocks toward the sacrum; the deeper end, which has a handle, goes just under the upper thighs. The pan needs to be high enough that feces enter it. The appropriate position for the client is 30 to 60 degrees. A client may be positioned on a bedpan by having them roll to the opposite side (using the side rail for leverage) or lifting up their buttocks so the pan may be placed. Potter, P., Perry, A., Stockert, P., Hall, A. (012022). Fundamentals of Nursing, 11th Edition. Last Updated - 15, Nov 2022

The nurse observes that an 85-year-old man at an adult daycare center fondly shares stories about traveling on the "orphan trains" prior to being adopted. The nurse should perform which intervention? A. Refer him for a geriatric psychiatric evaluation. B. Listen and ask him questions about his life. C. Distract him and change the conversation. D. Involve him in more social activities. Submit Answer

Explanation Choice B is correct. Taking the time to listen and ask the client questions about his life shows that the nurse is interested in the patient. It also helps increase his self-concept. Reminiscence about past life events, doing a life review, especially if the experiences were positive, is considered to be a regular psychosocial activity for older adults. It helps them to focus on past accomplishments and contributions to society, thus increasing their self-concept. Choice A is incorrect. If behavioral or significant memory problems had been noted, a geriatric psychiatric consult would be appropriate, but that is not so in this situation. Choices C and D are incorrect. While social activities and conversations should be encouraged, it should not be done to the point of demeaning the importance of his life stories. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Promoting health in older adults Last Updated - 18, Jan 2022

You are working in a pediatric unit with acutely and chronically ill pediatric clients. Which of the following pain assessment tools would you most likely use to assess pain and pain intensity among your clients who range in age from 2-years-old to 10-years-old? A. NIPS Pain Scale B. FLACC Scale C. PAINAD Pain Scale D. CRIES Scale Submit Answer

Explanation Choice B is correct. The FLACC Pain Scale is a valid and reliable pain assessment tool for the assessment of pain/pain intensity among clients who range in age from 2 years old to 10 years old. The FLACC scale consists of pain behavior assessments, such as: F: Face expressions, such as grimacing L: Movement of the legs A: Level of activity C: Crying C: Degree to which the child is consolable Choice A is incorrect. You would not use the Neonatal Infant Pain Scale (NIPS). The NIPS scale is only valid and reliable for infants and neonates. Choice C is incorrect. You would not use the PAINAD Pain Scale. The PAINAD Pain Scale is only valid and reliable for elderly adults who are adversely affected with advanced dementia. Choice D is incorrect. You would not use the CRIES pain scale because this pain assessment tool is valid and reliable only for neonates. Last Updated - 15, Jan 2022

The nurse is planning a staff development conference about vaccines. Which of the following information should the nurse include? A. MMR vaccine should be administered in the first trimester of pregnancy. B. Human Papillomavirus vaccine can reduce the risk of cervical cancer. C. Influenza vaccine may be administered to an infant at 3 months. D. Herpes zoster vaccine is recommended starting at age 40.

Explanation Choice B is correct. The Human Papillomavirus (HPV) vaccine is the only vaccine proven to decrease the risk of cervical cancer. Nearly all cases of cervical cancer are linked to HPV and thus, the vaccine is an effective primary prevention method. Choices A, C, and D are incorrect. MMR vaccine is contraindicated during pregnancy. The client should not receive this vaccine or any other live vaccines during the pregnancy period. The seasonal influenza vaccine is an effective prevention method for children 6 months and older. Herpes zoster immunization is recommended starting at age 50. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Vaccine administration Question type: Analysis Additional Info The MMR vaccine should not be administered to clients currently pregnant or four weeks prior to pregnancy. This is a two-series vaccine and is recommended for children starting at 12 to 15 months. The HPV Vaccine is available as a two or three-dose vaccine depending on which age it is started. Initial vaccination is recommended for males and females aged 11 to 12. The vaccine is recommended up to age 26. This vaccine is not recommended during pregnancy. The influenza vaccine comes in a variety of preparations - recombinant influenza vaccine, this vaccine is recommended for those aged 18 or older; inactivated influenza vaccine (IIV), which is recommended for ages six months or greater; live attenuated influenza vaccine (LAIV) that is given intranasally for those aged 2 through 49. The herpes zoster vaccine is recommended for individuals aged 50 or greater. This vaccine protects a client against shingles. This vaccine should be administered regardless of prior infection of varicella or herpes zoster. Last Updated - 28, Apr 2022

A client with episodes of vertigo who has a fractured leg has been ordered crutches and not to bear weight on the affected extremity. The most appropriate crutch-walking gait the nurse should teach the client is the A. Two-point gait B. Three-point gait C. Four-point gait D. Swing-through gait Submit Answer

Explanation Choice B is correct. The three-point gait is most appropriate because the client is of non-weight bearing status on the affected leg. In a three-point gait, the client bears weight on both crutches and then the unaffected leg. This gait is also appropriate because it is slower than the swing-through gait, which requires more balance and is faster. Choices A, C, and D are incorrect. The two-point gait requires at least partial weight bearing on each foot. This gait would be inappropriate because the client is instructed to have non-weight bearing status on the affected leg. The four-point, gait gives stability to the client but requires weight-bearing on both legs. This gait would be inappropriate because the client has non-weight bearing status ordered to the affected extremity. If the client has complete paralysis of the hips and legs, the swing-to gait or swing-through gait is utilized. While a swing-to gait may be utilized if the client has a non-weight bearing status of an extremity, this would not be recommended because the client has a history of vertigo. The swing-through gait requires the client to swing forward as a pendulum, which may increase their risk of falling. Additional Info The basic crutch stance is the tripod position, formed when the crutches are placed 6 inches in front of and 6 inches to the side of each foot. This position maintains a client's balance by providing a wider support base. Last Updated - 07, Jul 2022

Which type of intravenous therapy complication is most likely to occur when the intravenous catheter is too large for the vein that is being used for intravenous therapy? A. Hematoma B. Mechanical phlebitis C. Fluid overload D. Bacterial phlebitis Submit Answer

Explanation Choice B is correct. The type of intravenous therapy complication that is most likely to occur when the intravenous catheter is too large for the vein that is being used for the intravenous therapy is mechanical phlebitis. Mechanical phlebitis, one of the three types of intravenous therapy phlebitis, occurs as the result of vein irritation, which can happen when the vein becomes irritated by a catheter that is too large for the vein. Choice A is incorrect. Hematoma, secondary to intravenous therapy, does not occur when the intravenous catheter is too large for the vein; it occurs as the result of other potential causes. Choice C is incorrect. Fluid overload, secondary to intravenous therapy, does not occur when the intravenous catheter is too large for the vein; it occurs as the result of other potential causes. Choice D is incorrect. Bacterial phlebitis, secondary to intravenous therapy, does not occur when the intravenous catheter is too large for the vein; it occurs as the result of other potential causes. Last Updated - 20, Dec 2021

The nurse preceptor is observing a newly hired nurse care for a client with a tracheostomy. Which of the following actions by the newly hired nurse would require follow-up by the observing nurse preceptor? A. Applies suction to the catheter as it is removed in a twirling motion. B. Inflates the tracheostomy's cuff with 5 mL of air prior to suctioning. C. Preoxygenates the client with 100% oxygen prior to suctioning. D. Provides mouth care after suctioning the tracheostomy. Submit Answer

Explanation Choice B is correct. These observations are inappropriate and require follow-up. Inflating the cuff of the tracheostomy is not something that is done before suctioning. The purpose of the cuff is to keep the tracheostomy in place. Overinflation can result in significant damage; thus, monitoring the cuff pressure should be done with a manometer. Normal pressure should range between 14-20 mmHg. Choices A, C, and D are incorrect. Suctioning the catheter using a twirling motion is appropriate if the suction is applied during the removal of the catheter. This should only occur once the client has been preoxygenated with 100% oxygen prior to suctioning. Mouth care should be completed after suctioning because this helps decrease pneumonia and promotes comfort. Additional Info Source : Archer Review Cuff pressure should be checked at least once a shift with a manometer. If the cuff is overinflated, it may cause ischemia in the mucosa. Inflating the cuff is indicated if the client is receiving mechanical ventilation as this ensures that it is securely in place to receive the ventilations. A leak in the cuff would trigger the low-pressure alarm if the client were receiving mechanical ventilation.

The nurse is caring for a patient that has just undergone left-sided thoracentesis. All of the following should be included by the nurse in his/her care plan, except: A. Document the amount of fluid withdrawn from the patient. B. Have the client turn on his left side. C. Have the client turn on his right side. D. Palpate the area around the site for a crackling sensation.

Explanation Choice B is correct. This is not an appropriate intervention, therefore the correct answer to the question. Following thoracentesis, the nurse should place the client on his unaffected side (right side in this case) for one hour to facilitate lung expansion. Placing on the left side is inappropriate in a client who just underwent left-sided Thoracentesis. Choices A, C, and D are incorrect. These are appropriate interventions that should be included in the nursing care plan post-Thoracentesis. The nurse should document the amount of fluid drained from the patient (Choice A) to ascertain how much residual fluid may be left in the pleural space. This documentation is also necessary so that it can be sent to the lab for analysis if needed. The nurse should place the client on his unaffected side (Choice C) for one hour to facilitate lung expansion. Subcutaneous emphysema is defined as a condition where the air gets into soft tissues under the skin. Often, it manifests as painless swelling of tissues. The characteristic clinical sign is a crackling sensation (Choice D) upon touch (like touching a sponge beneath the fingers). Subcutaneous emphysema is a common occurrence during a Thoracentesis and should be assessed by the nurse. Although it does not cause any problem, clients need to be reassured to prevent anxiety. Last Updated - 15, Nov 2022

Tympany is a percussion sound commonly located in the: A. Upper arm B. Abdomen C. Lower leg D. Thorax

Explanation Choice B is correct. Tympany is the percussion sound heard over the abdomen. Percussion is part of the physical assessment, which is done to produce sound or elicit tenderness. The person who is assessing will tap fingers on the patient, similar to the tapping of a drumstick on a drum. The vibrations that the fingers produce create percussion tones conducted into the patient's body. If the waves travel through dense tissue, the percussion tones are quiet or flat. If they go through air or fluid, the tones are louder. The loudest tones are over the lungs and hollow stomach. The most peaceful percussion sounds are heard over bones. Percussion sounds are described as hyperresonant (diseased lungs), full (healthy lungs), tympanic (abdomen), dull (organs), and flat (over bones). Choices A, C, and D are incorrect. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Percussion Last Updated - 12, Feb 2022

The nurse has just inserted an indwelling urinary catheter for a male client. The nurse plans on securing the catheter to the client's A. inner thigh. B. lower abdomen. C. outer thigh. D. medial thigh. Submit Answer

Explanation Choice B is correct. When securing an indwelling urinary catheter for a male, it is appropriate to anchor it to the lower abdomen or upper thigh. The catheter tubing should be secured to the lower abdomen or the upper thigh to prevent urethral injury. Choices A, C, and D are incorrect. These are anatomical locations are inappropriate for securing an indwelling catheter. When securing an indwelling catheter for a female, it should be anchored to the inner thigh. Additional Info When securing an indwelling catheter, the following should occur - The catheter should be attached to a male's upper thigh or lower abdomen. For a female, the catheter should be connected to the inner thigh. The catheter should be secured with an adhesive device. The device is typically gently removed with an alcohol swab to avoid a shearing injury to the skin.

The nurse is assigned to supervise a new unlicensed assistive personnel (UAP) in completing personal hygiene tasks. Following the UAP gathering the needed supplies, performing hand hygiene, and donning clean gloves, you observe the UAP provide a bed bath to an elderly client on complete bed rest. The UAP begins by first washing the client's forehead. What should be the nurse's next action? A. Praise the new UAP because they have correctly washed the client's forehead first. B. Instruct the UAP that the inner canthus of the eyes should be washed first and use a new washcloth to do so. C. Instruct the new UAP that the outer canthus of the eyes should be washed first. D. Have the UAP stop and don sterile gloves for the bed bath. Submit Answer

Explanation Choice B is correct. You would instruct the new UAP that the inner canthus of the eyes should be washed first, followed by the outer canthus of the eyes. Once the eyes have been cleansed in this manner, the UAP may then move on to the remainder of the face. Choice A is incorrect. As described in Choice B, the forehead is not the correct area to cleanse first; therefore, you would not provide positive feedback to a UAP who initiates a bed bath by cleansing the forehead region. Choice C is incorrect. As described in Choice B, the outer canthus is not the correct area to cleanse first; therefore, you would not provide positive feedback to a UAP who initiates a bed bath by cleansing the outer canthus prior to the inner canthus. Choice D is incorrect. Before performing this bed bath, the UAP correctly performed hand hygiene and donned clean gloves. Sterile gloves are not needed when performing a bed bath and instructing the UAP to don sterile gloves would be incorrect. Learning Objective Recognize the correct manner to perform a bed bath in order to minimize the risk for infection. Additional Info To reduce the risk of infection, always perform hygiene measures while moving from cleanest to less clean or dirty areas. This often requires you to change gloves and perform hand hygiene during care activities. Begin with the inner canthus and move to the outer canthus. Bathing the eye from inner to outer canthus prevents secretions from entering the nasolacrimal duct. When washing a client's eyes, use plain warm water, as soap irritates the eyes. Use different sections of the washcloth or mitt for each eye to avoid transmission of any infection. Any rough patches may need to be soaked prior to removal. Gently, but thoroughly, dry the eyes as pressure can cause internal injury.

You have offered one of your newly admitted clients a partial bed bath. The client states, "I took a bath at home three days ago. I do not need a bath for another 3 or 4 days." How should you respond to this client? You should respond by saying: A. "Would it be okay with you if I teach you about the benefits of and the need for daily bathing?" B. "That is fine. At what time of the day do you prefer to bathe and do you prefer a shower or tub bath?" C. "A once a week bath is not good. You have to bathe at least every other day to protect against infection." D. I am sorry but we have rules here. All clients must be bathed at least every other day. Let's start the bath." Submit Answer

Explanation Choice B is correct. You would respond with, "That is fine. At what time of the day do you prefer to bathe, and do you prefer a shower or tub bath?" when one of your newly admitted clients refuses a partial bed bath by stating, "I took a bath at home three days ago. I do not need a bath for another 3 or 4 days." This response acknowledges the fact that the frequency of bathing, bathing routines, and practices vary among individuals and cultures. Clients should be assessed for their bathing needs in preferences of their type of bathing and time of bathing. Additionally, a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic. Choice A is incorrect. You would not respond with, "Would it be okay with you if I teach you about the benefits of and the need for daily bathing?" because a daily bath is not always necessary and a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic. Choice C is incorrect. You would not respond with, "A once a week bath is not good. You have to bathe at least every other day to protect against infection" because a daily bath is not always necessary, and a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic. Choice D is incorrect. You would not respond with, "I am sorry, but we have rules here. All clients must be bathed at least every other day. Let's start the bath" because a daily bath is not always necessary, and a bath once a week is acceptable as long as the client remains clean, without bodily odors, and is still hygienic. Additionally, you're saying, "Let's start the bath," which indicates that you are violating this client's right to choose and refuse all care and treatments. Last Updated - 02, Dec 2021

The nurse is caring for a client with the following clinical data. Based on the clinical data, the nurse should clarify which prescription with the primary healthcare provider (PHCP)? See the image below. A. Urine analysis (UA) B. Head CT Scan C. Regular diet D. Ammonia level Submit Answer

Explanation Choice C is correct. A regular diet prescription should be questioned because of the client's medical history of diabetes mellitus and hypertension. The appropriate diet would be one restricted in carbohydrates and sodium. Thus, the nurse should follow up with the PHCP regarding this order. Choices A, B, and D are incorrect. A UA is a logical and plausible prescription for this client. Older adults may manifest infection as altered mental status. A CT scan should be obtained to rule out any structural abnormalities such as infarcts. An ammonia level is useful to determine if the patient has any type of metabolic encephalopathy. The level would be high if this was concerning. Additional Info AMS may be caused by a plethora of reasons, including infections such as neurosyphilis, cystitis, brain injury, dementia, delirium, or a psychiatry pathology. The nurse must implement measures to keep the client safe such as fall precautions. The client with altered mentation is at increased risk of falling. Last Updated - 31, Aug 2022

The nurse is caring for a client that underwent an above-the-knee amputation more than 24 hrs ago. Which intervention by the nurse should not be included in the care of the client? A. Placing the client in prone position. B. Elevate the foot of the bed with the head flat. C. Elevate the residual limb on a pillow. D. Maintain the application of an elastic compression wrap. Submit Answer

Explanation Choice C is correct. Elevating the residual limb using a pillow is an incorrect intervention, therefore the correct answer to this question. Proper positioning of the residual limb is crucial in preventing flexion contractures. For the first 24 hours, the residual limb should be elevated using a pillow to increase venous return and decrease edema. However, beyond 24 hours, the pillow must be removed and the residual limb should be placed flat on the bed. Elevation of the residual limb on a pillow beyond 24 hours makes the client with above-knee-amputation prone to hip flexion contractures. A flexion contracture refers to the shortening of muscles and tendons leading to deformity and rigidity of joints. The client should be encouraged to lay prone for at least 30 minutes several times a day to reduce the risk of contractures. Prolonged sitting in a chair and semi-Fowler's position must be discouraged. The nurse should also educate the client to avoid external rotation of the hip by using a trochanter roll in bed. Choice A is incorrect. This is a correct intervention. Placing the client in a prone position stretches the muscles and helps prevent hip flexion contractures. Choice B is incorrect. This is a correct intervention. Elevating the foot end of the bed helps prevent edema; keeping the head flat helps in preventing hip flexion contractures. Choice D is incorrect. This is a correct intervention. Elastic wraps on the client's residual limb help with swelling, minimizing pain, and molding it in preparation for a prosthesis. Last Updated - 14, Jan 2022

Ergonomically designed chairs are best designed to provide support to which region of the spine? A. The cervical spine B. The thoracic spine C. The lumbar spine D. The sacral spine Submit Answer

Explanation Choice C is correct. Ergonomically designed chairs are commonly designed with a primary focus on providing lumbar spine support. Although the chairs often provide some level of support to various levels of the spinal column, the lumbar spine is the most common region for back pain to occur and therefore is the spinal region ergonomically designed chairs routinely support. Each curve of the spine (including lumbar) is shown in the image below. Choice A is incorrect. The cervical spine is not typically supported by ergonomically designed chairs. Choice B is incorrect. Although ergonomically designed chairs do support the thoracic spine when an individual leans back, proper positioning would often have an individual sitting upright at a 90-degree angle. Choice D is incorrect. While ergonomically designed chairs do support the sacral spine, the chairs concentrate on the lumbar region of the back primarily due to society's high prevalence of lumbar back pain complaints. Learning Objective Correlate the lumbar spinal column as the region of the back which needs support when sitting in ergonomic office chairs. Additional Info The lumbar spine—where most back pain occurs—includes five vertebrae (L1-L5). The lumbar region supports the majority of the upper body weight.

A client is about to go for a CT angiogram, which involves the administration of an intravenous radiopaque dye. In preparing the client for the procedure, the nurse's responsibility is to educate him by saying: A. "You should expect some chest tightness during the procedure." B. "You should expect a burning sensation at the intravenous site." C. "You will likely experience flushing of the face." D. "An allergic reaction may cause a decline in your kidney function."

Explanation Choice C is correct. Flushing of the face is an expected response to the intravenous administration of contrast dye. Many diagnostic and imaging procedures (CT scans, angiograms, myelograms) involve intravenous radiocontrast (intravenous dye, iodinated contrast). These contrast dyes contain iodine. Most patients experience a warm sensation throughout the body shortly after contrast dye infusion. This is more pronounced in the face and throat and moves to the pelvic area after that. Choice A is incorrect. Chest tightness may be experienced during a moderate to severe hypersensitivity reaction and is not an expected response. Choice B is incorrect. Burning at the intravenous site is not a usual expected response with the use of IV contrast dye. Choice D is incorrect. Iodinated contrast is also toxic to the kidneys, and this is not an allergy and is a direct harmful effect. The serum creatinine of the clients receiving iodinated contrast must be checked before the procedure. Contrast dye must not be given if the estimated glomerular filtration rate (GFR) is less than 30 ml/min. For those at risk of renal toxicity, intravenous hydration must be given following contrast-containing procedures. NCSBN Client Need: Topic: Physiological integrity; Sub-topic: Reduction of Risk Potential. Additional Info Allergic reactions to intravenous contrast are seen only in about 5% to 8% of patients. Such reactions, therefore, are not expected responses. The contrast media acts directly to release histamine and other mediators from mast cells. There is no allergic antibody mediating this reaction, and hence, it is referred to as a "pseudo-allergy." Last Updated - 19, Nov 2021

The mother of a 14-year-old boy with cystic fibrosis approached the nurse and voiced out her concern, "I caught him masturbating, and it disturbs me. How do I make it stop?" The most appropriate response for the nurse is: A. "Let him be. Not masturbating results in nocturnal emissions." B. "Tell him off. That behavior is not normal for 14-year-olds." C. "Let him be. It is completely normal and provides a sexual experience for him without invoking risk or harm." D. "That is not appropriate at all. It suggests a lack of interest in normal sexual expression." Submit Answer

Explanation Choice C is correct. Masturbation is normal behavior during adolescence, that provides for sexual relief without requiring a sexual relationship, for which an adolescent may not be ready. Choices A, B, and D are incorrect. Masturbation is not associated with nocturnal emissions and is considered normal behavior for 14-year-olds. Last Updated - 02, Feb 2022

You are caring for an infant who may or may not be experiencing pain as a result of circumcision. Which independent nursing intervention would you implement in terms of managing this pain, if any pain is present? A. No interventions are needed because infants do not experience pain with a circumcision. B. Apply topical lidocaine to the penis. C. Play an audiotape of a heartbeat. D. Give the infant a "magic" blanket to take the pain away.

Explanation Choice C is correct. Please note that the question is asking for an age-appropriate and independent nursing intervention. In this case, playing an audiotape of a heartbeat that mimics the mother's heart when the infant was in utero is an age-appropriate, independent nursing intervention that you could implement in terms of managing this pain. Choice A is incorrect. It is not accurate to say that no interventions are needed because infants do not experience pain with a circumcision - infants do experience pain with a circumcision. Some studies have described circumcision as one of the most painful procedures performed in neonatal medicine. Pain in these infants can cause increases in heart rate to as high as 50 percent above the baseline. Their level of pain can be assessed with an infant pain scale like the CRIES scale, which has pain behavior criteria. Choice B is incorrect. The application of topical lidocaine to the penis is not an independent nursing intervention; it is a dependent intervention that requires a doctor's order. Choice D is incorrect. Giving the infant a "magic" blanket to take the pain away is not an age-appropriate, independent nursing intervention that you could implement in terms of managing this pain. Magical and mystical thinking begins when the child is a toddler. So, a toddler, rather than an infant, can benefit from a "magic" blanket to reduce the pain.

The nurse is talking to a woman who had just finished a radioiodine test in the outpatient department. The nurse is instructing her about strategies that she should implement after the test to avoid contaminating her family with radiation. The nurse knows that the client needs additional health teaching when she states: A. "I will have to stop sharing my food with my husband for a couple of days." B. "My kids will be missing my hugs and kisses for a few days." C. "I guess I'll go on holiday for a couple of weeks to prevent my kids from getting any radiation from me." D. "I'll need to remember to double flush the toilet for the next few days." Submit Answer

Explanation Choice C is correct. The client states that she needs to isolate herself from her family by going on a vacation for a few weeks is inaccurate. Unless the dosage is extremely high, there is no need to separate the client from her family. Choice A is incorrect. The client saying that she will have to stop sharing food with her husband for the next few days is a correct statement regarding strategies that prevent radioactive contamination. The client's bodily fluids are contaminated with radiation for the next few days until it is excreted from her system. Plans would include the following: avoid sharing food and eating utensils, avoid having close contact with children and kissing for several days, flush the toilet twice after use, and avoid breastfeeding. Choice B is incorrect. The client saying that she will have to stop hugging and kissing her children for the next few days is a correct statement regarding strategies that prevent radioactive contamination. The client's bodily fluids are contaminated with radiation for the next few days until it is excreted from her system. Plans would include the following: avoid sharing food and eating utensils, avoid having close contact with children and kissing for several days, flush the toilet twice after use, and avoid breastfeeding. Choice D is incorrect. Double flushing the toilet makes sure that the client's urine is wholly flushed away, preventing any radioactive substances to pool into the toilet bowl. Last Updated - 04, Feb 2022

What is the priority nursing intervention for a newly admitted client with the possible nursing diagnosis of self-care deficit: bathing and hygiene? A. Helping the client with their self-care needs in terms of bathing and hygiene. B. Asking a family member to assist the client with their bathing and hygiene self-care needs. C. A thorough assessment of the client in terms of their self-care strengths and weaknesses. D. A thorough assessment of the client in terms of their bathing and hygiene preferences.

Explanation Choice C is correct. The priority nursing intervention for a newly admitted client with the possible nursing diagnosis of "self-care deficit: bathing and hygiene" is to perform the priority first phase of the nursing process. Your priority nursing intervention is to perform a thorough assessment of the client in terms of their bathing and hygiene self-care strengths and weaknesses so that you can determine if the client has or does not have a possible self-care deficit in terms of bathing and hygiene. Choice A is incorrect. Helping the client with their self-care needs in terms of bathing and hygiene may be an appropriate nursing intervention for this client. However, there is something else that you would do first. Choice B is incorrect. Asking a family member to assist the client with their bathing and hygiene self-care needs may be an appropriate nursing intervention for this client. However, there is something else that you would do first. Choice D is incorrect. Although you would perform a thorough assessment of the client in terms of their bathing and hygiene preferences, this is not the priority. There is something else that you would do first. Last Updated - 07, Dec 2021

A newly licensed registered nurse is tasked by a nurse educator to perform a wet-to-dry dressing change on a client with a stage 3 pressure ulcer. Which action would indicate to the nurse educator that the registered nurse is following proper technique? A. The registered nurse cleans the ulcer from the outside, rotating into the inside of the ulcer. B. The registered nurse packs the incision with sterile gauze, then pours sterile normal saline over the dressing. C. The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin. D. The registered nurse saturates the old dressing with sterile saline before removing it.

Explanation Choice C is correct. The wet dressing should not touch the intact skin as this may cause skin breakdown and potentially introduce additional pathogens into the wound. Choice A is incorrect. The registered nurse should clean in a circular motion, beginning from the inside and rotating outward. Once the nurse reaches the edge of the wound, the nurse should change gloves and equipment. Choice B is incorrect. When a wet-to-dry dressing is ordered, dressings are to be soaked before application to the client's tissue. The dressing is then allowed to dry while on the client, therefore allowing the removal of that dressing to essentially debride a small portion (i.e., existing debris and necrotic tissue if applicable) of the wound before the replacement dressing is applied. Choice D is incorrect. Saturating the existing dressing prior to removal would defeat the purpose of having the dressing removed dry. Dry removal allows debris and necrotic tissue to be removed with the dressing. Learning Objective When performing a wet-to-dry dressing, correctly identify that the proper technique includes avoiding having the wet dressing touch the intact skin. Additional Info A wet-to-dry dressing is a dressing that provides a type of mechanical debridement. The dressing should consist of one continuous length of gauze. Utilize the expertise of wound care clinicians in the treatment of pressure ulcer clients. Pressure injuries can develop secondary to immobilization and hospitalization, particularly in clients who are elderly, incontinent, and/or undernourished. Base the risk of pressure injury on standardized scaling systems and on the assessment of skilled clinicians. Last Updated - 28, Nov 2022

The nurse is teaching a client about ambulating with a cane. It would indicate effective teaching if the nurse observes the client A. position the cane on their weaker side. B. advances their weaker leg first, then the cane. C. measures the height of the cane from their wrist crease. D. advances the cane 12-16 inches with each step. Submit Answer

Explanation Choice C is correct. This observation is correct and reflects effective teaching. The nurse should instruct the client that the height of the cane should be measured with the client facing forward, wearing their shoes, and either from their wrist crease or greater trochanter. Choices A, B, and D are incorrect. These observations are incorrect and require further teaching. The cane should be positioned on the client's unaffected (stronger) side. The cane should be advanced at the same time as the affected (weaker) leg, followed by the unaffected (stronger) leg. To prevent the client from falling, the cane should be advanced 6-10 inches. Additional Info When a client ambulates with a cane, the nurse should ensure that a gait belt is applied before getting out of bed. The nurse is positioned on the client's affected (weaker) side, slightly behind the client. Measure the height of the cane from the wrist crease or greater trochanter The cane should be held on the unaffected (stronger) side. The elbow should be flexed 15-30 degrees. The cane should be advanced (6-10 inches) along with the affected (weaker) leg. Remember the mnemonic: COAL- Cane Opposite Affected Leg. Then, the unaffected (stronger) leg should be advanced just past the cane. A rubber tip should always be applied to a cane to ensure appropriate traction with the ground.

The nurse supervises a student nurse auscultating lung sounds on a group of clients. Which statement by the student nurse would require follow-up? A. "Wheezes arise from the small airways and usually do not clear with coughing." B. "A pleural friction rub causes loud, rough, scratching sounds usually during inspiration." C. "Thick, tenacious secretions that clear with coughing cause crackles." D. "Fluid or secretions in large airways typically cause coarse crackles." Submit Answer

Explanation Choice C is correct. This statement requires follow-up because it is incorrect. Thick, tenacious secretions that clear with coughing cause rhonchi. Choices A, B, and D are incorrect. These statements are factual and do not require any follow-up. Please see the additional information section for an overview of the adventitious lung sounds. Additional Info Wheezing creates squeaky, musical, continuous sounds associated with air rushing through narrowed airways; it may be heard without a stethoscope. Wheezes originate from the small airways and usually do not clear with coughing. Treatment for wheezing is bronchodilators and inhaled anticholinergics. Pleural friction rub is characterized by loud, rough, grating, scratching sounds caused by the inflamed surfaces of the pleura rubbing together, often associated with pain on deep inspirations. Stridor is a medical emergency and indicates that the upper airways (larynx or pharynx) are closing. Coarse crackles are lower-pitched, coarse, rattling sounds caused by fluid or secretions in large airways, likely to change with coughing or suctioning. Fine crackles sound like popping, discontinuous sounds caused by air moving into previously deflated airways; sounds like hair being rolled between fingers near the ear. Rhonchus (rhonchi) are lower in pinch and sound like continuous snoring sound. These sounds arise from the large airways and usually can be cleared with coughing. Last Updated - 11, Jul 2022

A nurse is caring for a client receiving total parenteral nutrition (TPN). Strict surgical asepsis is required when changing TPN dressings and tubing because: A. The TPN requires refrigeration, and once the TPN is opened and is no longer refrigerated, it presents a risk for infection. B. The presence of manganese and zinc in TPN increases the risk of infection. C. The magnesium and cobalt often present in TPN increases the risk of infection. D. The high concentration of dextrose in TPN increases the risk of infection.

Explanation Choice D is correct. Due to the nutritional needs of clients requiring total parenteral nutrition (TPN), formulations of TPN typically contain a high concentration of dextrose (typically 10% to 50%), leading to an increased predisposition to catheter-related bloodstream infections. To prevent these infections, aseptic technique is utilized. Choice A is incorrect. TPN does not require refrigeration. Choice B is incorrect. Although specific formulations of TPN may contain varying amounts of manganese and zinc, these elements do not predispose the client to increased infection risks. Choice C is incorrect. While certain formulations of TPN may contain magnesium and cobalt, these minerals do not increase a client's risk for infection. Learning Objective Understand why an aseptic technique is utilized when performing dressing or tubing changes for clients receiving total parenteral nutrition (TPN). Additional Info TPN lines should not be used for any purpose other than TPN administration. A single container of parenteral nutrition should never hang for more than 24 hours. Lipids should not hang for more than 12 hours. Last Updated - 13, Aug 2022

Which of the following is a physiological alteration that can occur with stress? A. Decreased visual acuity B. Increased peristalsis C. Decreased glucocorticoids D. Hyperglycemia Submit Answer

Explanation Choice D is correct. Hyperglycemia is a physiological alteration that can occur with stress among both diabetic and non-diabetic clients. This hyperglycemia occurred as the result of increased secretion of glucocorticoids and increased gluconeogenesis that is part of the general adaptation syndrome and the "fight or flight" phenomena. Choice A is incorrect. Increased, rather than decreased, visual acuity is the result of the general adaptation syndrome and the "fight or flight" phenomena. Improved visual acuity allows the person to be more vigilant and aware of their environment. Choice B is incorrect. Decreased, rather than increased, gastrointestinal system peristalsis occurs as the result of the general adaptation syndrome and the "fight or flight" phenomena in response to stress. Natural resources are directed to higher priority bodily functions rather than gastrointestinal functioning. Choice C is incorrect. The increased secretion of glucocorticoids, rather than decreased glucocorticoids, in addition to increased gluconeogenesis, are part of the general adaptation syndrome and the "fight or flight" phenomena. These increases raise blood sugar levels. Last Updated - 23, Dec 2021

The nurse is using the therapeutic communication technique while caring for her prenatal client. Which phrase, when used by the nurse, is an example of "focusing"? A. "You're afraid your baby will be born after your due date. Is that correct?" B. "I've noticed a lot of bruising on your arms." C. "What would you like to talk about during our appointment today?" D. "Earlier you mentioned feeling scared at home. I'd like to talk about that a bit more. What is causing you to feel scared at home?" Submit Answer

Explanation Choice D is correct. Saying, "Earlier you mentioned feeling scared at home. I'd like to talk about that a bit more. What is causing you to feel scared at home?" is an example of a therapeutic communication technique known as "focusing". During conversations, patients may mention certain issues that are important to them. When this happens, nurses can focus on the client's self-perceived priorities, prompting them to discuss issues further. Choice A is incorrect. Saying, "You're afraid your baby will be born after your due date, is that correct?" is known as seeking clarification. Choice B is incorrect. Saying, "I've noticed a lot of bruising on your arms," is making an observation. Choice C is incorrect. Saying, "What would you like to talk about during our appointment today?" is known as using a broad opening. Last Updated - 10, Feb 2022

The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first? A. Administer PRN analgesic. B. Obtain STAT EKG. C. Encourage ambulation. D. Discuss the pain with the patient. Submit Answer

Explanation Choice D is correct. Shoulder pain may occur following a cesarean section due to gas or referred pain from the surgery. The nurse should assess the patient's pain to determine the cause before administering medications or other interventions. Choice A is incorrect. The nurse should first assess the patient's pain to determine the cause before administering pain medication. Choice B is incorrect. The nurse should first assess the patient's pain. If assessment data indicates the patient's pain is cardiac, an EKG may be indicated. Choice C is incorrect. Ambulation may help if the patient's pain is related to gas/indigestion, but the nurse should first assess the patient's pain before implementing this intervention. NCSBN Client Need Topic: Prioritization, Subtopic: Establishing priorities, postpartum care, the potential for complications from surgical procedures Last Updated - 15, Feb 2022

The nurse is caring for a patient who has had an endotracheal tube removed within the last hour. What sign if noticed in the patient, should be reported to the primary care physician immediately? A. Slightly pink sputum B. A hoarse voice or sore throat C. Respiratory rate of 22 D. Stridor Submit Answer

Explanation Choice D is correct. Stridor indicates respiratory distress and should be immediately reported to the health care provider. Stridor sounds high-pitched and coarse, it is usually heard with the stethoscope over the trachea. Choice A is incorrect. Slightly pink sputum is generally normal after the removal of an endotracheal tube and should resolve within a few days. Choice B is incorrect. A sore throat and hoarse voice are normal for a few days after the removal of the endotracheal tube. Choice C is incorrect. While a respiratory rate of 22 breaths per minute should be monitored, the doctor does not need to be notified immediately. NCSBN client need Topic: Reduction of risk potential, Potential alterations in body systems Last Updated - 02, Jul 2021

The nursing assessment of an older adult focuses the health history on which of the following? A. Birth history, immunizations, as well as growth and development B. Previous pregnancies, obstetrical history, and psychosocial factors C. Religion, spirituality, culture, and values D. Sensory deficits, illness history, and lifestyle factors

Explanation Choice D is correct. This answer choice includes items that are significant with aging. When obtaining a health history from an older adult, it is essential to be aware of the increased risk for deficits that might alter the history taking, such as loss of vision or hearing. Older adults may have more complex histories because of their increased prevalence of disease and may require some additional time to process information. It's necessary to identify the pattern of any illnesses and how they may be related. Nurses should take note of a patient's family history and lifestyle choices, as these may influence health later in life. Choice A is incorrect. Birth history, immunizations, and growth history are most important for children to identify the risk for problems, provide primary prevention, and assess current issues. Choice B is incorrect. Pregnancies and obstetric history are pertinent to the pregnant female. Choice C is incorrect. Religion and culture are assessed during the cultural assessment. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential Last Updated - 08, Nov 2021

The nurse is reviewing laboratory data for a male client scheduled for surgery. Which laboratory data requires follow-up with the primary healthcare physician (PHCP)? Select all that apply. A. Calcium 7.9 mg/dL B. Potassium 3.3 mEq/L C. Sodium 143 mEq/L D. BUN 17 mg/dL E. Creatinine 0.9 mg/dL Submit Answer

Explanation Choices A and B are correct. A Calcium of 7.9 mg/dL is critically low (normal 9.0 - 10.5 mg/dL) and requires the nurse to follow up with the PHCP. A potassium level of 3.3 mEq/dl is low (normal 3.5 - 5.0 mEq/dL), and the PHCP should also be notified of this finding. Choices C, D, and E are incorrect. The laboratory values for the sodium (normal 135-145 mEq/dL), BUN (normal 10-20 mg/dL), and creatinine (0.6-1.2 mg/dL for males) are all within normal limits and do not require notification to the PHCP. NCLEX Category: Reduction of Risk Potential Related Content: Lab Values Question Type: Analysis Additional Info When preparing a client for surgery, the nursing responsibilities include: Ensuring that all pre-procedure paperwork is completed, including consent and corresponding checklists. Maintaining the client on "by mouth (NPO)" status, if appropriate. Appropriate attire and hygiene, including preprocedural bath with specified soap, clean gown, and anti-embolism stockings or sequential compression devices (SCDs). Recent laboratory data including CBC, CMP, UA, clotting factors (PTT, PT/INR), and HCG if the client is a female. Last Updated - 27, Apr 2022

The nurse is teaching the parents of a client diagnosed with viral gastroenteritis. To prevent dehydration, the nurse should encourage the client to consume which dietary items? Select all that apply. A. Watermelon B. Ice Cream C. Cola D. Canned Vegetables E. Orange slices

Explanation Choices A and E are correct. Watermelon and orange slices are rich in water and are recommended to treat and prevent dehydration. Both choices of fruit provide ample amount of vitamin C. Choices B, C, and D are incorrect. Ice cream would be an inappropriate choice because it is rich in sugar and this would cause an elevation in blood glucose thus, it would contribute to the dehydration. Cola contains caffeine which will further dehydrate the client. Canned vegetables contain a high amount of sodium and would further dehydrate the client. Additional Info For illnesses that may cause dehydration, the client needs to consume water-rich foods. Melons, cucumbers, tomatoes, and celery are products dense in water. The client should avoid foods rich in sugar, caffeine, and sodium, as these would further cause dehydration. Last Updated - 22, Aug 2022

Which of the following is appropriate for the nurse to include when documenting objective data regarding a client's general appearance and behavior? Select all that apply. A. "Skin diaphoretic." B. "Clothes disheveled." C. "Alert and oriented x 3." D. "Gait steady." E. "Reports fatigue."

Explanation Choices A, B, C, and D are correct. Objective data describes actual, measurable, and observable findings that are obtained through observation, physical examination, and laboratory/diagnostic testing. The appearance of the client's skin, clothing, and the client's current level of consciousness are measurable by the nurse's assessment. The client's steady gait is also an objective finding because it is observable by another person other than the client. Choice E is incorrect. Subjective data is information from the client's point of view ("symptoms"), including feelings, perceptions, and concerns obtained through interviews. A client's report of fatigue is an example of subjective data because it is based on the client's own experience and cannot be measured or observed by another person. Additional information: It is important to consider both objective and subjective information when caring for a client, as using both is essential to developing an individualized plan of care. Observations of the client's appearance and behavior provide information about various aspects of the client's health. Observations about the client's speech, facial expressions, ability to relax, eye contact, and behavior provide clues to mood and mental health status. Examples of objective data include: Blood pressure, heart rate, respiratory rate, oxygen saturation Gait and posture Uncoordinated or spontaneous body movements Hygiene and grooming NCLEX Category: Health Promotion and Maintenance Related Content: Techniques of Physical Assessment Question Type: Application

The nurse is caring for a client with a port. Which of the following actions would be appropriate to take? Select all that apply. A. Access the port using sterile technique. B. Flush the port with heparin prior to de-access. C. Access the port using a 16-gauge catheter. D. Have the client wear a mask during the dressing change. E. Aspirate for blood return prior to medication administration. Submit Answer

Explanation Choices A, B, D, and E are correct. A port is a central venous line that is useful for individuals receiving chemotherapy. The nurse should utilize an aseptic technique to prevent central line-associated bloodstream infections (CLABSIs) when the port is accessed. This includes the nurse and the client wearing a mask as well as the nurse using sterile gloves. Occlusion is a common complication with a port, and prior to de-accessing, the nurse should flush heparin. Further, the client should be instructed to wear a mask to prevent contamination during dressing changes. Finally, the nurse must verify appropriate access by aspirating for blood return prior to medication administration. Choice C is incorrect. The nurse utilizes a non-coring needle to access a port. A 16-gauge catheter will be an option if a nurse starts a large-bore peripheral IV. When a port is accessed, it is accessed with a non-coring needle that is 0.5 to 2 inches, with the gauge being 19 to 22. Additional Info When caring for a client with a port, it is essential to prevent CLABSIs through meticulous hand hygiene and aseptic dressing changes. The nurse should instruct the patient to avoid getting the accessed port wet and report signs of infection such as erythema. If the port is not in use, it needs to be accessed and flushed once a month to maintain patency. Last Updated - 27, Aug 2022

The nurse is preparing for the first interaction with a client recently admitted to the hospital. Which of the following would help establish trust during this encounter? Select all that apply. A. Make sure the client's bed is set up properly ahead of time. B. Review the client's name, diagnosis, and anticipated length of stay before he or she arrives. C. Speak confidently and do not tell the patient that one of the nurses providing care is a student nurse. D. Show the client how to use the bed and call light. E. Avoid spending too much time talking with the client. F. Ask about the client's expectations and concerns when taking the health history.

Explanation Choices A, B, D, and F are correct. Preparing the room and gathering necessary information ahead of time, such as name, diagnosis, and anticipated length of stay allows for more efficient greeting and admission and are appropriate ways to help establish trust with the client. The nurse should also orient the client to the room by making sure the client understands how to use the bed controls, call light, and any necessary equipment. Showing an interest in the client's expectations and concerns shows the client that their feelings are cared about, which helps to establish trust. Choices C and E are incorrect. Many clients are open to being cared for by nursing students, and aware that students have more time to spend with them; being forthcoming regarding the level of experience is likely to establish an atmosphere of trust. Taking the time to get to know the client also helps to establish a trusting relationship. Additional Information: When clients are admitted to a hospital or other care facility, they need support in their transition to wellness, in dealing with the unknown, and in adjusting to a new environment. The relationship and trust established in the first interaction with clients can go a long way toward relieving anxiety and preserving the energy needed for healing. The nurse should take time to get to know the client and try to set a tone of caring, respect, empathy, and understanding. NCLEX Category: Psychosocial Integrity Related Content: Therapeutic Communication Question Type: Application Last Updated - 13, Nov 2021

The nurse performs a head-to-toe assessment on an assigned client. Which of the following client findings are examples of subjective data? Select all that apply. A. The client reports feeling nauseated. B. The client's lower extremities are swollen. C. The client expresses nervousness about test results. D. The client reports that their leg is itching. E. The client rates pain at a 6 on a scale of 1 to 10. F. The client vomits twice after eating dinner. Submit Answer

Explanation Choices A, C, D, and E are correct. Subjective data is information that is perceived only by the person affected. This data cannot be seen or verified by another person. Feeling nauseous or nervous, itchiness, and pain are all examples of subjective data. Choices B and F are incorrect. These answer choices are examples of objective data. Objective data is observable and measurable data that can be heard, seen, or felt by someone other than the person who is experiencing them. Examples of objective data include edema, vomiting, or having an elevated body temperature. Additional Info Subjective data is an important component of a nursing assessment because it helps the nurse gather information about how a client feels about and perceives their experience of health problems. This type of data can give the nurse insight into the client's fears and risk factors, and can sometimes provide a warning to potential issues before they can be seen in objective data. Incorporating this aspect, and not just the objective data, helps the nurse to develop an effective, individualized care plan. Examples of subjective data include: Pain Fatigue Dizziness Shortness of breath Palpitations Last Updated - 17, Nov 2022

Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply. A. "My mother has the same thing." B. "I'll sit with you for a while." C. "I think you should try having surgery." D. "Don't cry, everything is going to be okay." E. "Do you have any questions for me right now?" Submit Answer

Explanation Choices A, C, and D are correct. The nurse should focus on therapeutic communication techniques for a client who has received a poor prognosis. Sharing personal details about the diagnosis does not do anything to comfort the client. It is not appropriate or within the nurse's scope to provide recommendations to influence a client's decision for treatment and procedures. When discussing any diagnosis with a client, the nurse should avoid giving false hope or making promises. Choice B and E are incorrect. Being present and using silence are useful tools in such circumstances; offering to sit with the client is an appropriate response (therefore an incorrect answer to the question). Using broad questions to invite the client to share concerns or questions would be an example of therapeutic communication and would allow the client to express themself openly without added pressure. Additional Information: Therapeutic communication is a basic tool used in developing a caring relationship with clients. In therapeutic communication, the interaction focuses on the client and the client's concerns. Nurses must assist clients as they work through their feelings and explore options related to the situation, outcomes, and treatments. This skill takes practice but can be learned with awareness and close attention. Therapeutic communication means taking the time to listen for messages that may otherwise be unheard. Nurses who practice therapeutic communication techniques typically find it easier to develop good nurse-client relationships. NCLEX Category: Psychosocial Integrity Related Content: Therapeutic Communication Question Type: Application Last Updated - 29, Mar 2022

The nurse is assisting a client in choosing food choices that are appropriate for hypertension. Which food items would be appropriate to select? Select all that apply. A. Grilled chicken B. Bacon C. Scrambled eggs D. Smoked salmon E. Boiled lentils

Explanation Choices A, C, and E are correct. Hypertension is best managed with a low sodium diet. Choices A, C, and E are low sodium foods. Choices B and D are incorrect. Bacon and smoked salmon contain a high content of sodium. The client should be instructed to avoid these foods. Clients with hypertension should avoid foods that are high in sodium. A diet high in sodium increases fluid accumulation, raising the client's blood pressure. The client should be educated to avoid processed, cured, or canned foods. The client should use natural seasonings over table salt to flavor food.

The nurse is caring for a group of assigned clients. Which of the following actions by the nurse is an example of a nurse-initiated intervention? Select all that apply. A. The nurse administers 1000 mg of ciprofloxacin to a client with pneumonia. B. The nurse consults with a psychiatrist for a client suspected of pain medication abuse. C. The nurse checks the skin of bedridden clients for signs of breakdown. D. A nurse assists an orthodox Jewish client with ordering a kosher meal. E. The nurse records the intake & output of a client as prescribed by her physician. F. The nurse provides teaching to a client on how to care for a newly placed ostomy.

Explanation Choices C, D, and F are correct. Nurse-initiated interventions, also known as independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of client needs that are written on the nursing care plan, as well as other activities that nurses can initiate without the direction or supervision of another healthcare personnel. The nurse can take initiative independently by monitoring clients' skin for breakdown, assisting a client to order an appropriate meal, and providing education to clients and family members. Choices A, B, and E are incorrect. Administration of medications and initiation of intake-output monitoring are dependent interventions because these actions require a physician's order or physician supervision. Consulting with a psychiatrist is a collaborative intervention, not an independent nursing action. NCLEX Category: Management of Care Related Content: Collaboration with Interdisciplinary Team Question Type: Application Additional Info A nurse-initiated intervention is an independent action based on the scientific rationale that a nurse executes in order to benefit the client in a predictable way that takes into account the nursing diagnosis and expected outcomes. Nursing interventions are actions performed by the nurse to: Monitor client health status and response to treatment Reduce risks Resolve, prevent, or manage a problem Promote independence with ADLs Promote an optimum sense of physical, psychological, and spiritual well-being Give clients the information they need to make informed decisions and be independent Nurse-initiated interventions do not require a physician's order. Instead, like client goals, they are derived from the nursing diagnosis. Last Updated - 27, Apr 2022

While on your first posting at a Sleep clinic, you are reviewing the stages of sleep. Place the following steps or phases of sleep in an appropriate sequential order of the sleep cycle. The stage of the sleep cycle that is characterized by delta waves. The stage of the sleep cycle that is characterized with vivid dreams. The stage of the sleep cycle that is characterized with 10 to 20 minutes duration. The stage of the sleep cycle that is characterized with a brief period of very light sleep. Submit Answer

Explanation Several clients suffer from sleep-related disorders and insomnia. Knowing the sleep cycle and its various stages helps the nurse to understand the sleep pattern disturbances better. Each sleep cycle lasts 90 to 120 minutes and repeats throughout the night. In general, the sleep cycle has two components based on whether it is accompanied by rapid eye movements (REM): The phases or stages of sleep in an appropriate sequential order of the sleep cycle are: NREM Stage 1: The stage of the sleep cycle that is characterized by a brief period of light sleep. This is a transition period from wakefulness to sleep and lasts about 5 to 10 mins. NREM Stage 2: During this period, both heart rate and body temperature drop. The brain produces bursts of rapid, rhythmic brain wave activity known as "sleep spindles" - most people spend about 50% of the total sleep in this stage. NREM Stage 3: This was previously divided into stages 3 and 4. This is the stage of the sleep cycle that is characterized by difficulty in terms of awakening (Deep Sleep). During this period, muscles relax, blood pressure, and breathing rate decrease. It is also referred to as delta sleep because it is characterized by deep, slow brain waves (low frequency, high amplitude) known as delta waves. This stage represents 10 to 20 percent of the total sleep time in young to middle-aged adults but decreases with age. Most parasomnias such as sleepwalking (somnambulism) occur during this stage. REM Sleep: This is the stage that follows NREM deep sleep and is characterized by vivid dreams (REM sleep). In this stage, the brain becomes more active, the body becomes relaxed and immobilized, and eyes rush. REM sleep, on an average, begins 90-minutes after falling asleep. When REM sleep is complete, the cycle returns to stage 2 sleep. Sleep cycles through these stages about four to five times throughout the night. NCSBN Client Need Topic: Basic Care and Comfort, Sub-Topic: Rest and Sleep. Last Updated - 13, Nov 2021

The nurse is caring for a client with the following clinical data. Which prescription would the nurse request from the primary healthcare provider (PHCP) based on the clinical data? Select all that apply. See the exhibits. A. Albuterol B. Hydrocortisone C. Diltiazem D. Nitroglycerin E. Furosemide

Explanation Choices D and E are correct. Pulmonary edema secondary to acute decompensated heart failure (ADHF) is a medical emergency and requires rapid treatment. Vasodilators such as nitroglycerin help decrease preload and afterload, reducing the heart's workload. This medication is often combined with a loop diuretic such as furosemide or bumetanide to decrease volume. If vasodilators or loop diuretics are prescribed, close blood pressure monitoring is essential. Choices A, B, and C are incorrect. Albuterol would be unnecessary and harmful for a client with pulmonary edema and ADHF. This would be useful for a client experiencing bronchoconstriction, such as an asthma exacerbation. The assessment for this client revealed crackles in the lung fields - not wheezes. Hydrocortisone is a steroid and would be unhelpful in the management of ADHF. This medication may be detrimental as this medication leads to fluid retention. Diltiazem is a calcium channel blocker and is grossly contraindicated in ADHF because of its negative inotropic effects. Additional Info Priority nursing care for a client with pulmonary edema and ADHF includes: Airway assessment and pulse oximetry monitoring High flow oxygen therapy via nonrebreather or intubation if clinically indicated Cardiac and vital sign monitoring with critical care placement High-fowler's positioning Emergent intravenous diuresis and vasodilators, as prescribed Once the client has been stabilized, the urinary output should be monitored along with daily weights to evaluate response to the therapy. VTE prophylaxis should be maintained coupled with prescriptions such as ACE inhibitors (lisinopril). Last Updated - 26, Nov 2022

You are working in the pediatric emergency department. A six-year-old child is brought in lethargic with a weak pulse, blood pressure of 60/40 mm Hg, and a heart rate of 40 beats per minute. You estimate that the child weighs 20 kg. A peripheral IV is in place. The physician has ordered IV epinephrine to treat the symptomatic bradycardia. You know that a reasonable dose for this patient would be: A. 2 mL of the 1:10000 concentration IV every 3 to 5 minutes B. 2 mL of the 1:10000 concentration IV every 1 to 2 minutes C. 2 mL of the 1:10000 concentration IV one time only D. None of the above Submit Answer

Explanation Choice A is correct. Epinephrine is the drug of choice for bradycardia (heart rate less than 60 beats per minute) with hypotension/ shock in a child. In a six-year-old child, systolic blood pressure less than 80 mm Hg is abnormally low. In this child, bradycardia is resulting in shock. This question requires that the nurse knows: the correct dosage of epinephrine, the calculation for the total amount of drug to give for the child's weight, and the frequency of administration. Epinephrine should be given every 3 to 5 minutes until the bradycardia is resolved. Since the child has an IV, the nurse should use the 1:10000 concentration of the medication. If the child has an ET tube in place and no IV or IO access, the nurse should use the 1:1000 concentration and administer down the ET tube. The correct dosage, in this case, is 0.1 mL/kg of epinephrine. Since the child weighs 20 kg, you would give 2 mL of the epinephrine (20 kg X 0.1 mL/kg = 2 mL of epinephrine). Choice B is incorrect. This is the correct dosage of the epinephrine to be administered, but the timing of the dosage is inappropriate. This medication should only be administered every 3 to 5 minutes, not every 1 to 2 minutes. Choice C is incorrect. This is the correct dosage of the epinephrine to be administered to this client but this will likely not be a one-time only drug. This medication typically needs to be administered multiple times in critical care scenarios or scenarios involving cardiac compromise. This medication is administered every 3 to 5 minutes in a client who has hypotension and signs of poor perfusion. Choice D is incorrect. The correct response was Choice A. Learning Objective Understand that epinephrine is the drug of choice in a child with symptomatic bradycardia with hypotension, and know the dosage and dose calculation. Additional Info Source : ArcherReviewSource : ArcherReview In a child with bradycardia, first, identify and treat the cause. Several causes of bradycardia include hypoxia, hyperkalemia, hypothermia, heart block, acidosis, toxins/ drug overdoses, and trauma. If hypoxia, administer oxygen If hyperkalemia, administer IV calcium gluconate, reduce extracellular potassium ( insulin + dextrose, beta-2 agonists), and reduce total body potassium levels ( kayexalate, hemodialysis) If hypothermia, rewarm slowly. If there is a heart block, consult a pediatric cardiologist, administer atropine, and consider an external pacemaker ( transcutaneous and transvenous pacing). If acidosis, ventilate to washout Co2. In select cases, use sodium bicarbonate. If there is a drug overdose, supportive care and administer an antidote if available If trauma, oxygenation/ ventilation if necessary If the child is in shock or hypotensive, must proceed with immediate drug choice, which is epinephrine ( note that epinephrine is the drug of choice in a child with bradycardia and shock, whereas atropine is used first in an adult with symptomatic bradycardia) Administer epinephrine. The dose is 2 mL of the 1:10000 concentration IV and repeated every 3 to 5 minutes as needed If epinephrine fails, consider atropine 0.02 mg/kg ( max 0.5mg) consider external pacemaker

The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child A. left lateral recumbent. B. prone. C. right lateral recumbent. D. modified trendelenburg. Submit Answer

Explanation Choice A is correct. A myringotomy is a procedure performed to facilitate drainage from the eardrum. This is often performed to relieve pressure and pain with acute otitis media. Tympanostomy tubes may be placed to remove exudate and equalize the middle ear and atmospheric pressures. Following this procedure, the child should be placed on the affected side to facilitate drainage via gravity. Choices B, C, and D are incorrect. The client should be positioned on the affected side to facilitate the removal of the drainage. The client should not be placed prone or modified Trendelenburg. The modified Trendelenburg position is commonly used for clients in shock because having the client's legs raised passively allows for venous return. Additional Info ✓ Myringotomy is a procedure to drain fluid from the ear drum. ✓ This procedure is often coupled with the placement of tympanostomy tubes to promote further drainage and equalize pressure. ✓ This procedure may be done with or without general anesthesia. ✓ The TT is eventually pushed out of the eardrum, usually 8 to 18 months after tube placement. Last Updated - 12, Feb 2023

The nurse is teaching a client who is scheduled for a percutaneous kidney biopsy. Which of the following information should the nurse include? A. "You will need to lay flat immediately after this procedure." B. "A heating pad will be applied to the affected area for pain relief." C. "Before you eat, your gag reflex will need to return." D. "You will not be allowed to eat or drink eight hours before this test."

Explanation Choice A is correct. A percutaneous kidney biopsy will be required to lay supine immediately following the procedure to achieve and maintain hemostasis. Choices B, C, and D are incorrect. The client should not have a heating pad applied to the affected area as this would potentially cause bleeding through vasodilation. The client does not need to be NPO status for this procedure as local anesthesia is used. Finally, this procedure is conducted through the skin, and the patient will not have their gag reflex affected. Additional Info A percutaneous kidney biopsy is indicated for several reasons, including the diagnosis of idiopathic nephrotic syndrome. The client will be positioned prone for the procedure, and immediately following the procedure, the client should be supine for four to six hours to ensure hemostasis. Urine output will be monitored closely post-procedure. The nurse should immediately report any bruising to the area as well as hematuria. Last Updated - 16, Feb 2022

The nurse is working with a patient who is receiving a new prescription of prednisone. The nurse would be most correct in instructing the client to take this medication at which time every day? A. In the morning B. Around noon C. Before bed D. Anytime, but at the same time every day

Explanation Choice A is correct. Corticosteroids should be taken in the morning, preferably before 9 AM. This mimics the natural release of glucocorticoids from the adrenal glands in the morning. Choice B is incorrect. The best time to take prednisone is not around noon. Choice C is incorrect. The best time to take prednisone is not before bed. Taking prednisone before bed could cause restlessness or insomnia. Choice D is incorrect. There is a more specific time to take prednisone. NCSBN client need Topic: Physiological Adaptation, Pharmacological and Parenteral Therapies Additional Info Last Updated - 24, Jan 2022

Ergonomic principles are most closely associated with: A. Normal bodily alignment B. The control of infection C. Preventing congenital abnormalities D. Preventing hospital-acquired infections Submit Answer

Explanation Choice A is correct. Ergonomic principles are most closely associated with normal bodily alignment. Ergonomics is defined as a body of knowledge and laws related to human anatomy, physiology, and proper physical alignment. Ergonomics and the ergonomic design of workplace items aim to protect the safety, comfort, and efficiency of work processes. Choice B is incorrect. Standard precautions and transmission-based precaution principles are closely associated with the control of infection, not ergonomic principles. Choice C is incorrect. Ergonomic principles have nothing to do with the prevention of congenital abnormalities. However, proper prenatal care standards and policies do. Choice D is incorrect. Standard precautions and transmission-based precaution principles are closely associated with preventing hospital-acquired infections, not ergonomic principles. Last Updated - 15, Feb 2022

The nurse is caring for a client scheduled for surgery who is nothing by mouth (NPO) status. Which of the following prescriptions should the nurse clarify with the primary healthcare physician (PHCP)? A. Lispro insulin 5 units SubQ TID B. Glargine insulin 15 units SubQ QHS C. Vitamin B12 100 mcg IM Daily D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days Submit Answer

Explanation Choice A is correct. For a client who is NPO awaiting surgery, they should not receive rapid or short-acting insulin. This insulin is intended to be given before meals, and the client could develop life-threatening hypoglycemia if they are given this type of insulin with no meal. When a client is NPO, while a medication tray may not arrive, the medication order does not get suspended. Thus, this requires follow-up. Choices B, C, and D are incorrect. Glargine insulin is long-acting and has no peak. This basal insulin is appropriate to give to a client who is NPO. It is quite unlikely that the client would develop hypoglycemia with this insulin because it has no peak. Vitamin B12 IM may be given to a client as it is given parenterally. Finally, the clonidine patch may be applied to this client because it is not absorbed orally. This patch is applied for seven days and changed as prescribed thereafter. Additional Info Source : Archer Review For a client NPO, it is essential that the nurse examine the MAR closely for medications that are appropriate and inappropriate to administer. Classes of medications that should be clarified include - Certain endocrine medications (rapid- and short-acting insulin, levothyroxine, short- and long-acting insulin, steroids) Neuropsychiatric medications (anti-psychotics, anti-epileptics) Cardiovascular (antihypertensives, anti-dysthymic)

The nurse is caring for a client who has been prescribed olanzapine. Which of the following assessment findings would warrant immediate notification to the primary healthcare physician (PHCP)? A. Muscle rigidity B. Weight gain C. Hyperglycemia D. Fatigue

Explanation Choice A is correct. Olanzapine is an atypical antipsychotic drug. Adverse reactions of olanzapine include neuroleptic malignant syndrome, which is manifested by tachycardia, delirium, fever, and muscle rigidity. Thus, muscle rigidity should be reported to the provider immediately. Choices B, C, and D are incorrect. Weight gain, hyperglycemia, and fatigue are all side-effects of this drug class but do not require immediate notification to the provider. Additional Info Source : Archer Review Last Updated - 22, Jan 2022

Religious and cultural rituals/practices often surround death. Which of the following populations prefer cremations rather than burying the remains of the deceased person? A. Hindus B. Islam C. Mormons D. Eastern orthodox

Explanation Choice A is correct. The Hindus prefer cremations rather than burying the remains of the deceased person. The ashes are then typically spread over the holy river. Cremations are viewed as discouraged or forbidden among those who practice Islam, Mormonism, and the Eastern Orthodox religion. Choice B is incorrect. Cremations are viewed as discouraged or forbidden among those who practice the Islam religion. Choice C is incorrect. Cremations are viewed as discouraged or forbidden among those who practice the Mormon faith. Choice D is incorrect. Cremations are viewed as discouraged or forbidden among those who practice the Eastern Orthodox religion. Last Updated - 15, Dec 2021

The nurse supervises unlicensed assistive personnel (UAP) assist a client who is bed-bound with oral hygiene. Which action by the UAP requires follow-up? Select all that apply. A. Raises the head of the bed (HOB) to 15 degrees B. Holds the toothbrush bristles at a 45-degree angle to the gum line C. Performs hand hygiene and applies clean gloves D. Removes the towel and places it in a biohazard bag E. Applies moisturizing lubricant to the lips after brushing and rinsing Submit Answer

Explanation Choices A and D are correct. These actions by the UAP are incorrect and require follow-up. The HOB should be between 30-45 degrees to facilitate effective oral hygiene and prevent aspiration. A towel is placed across the client's chest to prevent soiling of their clothes. This towel should be placed in a linen bag following its use. Items that should be deposited in a biohazard bag will be saturated with blood or blood products. This bag prevents the safe transport of products that may contaminate other areas in the facility. Gross bleeding is not expected during basic oral hygiene. Choices B, C, and E are correct. These actions are correct by the UAP. The UAP should perform hand hygiene before and after this procedure. Clean gloves should be worn because of exposure to body fluids. The correct brush technique is holding the toothbrush bristles at a 45-degree angle to the gum line. Applying moisturizing lubricant after the client has brushed and rinsed is appropriate. Additional Info 1. Explain procedure to client, discussing client's preferences; assess client's ability to grasp and manipulate toothbrush and willingness to help with oral care. 2. Place paper towels on over-bed table and arrange other equipment within easy reach. 3. Provide privacy by closing room doors and drawing room divider curtain. Raise bed to comfortable working position. 4. Raise head of bed (if allowed) and lower near side rail. Move client or help them move closer to side. Place client in side-lying position if needed (if aspiration risk). Place towel over client's chest. 5. Apply clean gloves. Apply enough toothpaste to brush to cover length of bristles. Hold brush over emesis basin. Pour small amount of water over toothpaste. 6. Client may help with brushing. Hold toothbrush bristles at 45-degree angle to gum line. Be sure that tips of bristles rest against and penetrate under gum line. Brush inner and outer surfaces of upper and lower teeth by brushing from gum to crown of each tooth. Clean biting surfaces of teeth by holding top of bristles parallel with teeth and brushing gently back and forth. Brush sides of teeth by moving bristles back and forth. 7. Have client hold brush at 45-degree angle and lightly brush over surface and sides of tongue. Avoid initiating gag reflex. 8. Allow client to rinse mouth thoroughly by taking several sips of cool water, swishing water across all tooth surfaces, and spitting into emesis basin. Use this time to observe client's brushing technique and teach the importance of regular hygiene. 9. Have client rinse mouth with antiseptic rinse for 30 seconds. Then have client spit rinse. 10. Allow client to rinse mouth thoroughly with cool water and spit into emesis basin. Help wipe the client's mouth. 11. Inspect oral cavity to determine effectiveness of oral hygiene and rinsing. Ask client whether mouth feels clean or if there are any sore or tender areas. Remove towel and place in linen bag. 12. Remove and dispose of gloves and perform hand hygiene. Return client to a comfortable position. Raise side rails (as appropriate), and lower bed to lowest position. Place nurse call system within client reach. Potter, P., Perry, A., Stockert, P., Hall, A. (012022). Fundamentals of Nursing, 11th Edition. Last Updated - 31, Jan 2023

The nurse is taking a sample of the fluid pulled from a nasogastric tube to ensure proper placement. The nurse will confirm appropriate placement of the NG tube if the stomach contents have a pH of: A. 3.4 B. 7 C. 5.9 D. 8

Explanation Choice A is correct. The nurse would believe that the NG tube is correctly placed if the aspirate shows a pH below 5.5. Stomach contents should be acidic ( a pH less than 5.5). Before medication or food administration, it is crucial always to verify the correct placement of the nasogastric tube ( NGT). The gold standard to verify tube placement is visualization on an x-ray. However, given the risks of radiation exposure with X-rays and delayed feeding, alternative options are often used to verify the tube placement before feeding or giving medications to the client. The most commonly used first-line verification method is measuring the pH of the NG tube aspirate to make sure it falls in line with that of gastric contents. Most guidelines recommend that the pH of an NGT aspirate should be ≤5.5 (acidic) to confirm proper placement. Choices B, C, and D are incorrect. A pH of 7 or 8 is alkaline ( Choices B and D). An alkaline pH ( >7.0) often indicates a lung aspirate ( respiratory tract) rather than gastric. If the pH of the aspirate is greater than 5.5, a chest x-ray must subsequently be ordered to evaluate the NGT placement. Similarly, a pH of 5.9 ( Choice C) is not low enough to be considered a normal finding for gastric contents and hence, not adequate to ensure a proper NG tube placement. The subsequent step is to obtain a chest x-ray since this pH is greater than 5.5. Last Updated - 18, Jul 2022

A nurse on a rehabilitation floor is educating a post-cerebrovascular accident (CVA) client with right-sided hemiplegia on how to transfer himself from a bed to a wheelchair without assistance. Which of the following statements, if communicated by the client, would indicate the need for additional education on this transfer technique? A. "I'm going to put the wheelchair on the right side of my bed and make sure it is locked." B. "I'm going to use my left hand and foot to move myself towards the edge of the bed." C. "When my legs drop over the bed, I need to swing my torso up to a sitting position." D. "I will push myself up to a standing position with my left hand and leg, reaching over the wheelchair to sit myself down." Submit Answer

Explanation Choice A is correct. This statement by the client is incorrect and needs to be addressed by the nurse. Here, the client is affected by right-sided hemiplegia following his CVA. The client should always place the wheelchair on the unaffected side (here, his left side) to facilitate a safe and ergonomic transfer using the strength remaining in his left arm and leg. Placing the wheelchair on the right side of the bed (i.e., on the client's affected side) greatly increases the client's fall risk and risk for injury. Choice B is incorrect. This statement is correct and does not require further teaching. The client should use his unaffected hand and foot to maneuver towards the edge of the bed. Choice C is incorrect. This statement is correct and does not require additional instruction. After the client is positioned in a sitting position on the side of the bed, he should push himself up to a standing position with his unaffected leg, using his unaffected arm to grasp the locked wheelchair and gently sit down. Choice D is incorrect. This statement is correct and does not require additional teaching. Once the client is in a sitting position on the side of the bed, he should push himself up to a standing position with his unaffected leg, using his unaffected arm to grasp the locked wheelchair and gently sit down. Learning Objective When provided a list of steps necessary for a client affected with hemiplegia when transferring himself from a bed to a wheelchair without assistance, recognize that the locked wheelchair should be placed on the client's unaffected side. Additional Info For clients with hemiplegia, significant inpatient rehabilitation must occur prior to discharge. When performing client education for hemiplegia clients transferring from a bed to a wheelchair, emphasize the need for the wheelchair to be locked and placed on the client's unaffected side. Many clients utilize a slide board to facilitate the transfer from the bed to a wheelchair. Last Updated - 21, Aug 2022

The nurse is observing a nursing student prepare to give an intramuscular (IM) injection in a client's deltoid. Which action by the student requires follow-up? A. Depresses the plunger during the insertion of the needle. B. Locates the upper third of the acromion process. C. Positions the client either lying or sitting position. D. Dons clean gloves before administering the injection. Submit Answer

Explanation Choice A is correct. This technique is not appropriate and requires follow-up. Depressing the plunger during the needle insertion is inappropriate because the medication is being discharged when it is not in the appropriate spot. Once the nurse has appropriately anchored the needle in the appropriate landmark, the nurse can then depress the plunger, ensuring that the medication is discharged in the appropriate location. Choices B, C, and D are incorrect. These actions are correct and do not require follow-up. Locating the upper third of the acromion process is the appropriate anatomical landmark to give an injection in the deltoid. When giving an IM in the deltoid, the client should sit or lie down. This best practice allows for the nurse to appropriately locate the anatomical landmarks. Additionally, if the client should develop syncope from the injection, this also prevents injury. Clean gloves should be worn for this procedure as the likelihood of coming into contact with blood is high. Additional Info When injecting into the deltoid muscle, the nurse should locate the acromion process; inject only into the upper third of the deltoid muscle that begins about two fingerbreadths below the acromion. The essential advantage of giving an IM in the deltoid is faster absorption rates than gluteal sites and easily accessible with minimal removal of clothing Last Updated - 29, May 202

You are admitting a new client. During your collection of data for the health history, you ask the client about the medications, including over-the-counter medications, herbs, supplements, and vitamins that they are taking at home. You are performing the: A. Medication reconciliation process as mandated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). B. Medication reconciliation process as mandated by the Institute for Healthcare Improvement. C. Unique identifier process as mandated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). D. Unique identifier process as mandated by the Institute for Healthcare Improvement. Submit Answer

Explanation Choice A is correct. You are performing the medication reconciliation process as mandated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) when you collect data for the health history about the medications, including over-the-counter medications, herbs, supplements, and vitamins that the newly admitted client had been taking at home. Although the Institute for Healthcare Improvement has defined and underscored the importance of the medication reconciliation process, it is the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and not the Institute for Healthcare Improvement that mandates it for all accredited healthcare facilities. Choice B is incorrect. Although the Institute for Healthcare Improvement has defined and underscored the importance of the medication reconciliation process, it is not the Institute for Healthcare Improvement that mandates it. Choice C is incorrect. Although the Joint Commission mandates the unique identifier process on the Accreditation of Healthcare Organizations (JCAHO), this process does not include the collection of data for the health history about the medications, including over-the-counter medications, herbs, supplements, and vitamins that the newly admitted client had been taking at home. Choice D is incorrect. The Institute for Healthcare Improvement does not mandate the unique identifier process. The unique identifier process does not include the collection of data for the health history about the medications, including over-the-counter medications, herbs, supplements, and vitamins that the newly admitted client had been taking at home. Last Updated - 08, Feb 2022

Which client will most likely get this device for intravenous therapy? A. An adolescent client in the emergency department with a high fever and a respiratory tract infection. B. A client who needs multiple ports and vesicant medications. C. An adolescent client in the emergency department with a high fever and a possible ruptured appendix. D. A client who will need intravenous replacement therapy for 5 days.

Explanation Choice B is correct. A client who needs multiple ports and vesicant medications will be the most likely to get a central venous access device. Central venous access devices can be categorized into two major types: tunneled venous access devices and non-tunneled venous access devices. The most commonly used type of non-tunneled venous access device is the Quinton catheter, and the most widely used tunneled venous access devices are the Hickman catheter and the Groshong catheter. Choice A is incorrect. An adolescent client in the emergency department with a high fever and a respiratory tract infection will most likely not get this intravenous therapy device. However, they are likely to have another type of intravenous therapy device for the one-time administration of an antibiotic before being discharged to the home with oral antibiotics. Choice C is incorrect. An adolescent client in the emergency department with a high fever and a possible ruptured appendix will most likely not get this intravenous therapy device. However, they are likely to have another type of intravenous therapy device. Choice D is incorrect. A client who will need intravenous replacement therapy for five days will most likely not get this intravenous therapy device. However, they are likely to have another type of intravenous therapy device because this device is used for longer durations of intravenous replacement therapy.

The nurse is reviewing the labs of a child who has recently had oral surgery. Which of the following lab results should the nurse pay the closest attention to? A. BUN level B. Prothrombin time C. Creatinine level D. Viral load Submit Answer

Explanation Choice B is correct. After oral surgery or a tonsillectomy, the physician will order a series of labs, including hematocrit, hemoglobin, and prothrombin time. The results of these labs are evaluated to determine whether or not the patient is experiencing bleeding as a result of the surgery and if they can adequately bleed. Choice A is incorrect. BUN levels, or blood urea nitrogen levels, help health care providers evaluate kidney function by calculating how nitrogen is in the blood. Nitrogen is a byproduct of urea, which is made by the kidneys when proteins are broken down. This test is not ordered routinely after oral surgery. Choice C is incorrect. Creatinine laboratory values evaluate kidney function. Creatinine is produced when muscles metabolize. This test is not ordered routinely after oral surgery. Choice D is incorrect. A test to evaluate viral load is used in cases of HIV and Hepatitis. This test is generally run when a viral disease is suspected or being managed. A patient's viral load is not ordered routinely after oral surgery. NCSBN client need Topic: Physiologic adaptation, reduction of risk potential Last Updated - 18, Ja

A. Assess the client for pain B. Assess the client's oxygen saturation C. Assess the client with the Glasgow Coma Scale (GCS) D. Assess the client's lung sounds Submit Answer

Explanation Choice B is correct. Assessing the client's oxygen saturation is essential because this client is demonstrating manifestations of hypoxia. Early signs of hypoxia include altered mental status and restlessness. Moderate sedation uses multiple medications, such as fentanyl and propofol, to achieve a state of altered consciousness, so procedures like shoulder reductions may be completed with very little pain. These medications are CNS depressants, and during the procedure, the client is often given supplemental oxygen. Post-procedurally, the nurse will monitor the client's vital signs very closely. Choices A, C, and D are incorrect. Assessing the client's pain level, GCS, and lung sounds will not clue the nurse into the most serious problem of hypoxia. These are key assessments but are not the priority when looking at the client's airway, breathing, and circulation. Additional Info ✓ A moderate sedation procedure requires informed consent, and the nurse will serve as a witness. ✓ Common medications utilized for moderate (conscious) sedation include fentanyl, midazolam, or propofol. ✓ Anesthesia providers, other physicians, dentists, and oral surgeons are qualified to administer conscious sedation, and the nurse does not administer anesthesia intravenously. ✓ When this type of sedation is utilized for a closed reduction, it is a quick process that requires close monitoring of the client's vital signs, end-tidal carbon dioxide (normal is 20 and 40 mm Hg), cardiac rhythm, and level of consciousness. Last Updated - 06, Feb 2023

When a nursing student asks a nurse on her assigned floor what cyanosis means, what is the nurse's best response? A. Cyanosis means the patient has been exposed to cyanide poisoning. B. Cyanosis is the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood. C. Cyanosis is the primary indication that the patient has pneumonia. D. Cyanosis is the blue coloring of skin and mucous membranes in the presence of highly oxygenated blood.

Explanation Choice B is correct. Cyanosis is the bluish discoloration of the skin and mucous membranes that results in the presence of poorly oxygenated blood. Cyanosis, a bluish coloring of the skin, is caused by decreased peripheral circulation or reduced oxygenation of the blood. It may be related to cardiac, pulmonary, or peripheral vascular problems (e.g. arteriosclerosis). In dark-skinned patients, you can best see cyanosis by examining the conjunctiva, tongue, buccal mucosa, and palms and soles for a dull dark color. Choice A is incorrect. Cyanosis is not indicative of cyanide poisoning. Choice C is incorrect. Compromised respiration related to pneumonia may result in cyanosis if treatment is not initiated promptly, or if compromise continues. However, it is not the primary indication of pneumonia. Choice D is incorrect. Cyanosis is not caused by highly oxygenated blood. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort, Integument Last Updated - 15, May 2021

The nurse is preparing to administer haloperidol to a client. The nurse understands that this medication is prescribed to treat which of the following? A. Multiple sclerosis B. Schizophrenia C. Hyperthyroidism D. Parkinson's disease Submit Answer

Explanation Choice B is correct. Haloperidol is a typical antipsychotic which is indicated for schizophrenia. Choice A is incorrect. Multiple sclerosis is primarily treated with interferons. Choice C is incorrect. Hyperthyroidism would be treated with agents such as methimazole. Choice D is incorrect. Haloperidol is contraindicated for individuals with Parkinson's disease because of the medications' ability to worsen Parkinson's' symptoms. Additional Info Source : Archer Review Last Updated - 26, Oct 2021

The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their A. dairy intake. B. fiber intake. C. fat intake. D. calcium intake.

Explanation Choice B is correct. It is appropriate for the nurse to advise the client to increase their fiber intake. Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits. The patient should ingest about 30 to 40 g of fiber each day. Choices A, C, and D are incorrect. Dairy may be a trigger for a client with IBS, and while triggers are individualized, dairy is likely a trigger for an IBS flare. Fat and calcium has no bearing on IBS management, and the emphasis should be on the intake of fiber. Additional Info Irritable bowel syndrome (IBS) is a functional GI disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits. The client should ingest about 30 to 40 g of fiber each day. Eating regular meals, drinking 8 to 10 glasses of water each day, and chewing food slowly help promote normal bowel function. Last Updated - 18, Apr 2022

The nurse is caring for a prenatal client who is in labor and may need a blood transfusion. The nurse knows that which of the following spiritual groups prohibit the use of blood transfusions? A. Catholicism B. Jehovah's witnesses C. Islam D. Christian reform Submit Answer

Explanation Choice B is correct. Most Jehovah's witnesses do not condone the use of blood products and often refuse blood transfusions. This nurse should verify this information in the chart and with the patient. Most Jehovah's Witnesses believe that a human must not sustain his life with another creature's blood. They believe that Jehovah will turn their back on anyone who receives blood products. Choice A is incorrect: Members of the Catholic faith have no set doctrines that prohibit the administration of blood products. Choice C is incorrect: With regard to the Islamic faith, Muslims are allowed to participate in blood and organ donation in cases of necessity and/or if the donation will save another person's life. This mean's that in life or death situations a blood transfusion is allowable for members of the Islamic faith. Choice D is incorrect: The Christian Reformed Church believes that their salvation is a gift from God and that good works are the Christian response to the gift. None of their doctrines prohibit the use of blood transfusion or blood product donation. Learning Objective Differentiate major spiritual differences as they related to patient-centered care. Additional Info Source : Archer Image Library Any blood component may be removed from a donor and transfused into a recipient. Blood products may be transfused individually or collectively. This means that a client receiving a transfusion may receive blood products from one person or multiple people. Nursing responsibilities related to blood product transfusion focus on prevention of blood transfusion reactions and early recognization of transfusion reactions. A nurse will receie orders to transfuse blood. The nurse needs to ensure the patient has been informed of the risks and benefits to a blood transfusion and has signed a consent form. The nurse must also ensure the correct orders are in the patients medical record. The nurse will also need to ensure a blood type and screen has been submitted on their client within the last 72 hours. At any time and for whatever reason the client retains the right to refuse a blood transfusion. In this example, the nurses client that is a Jehovah's Witness retains the right to refuse a blood transfusion as it goes against the guidelines in her religion.

The primary healthcare provider (PHCP) prescribes the insertion of a nasogastric tube for a client with paralytic ileus. The nurse understands that the primary purpose of placing this tube is to A. feed the client. B. decompress the stomach. C. irrigate the stomach. D. administer medications. Submit Answer

Explanation Choice B is correct. Paralytic ileus is characterized by an interruption of peristalsis, which causes a client to have abdominal distention, persistent nausea and vomiting, hiccups, and decreased bowel sounds. An NGT is placed to decompress the stomach and relieve the pressure from the ileus. Choices A, C, and D are correct. Feeding the client, irrigating the stomach, and administering medications may be accomplished by inserting an NGT. However, the purpose of an NGT being placed in the context of paralytic ileus is gastric decompression. Additional Info Paralytic ileus is characterized when the abdominal wall is distended with no visible intestinal movement. Manifestations of an ileus include a distended abdomen, abdominal discomfort, vomiting, no passage of flatus or stool. The treatment goal is to restore gastrointestinal functioning by promoting GI rest. The client is placed on a nothing-by-mouth (NPO) status, prescribed intravenous hydration, and likely has an NGT placed to decompress the stomach, allowing GI rest. Last Updated - 30, May 2022

While monitoring the administration of intravenous heparin to a patient. The nurse asks the physician to order which medication in case of an emergency? A. Potassium chloride B. Protamine sulfate C. Vitamin K D. Naloxone

Explanation Choice B is correct. Protamine sulfate is the antidote to heparin therapy. Protamine sulfate should be readily available in case the patient experiences heavy bleeding or hemorrhage. Choice A is incorrect. Potassium chloride is given to patients experiencing a serum potassium deficit. Choice C is incorrect. Vitamin K is the antidote to warfarin sodium. Choice D is incorrect. Naloxone is the antidote to opiate medications. NCSBN client need Topic: Physiological integrity, pharmacological and parenteral therapy

Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain? A. A 36-year-old female client with abdominal pain. B. A 56-year-old male client with a leg amputation. C. A 76-year-old female client with terminal cancer. D. An 84-year-old male client with severe arthritis. Submit Answer

Explanation Choice B is correct. The 56-year-old male client with a leg amputation would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain. Contralateral massage, or stimulation, unlike other cutaneous nonpharmacological comfort interventions, entails the stimulation of the opposite part of the body rather than the direct stimulation of the painful, affected area. For this reason, contralateral stimulation of the intact opposite leg will promote comfort and decrease phantom pain that has occurred as a result of the amputation. Choice A is incorrect. A 36-year-old female client with abdominal pain would not benefit from contralateral stimulation to decrease pain; alternative comfort measures and pain management interventions may be indicated. Choice C is incorrect. A 76-year-old female client with terminal cancer would not benefit from contralateral stimulation to decrease pain; alternative comfort measures and pain management interventions may be indicated. Choice D is incorrect. An 84-year-old male client with severe arthritis would not benefit from contralateral stimulation to decrease pain; alternative comfort measures and pain management interventions may be indicated. Last Updated - 08, Feb 2022

Many clients at the end of life experience symptoms, such as pain, that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association's position on pain management at the end of life? A. Advocate for pain management unless life-threatening side effects occur. B. Advocate for pain management even if the life-threatening side effects hasten death. C. Prohibit the respiratory system from depressing drugs because this is euthanasia. D. Allow families to administer respiratory system depressing drugs to hasten death. Submit Answer

Explanation Choice B is correct. The American Nurses Association (ANA) advocates for pain management even if the life-threatening side effects hasten death. In the past, pain management agents like narcotic analgesics were not given if they caused a respiratory depression that could lead to the cessation of life. This administration of respiratory system depressing drugs at the end of life is not considered euthanasia. The American Nurses Association does not encourage families to administer respiratory system depressing drugs to hasten death but it does allow families to administer respiratory system depressing drugs to relieve pain at the end of life. Choice A is incorrect. The American Nurses Association does not advocate for pain management unless life-threatening side effects occur. Choice C is incorrect. The American Nurses Association does not prohibit the respiratory system depressing drugs because this is euthanasia; this association does permit respiratory system depressing medications for a specific reason. Choice D is incorrect. The American Nurses Association does not encourage families to administer respiratory system depressing drugs to hasten death. However, it does allow families to apply respiratory system depressing drugs to relieve pain at the end of life. Last Updated - 01, Feb 202

The nurse is preparing to administer a medication to a client. They check the following information: Name and DOB of the client Name of the medication Dosage Route Date and time of the medication order Frequency of the medication What other information should the nurse verify before administering the medication? A. The client's ethnicity B. The concentration of the medication C. The client's room number D. The brand name of the medication Submit Answer

Explanation Choice B is correct. The nurse should also verify the concentration of the drug before administering. This is an important right of medication administration. Many drugs come in different concentrations, and if the nurse does not verify this they may inadvertently administer the wrong dosage of the drug. Choice A is incorrect. The client's ethnicity is not relevant to the administration of their prescribed medication. Choice C is incorrect. The client's room number is not an appropriate patient identifier. The nurse correctly verified this patient's identity with their name and DOB. Other appropriate identifiers include the MRN or patient telephone number. Choice D is incorrect. The name brand of the medication does not need to be verified prior to administration. This is not a right of medication administration. Additional Info Source : Archer Review Last Updated - 29, Mar 2022

You are preparing a patient for surgery. The operative consent is signed, and you have an order to give Meperidine 75 mg IM before sending the patient to the pre-operative area. The medication you have on hand is shown in the exhibit. The total volume of the medication you will give is: A. 1 mL B. 1.5 mL C. 2 mL D. 2.5 mL

Explanation Choice B is correct. This question requires that the nurse understand the amount of medication in the vial, the total amount ordered, and the calculation for figuring the total amount of medication to give. The formula for this calculation is (Amount ordered/Available amount) X Volume available = Volume Required. In this case, you substitute the values into the formula (75 mg/50 mg) X 1 mL = 1.5 mL to administer. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Dosage Calculation, Medication Administration Last Updated - 16, Jan 2022

The nurse is preparing to insert a nasogastric tube (NGT). Which action should the nurse take? A. Rinse the tube with warm, soapy water B. Perform hand hygiene C. Don sterile gloves D. Obtain a computed tomography (CT) scan to verify placement. Submit Answer

Explanation Choice B is correct. To minimize the risk of infection, the nurse should wash their hands before inserting a nasogastric tube (NGT). Choices A, C, and D are incorrect. None of these actions are appropriate before inserting an NGT. The nurse should not wash the tube with warm, soapy water. While the insertion of an NGT is not a sterile procedure, the risk of contaminating the tube is significant if this should occur. Additionally, sterile gloves are not necessary. After the initial insertion, the nurse should verify placement via a radiograph (abdominal or kidneys, ureters, bladder [KUB]). Subsequent verification should occur by aspirating gastric content and assessing its pH (less than four is desired). Additional Info Good hand hygiene is a pillar in healthcare. As a key reminder, hands should be rinsed by keeping hands down and elbows up. Finally, hands should be dried thoroughly from fingers to wrists with a paper towel or single-use cloth. Last Updated - 12, Nov 2022

The nurse is performing a physical assessment. When assessing a client's eyes for accommodation, which of the following actions would the nurse perform? A. Bring a penlight from the side of the client's face and briefly shine the light on the pupil. B. Ask the client to gaze at a distant object and then at a test object. C. Obtain a tuning fork and place it in the middle of the client's forehead. D. Have the client stand twenty feet away from a Snellen chart. Submit Answer

Explanation Choice B is correct. To test for accommodation, the nurse should darken the room and ask the client to gaze at a distant object (the far wall) and then at a test object (finger or pencil) held approximately 4 inches from the bridge of the client's nose. The pupils normally converge and accommodate by constricting when looking at close objects. Choices A, C, and D are incorrect. Shining the light in the pupil is a test for pupillary responses, not accommodation. Testing for accommodation does not require the nurse to illuminate the penlight. The Weber test is placing a tuning fork at the center of the client's forehead. This test is utilized to determine if the client has conductive hearing loss. Visual acuity is tested using a Snellen chart where the client is asked to stand twenty feet away from an object, and they are asked to read the smallest possible line. Additional Info Source : Archer Review To test for accommodation, ask the client to gaze at a distant object (the far wall) and then at a test object (finger or pencil) held approximately 4 inches from the bridge of the client's nose. The pupils normally converge and accommodate by constricting when looking at close objects. The pupillary responses are equal. Testing for accommodation is important only if the client has a defect in the pupillary response to light. If the assessment of pupillary reaction is normal in all tests, record the abbreviation PERRLA (pupils equal, round, reactive to light, and accommodation). Last Updated - 16, May 2022

The nurse is administering warfarin. Prior to administering the dose, they review any contraindications that would require holding the medication. Which circumstances do not require the nurse to hold the prescribed dose of warfarin? A. After the patient has tested positive for pregnancy. B. After the patient has eaten a large kale salad. C. While the patient is receiving epidural anesthesia. D. When the patient has a platelet count below 30,000/mcL. Submit Answer

Explanation Choice B is correct. While warfarin is a medication with many food-drug interactions, there is no reason to hold the drug in a situation like this. Warfarin exerts its anticoagulant effect by antagonizing vitamin K, thereby reducing vitamin-K-dependent clotting factors. Kale is a food that decreases warfarin's effect because kale is rich in vitamin K. Rather than holding the medication, the nurse should give warfarin as prescribed and notify the prescribing physician regarding the patient's Kale intake. Physicians may request the labs to be drawn before the next due dose or within 48 hours to check if the INR remained within the therapeutic range, between 2.0 and 3.0. Choice A is incorrect. If the patient has tested positive for pregnancy, it is essential that the nurse holds the prescribed dose of warfarin. Warfarin is teratogenic, meaning that it causes birth defects, and should not be used in pregnancy. The anticoagulant of choice during pregnancy is low-molecular-weight heparin. Choice C is incorrect. If the patient is receiving epidural anesthesia, and they receive any anticoagulation such as warfarin, they have a high risk of bleeding around their spine. This serious complication can lead to paralysis. If the patient receiving an epidural must absolutely be anticoagulated, their INR will need to be closely monitored. Choice D is incorrect. If the patient has a platelet count below 30,000/mcL, that indicates that they are at high risk of bleeding. The nurse would hold the prescribed dose of warfarin since it is an anticoagulant and will cause the patient to bleed even further. Last Updated - 09, Jan 2022

The nurse is teaching a client about methotrexate (MTX). Which of the following statements should the nurse include? Select all that apply. A. "This medication may cause you to bruise more easily." B. "You will need to take folic acid with this medication." C. "You must remain upright for thirty minutes after taking a dose." D. "You should avoid receiving inactivated vaccinations." E. "Avoid large crowds and wash your hands frequently." Submit Answer

Explanation Choices A, B, and E are correct. Methotrexate (MTX) is indicated for a variety of autoimmune conditions. This medication carries serious adverse effects such as pancytopenia (low red blood cells, white blood cells, and platelets). Thus, the client may bruise more easily and be at a higher risk of infection, so avoiding crowded areas and practicing good hand hygiene is essential. MTX antagonizes folic acid, and while a client is taking MTX, folic acid supplementation is typically prescribed. Choices C and D are incorrect. Remaining upright after taking this medication is not indicated. This would be an appropriate instruction to reduce the risk of reflux for a client taking bisphosphonate medication. Methotrexate reduces inflammation by suppressing the body's immune response, so the client should be instructed to avoid live vaccines such as MMR, varicella, and herpes zoster (shingles). Inactivated vaccines such as pneumococcal and influenza would be appropriate to encourage. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Adverse Effects/Contraindications/Side Effects/Interactions Question Type: Knowledge/Comprehension Additional Info Methotrexate is a folate antagonist used in the treatment of conditions such as rheumatoid arthritis, psoriasis, and some cancers. Common drugs interactions that can occur with methotrexate include: Protein-bound drugs and weak organic acids such as salicylates, sulfonamides, phenytoin Penicillins, NSAIDs Live virus vaccines Theophylline Hepatotoxic drugs Last Updated - 27, Apr 2022

You are caring for a client with a terminal disease and this person has asked for a curandero. What should you do? A. Refer the family to a religious shop with Bibles and other holy books. B. Refer the family and the client to a member of the clergy who may be able to help. C. Give the client a candle then close all of the shades and blinds to darken the room. D. Arrange for the client to go to a religious service to get this special blessing. Submit Answer

Explanation Choice B is correct. You would refer the family and the client to a member of the clergy who may be able to help. A curandero is a healer who is believed to have supernatural powers that can cure the sick. These powers are derived from the fact that many believe that illnesses and diseases occur as the result of evil spirits and a curse from God. Choice A is incorrect. A curandero is not a holy book. Choice C is incorrect. You would not give the client a candle then close all of the shades and blinds to darken the room because this is not consistent with the person's desire to have a curandero. A curandero is not a religious or spiritual practice that uses a candle and a darkened room. Choice D is incorrect. A curandero is not a particular religious blessing. Last Updated - 18, Oct 2021

Which of the following nursing diagnoses is appropriate for your client when your client is not coping with a progressive disease in an adaptive manner? A. Ineffective coping related to fear secondary to a progressive disease. B. Ineffective coping related to role ambiguity secondary to a progressive disease. C. Ineffective coping related to role changes secondary to a progressive disease. D. Ineffective coping related to role conflict secondary to a progressive disease. Submit Answer

Explanation Choice C is correct. "Ineffective coping related to role changes secondary to a progressive disease" is the nursing diagnosis that is appropriate for your client when your client is not coping with a progressive disease adaptively. Choice A is incorrect. "Ineffective coping related to fear secondary to a progressive disease" is not correct because there is no indication that this client is affected by fear. Choice B is incorrect. "Ineffective coping related to role ambiguity secondary to a progressive disease" can occur when the client with a progressive disease is not sure about what is expected in their sick role. Still, there is no indication that this client is affected by this uncertainty. Choice D is incorrect. "Ineffective coping related to role conflict secondary to a progressive disease" is also not appropriate because there is no information in this question that indicates that the client has a role conflict. Last Updated - 06, Feb 2022

You have to begin an intravenous therapy line for a client who is dark-skinned. You are having difficulty locating a vein for this venipuncture. Which of these devices or procedures may be of benefit to you at this time? A. A doppler B. A surgical vein cut down C. A transillumination device D. A sonography Submit Answer

Explanation Choice C is correct. A transillumination device may be of benefit to you when you are having difficulty locating a vein for this venipuncture and have to begin an intravenous therapy line for a client who is dark-skinned. Transillumination devices light up the area, and this light is sufficient to locate veins regardless of the client's skin color. These devices are also capable of identifying veins that are not palpable or visible when the client is obese. Choice A is incorrect. A doppler is used to auscultate pulses and not to locate veins that are not palpable or visible when the client is dark-skinned. Choice B is incorrect. A surgical vein cut down is not recommended because other noninvasive devices and procedures can be done to locate the vein of the client who is dark-skinned. Choice D is incorrect. Sonography is not useful for locating a vein for venipuncture when the client is dark-skinned. Last Updated - 15

The nurse is caring for a 7-year-old child who is continuously anxious in the pediatric ward. The nurse plans to initiate therapeutic play to help the child's anxiety. During the therapeutic game, all of the following activities should be included, except: A. Encourage manipulation of equipment. B. Constantly monitor the child's anxiety levels throughout the activity. C. Provide structure for the play. D. Continue play sessions regularly.

Explanation Choice C is correct. All the other statements are accurate except option C. Therapeutic play should be unstructured. The child should use the equipment, however, or whenever he/she wants it. Choice A, B, and D are incorrect. These statements are accurate. The nurse should encourage the expression of the child's feelings through the manipulation of equipment. This action also lets the child share her feelings, knowledge, and perceptions throughout the activity. The nurse should continuously observe the child's anxiety levels throughout the activity to determine if intervention by the nurse is needed or not. The nurse should always remember that the event is designed to decrease the client's anxiety, not increase it. Therapeutic play should be done regularly once it is initiated. Last Updated - 07, Feb 2022

Your client, who is taking an anticonvulsant medication, is also using herbs and other alternative therapies at home. The client tells you that some of these substances include "ginkgo biloba, garlic supplements, and evening primrose." How should you respond to this client's statement? A. "You are really wasting your money on these things. None of them work." B. "Garlic supplements can lower your seizure threshold when you are taking your anticonvulsant medications." C. "Evening primrose can lower your seizure threshold when you are taking your anticonvulsant medications." D. "Ginkgo biloba can decrease your clotting time and increase the clotting risk" Submit Answer

Explanation Choice C is correct. Evening primrose oil is a rich source of omega-3 fatty acids. Although its effects are unproven, patients use it widely for self-treating inflammatory disorders. Some reports indicate evening primrose may lower the seizure threshold. When the seizure threshold is reduced, there is a higher risk of seizures. This mechanism of primrose may cause it to interact with anticonvulsant medications, thereby reducing therapeutic efficacy. Choice A is incorrect. This statement is confrontational, judgmental, and not necessarily true. To respond to the client that they are wasting money on these things and sounding judgmental is inappropriate. Choice B is incorrect. Garlic supplements do not lower the seizure threshold. Garlic, however, can reduce blood pressure and potentiate the action of antihypertensive medications. Choice D is incorrect. Ginkgo biloba does not decrease clotting time; instead, it increases the bleeding time. Ginkgo biloba is a widely available herbal supplement. Patients commonly use it for early-stage dementia (early Alzheimer's disease), tinnitus, and to treat intermittent claudication pain of peripheral vascular disease. Ginkgo does not interact with anticonvulsants, but it may increase the bleeding risk if combined with warfarin and antiplatelet agents (aspirin). Ginkgo affects platelet aggregation and increases the bleeding time. Since it increases the bleeding risk, Ginkgo should be discontinued before surgical procedures. Learning Objective Understand the interactions between commonly used herbal supplements and pharmacological therapies. This helps the nurse to provide specific teaching to the clients. Additional Info Patients commonly use certain herbal supplements. Nurses should be aware of the side effects of these herbal supplements and their interactions with other commonly prescribed medications.

The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside? A. Overhead trapeze B. Abduction pillow C. Transfer board D. Continuous passive motion (CPM)

Explanation Choice C is correct. Following a lumbar spinal fusion, the client will need to be log rolled. A transfer board/sheet, along with an ample amount of staff (at least three), will be necessary to facilitate the log roll. Choices A, B, and D are incorrect. None of this equipment is necessary following a lumbar spinal fusion. A trapeze is helpful if a client were to have a lower extremity amputation. Further, an abduction pillow may be warranted after hip arthroplasty. Finally, a CPM may be indicated following a joint replacement. Additional Info Log rolling after a lumbar spinal fusion is likely ordered to protect the client from injury. Log rolling aims to keep the spinal column in straight alignment to prevent further injury. A minimum of three individuals is necessary to perform log rolling safely. A transfer sheet or board assists with the client being rolled as one unit. Last Updated - 17, Sep 2022

A 63-year-old male is being seen in the clinic for his annual exam. Before performing a digital rectal exam. Which of the following questions should the nurse ask? A. "Are you exercising regularly?" B. "Has your diet changed dramatically in the past year?" C. "Have you had any difficulty starting a stream of urine when you attempt to use the toilet?" D. "Are you currently experiencing constipation?" Submit Answer

Explanation Choice C is correct. Health care practitioners perform digital rectal exams (DRE) to check their aging male patients for benign prostatic hyperplasia (BPH) or prostate enlargement. Patients experiencing BPH may have difficulty starting a stream of urine or completely emptying their bladder. Choice A is incorrect. While asking clients about exercise is a general question asked during most yearly exams, this question does not have an impact on digital rectal examinations. Choice B is incorrect. Dietary questions are common at yearly examinations, especially for aging patients. However, dietary changes should not impact digital rectal exams. Choice D is incorrect. Health care staff may ask the patient about their bowel health during an annual exam if they have complained about any discomfort or concerns. Still, this question does not impact the reasons behind digital rectal examinations. NCSBN client need | Topic: Health Promotion and Maintenance/Aging Process Last Updated - 07, Feb

The nurse is preparing to remove a central venous catheter. It would be appropriate to place the client in which position for this procedure? A. Reverse Trendelenburg B. Left lateral C. Trendelenburg D. High-Fowler's

Explanation Choice C is correct. Placing the client supine or Trendelenburg for this procedure would be appropriate. One of these two positions is acceptable to decrease the risk of air embolism. The client should not have their head elevated for this procedure. Choice A, B, and D are incorrect. The positioning of a client is essential to avoiding an air embolism. Thus, having a client high-Fowler's, lateral, or reverse Trendenlenberg would be contraindicated. If a client experiences an air embolism, turning the client to the left-lateral position would be appropriate, but not for the procedure of removing a central line itself. Learning Objective Recognize the safety interventions to minimize the risk of air embolism while removing a central venous catheter. These include placing the client in a Trendelenburg or supine position. Additional Info While removing a central venous catheter, the client should be positioned supine or in Trendelenburg. The catheter should not be removed while the client is sitting up because this would increase the risk of air embolism because the atmospheric pressure is relatively higher than the intrathoracic pressure. To ensure that the intrathoracic pressure is higher than atmospheric pressure, position the client in either supine or Trendelenburg and have the client hold their breath or perform a Valsalva maneuver during removal.

The nurse is caring for a client with a potassium of 3.2 mEq/dl. Which of the following medications may cause this abnormality? A. Spironolactone B. Triamterene C. Prednisone D. Lisinopril Submit Answer

Explanation Choice C is correct. Prednisone is a corticosteroid that increases aldosterone and is responsible for sodium retention and the elimination of potassium. Therefore, a client's potassium level will decrease while taking this medication. If a client is taking prednisone, the recommendation is that they reduce dietary sodium and increase dietary potassium. Choices A, B, and D are incorrect. Spironolactone, Triamterene, and Lisinopril are all medications that increase potassium. Therefore, the nurse must monitor the client for potential hyperkalemia (potassium greater than 5.0 mEq/L). Additional Info Source : Archer ReviewSource : Archer Review Last Updated - 22, Nov 2022

You are caring for a patient in a medical unit. You have an order to administer medication via the buccal route. How will you administer the medication? A. Into the ear B. Under the tongue C. In the mouth toward the cheek D. Into the nasal sinus

Explanation Choice C is correct. The buccal route is into the mouth toward the cheek. Choice A is incorrect. Administration of medications into the ear is referred to as auricular or otic administration. Choice B is incorrect. Administration of drugs under the tongue is referred to as sublingual administration. Choice D is incorrect. Administration of medicines into the nasal sinus is referred to as endosinusial administration. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Medication Administration Additional Info Source : Archer Review Last Updated - 16, Nov 2021

The nurse is caring for a client in pain. The nurse asks the client which level of pain he is in, and the client says it's 1 out of 10. The nurse notices that the client grimaces every time he moves. What is the nurse's most appropriate action? A. Administer analgesics to the client. B. Move on to other patients. C. Ask the client about his grimacing with every movement. D. Encourage the client to watch his favorite TV show.

Explanation Choice C is correct. The nurse needs to assess the situation further when conflicting information is noted. Although the client states that his pain level is 1/10, his grimace at every movement tells otherwise. The nurse should validate her observations and make further assessments. Choice A is incorrect. The nurse needs to validate her observations first alongside what the client tells her to perform a more appropriate intervention. Choice B is incorrect. The nurse should not dismiss her observations about the client. Choice D is incorrect. Before performing interventions such as distraction, the nurse should validate her observations first. Last Updated - 30, Jan 2022

Select the parenting style that is accurately paired with one of its advantages. A. The democratic style of parenting: It is relatively quick and easy to solve problems. B. The autocratic style of parenting: It gives the impression that the family is strong. C. The permissive style of parenting: It facilitates satisfaction among the members of the family. D. The laissez-faire style of parenting: It gives the impression that the family is loving. Submit Answer

Explanation Choice C is correct. The permissive style of parenting, like other parenting styles, has its advantages and its disadvantages. The permissive style of parenting facilitates satisfaction among the members of the family, however, it is disadvantageous because it can lead to undesirable behaviors because young children of the family may need more structure and clearer boundaries to develop appropriate behaviors. Choice A is incorrect. The democratic style of parenting is not a quick and easy way to solve problems; the democratic style of parenting is time-consuming but it also allows all members of the family to have input and a voice that is heard. Choice B is incorrect. The autocratic style of parenting does not give the impression that the family is strong; the impression that it gives is one that the family is rigid and highly structured. Choice D is incorrect. The laissez-faire style of parenting does not give the impression that the family is loving; the impression that it gives is one of being lazy and not caring. Last Updated - 18, Oct 2021

The nurse is caring for a client with the following clinical data, as shown in the exhibit. Which medication would the nurse be concerned about before administration based on the vital signs? See the exhibit. A. Metoprolol 50 mg PO Daily B. Lisinopril 40 mg PO Daily C. Albuterol 2.5 mg via nebulizer Daily D. Diltiazem XR 120 mg PO Daily Submit Answer

Explanation Choice C is correct. The vital signs (VS) show an increased pulse (123 bpm) and elevated blood pressure. Albuterol is a beta-receptor agonist and would foreseeably worsen the tachycardia that the client is already experiencing. The nurse should clarify the albuterol prescription with the primary health care provider (PHCP) because albuterol may increase heart rate. Choices A, B, and D are incorrect. Metoprolol and diltiazem treat hypertension and certain dysthymias, such as atrial fibrillation. These medications help decrease the heart rate and blood pressure. Therefore, they need not be held in this client with tachycardia and hypertension (choices A and D). Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that therapeutically decreases blood pressure without impacting the pulse (choice B). Lisinopril is indicated in treating congestive heart failure, diabetic nephropathy, polycystic kidney disease, and hypertension. The client is hypertensive, and it is appropriate to administer the prescribed lisinopril. Learning Objective Recognize that albuterol may increase the heart rate. Additional Info Albuterol is a beta-adrenergic agonist used to manage acute (asthma attack, bronchospasm) and chronic respiratory conditions (emphysema). Albuterol is a short-acting bronchodilator, is a priority treatment in acute asthma exacerbations, and is given emergently via nebulizer. Side effects of this medication include nervousness, palpitations, insomnia, and increased heart rate. Last Updated - 26, Nov 2022

You are preparing to start an IV on a patient recently admitted to your unit. You begin the IV using an 18 gauge intravenous catheter. The physician's order reads, "Give 500 mL of normal saline IV over the next four hours." The flow rate you will set is: A. 50 mL per hour B. 100 mL per hour C. 125 mL per hour D. 250 mL per hour Submit Answer

Explanation Choice C is correct. This question requires that the nurse understand the total volume ordered, the time for administration of the fluid, and the calculation for figuring the rate of fluid administration. The formula for this calculation is: Volume ordered/Total time for infusion = Flow rate in mL/hr. In this example, you would substitute the correct values into the equation. Therefore, 500 mL/4 hours = 125 mL/hr. Choices A, B, and D are incorrect. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Dosage Calculation, Medication Administration Additional Info Last Updated - 02, Aug 2021

A nurse is conducting pre-operative teaching to a client who will undergo surgery in 1 week. Which response by the client would prompt the nurse to give additional teaching? A. "Aspirin can possibly cause bleeding even after surgery." B. "Aspirin can adversely affect my clotting ability" C. "I should stop aspirin one day prior to my surgery." D. "It is important that I talk to my physician about the possibility of stopping aspirin before the surgery." Submit Answer

Explanation Choice C is correct. This statement by the client ("I should stop aspirin one day before my surgery.") needs further education and is, therefore, the correct answer to this question. Stopping Aspirin one day before surgery is not usually appropriate since platelet function would not recover enough in 1 day. Aspirin is an anti-platelet drug and can alter the platelet's ability to aggregate and may increase the risk of bleeding after surgery. Aspirin irreversibly affects the platelet function, therefore one should be aware that the effects of aspirin last for the duration of the life of the platelet (which is close to 10 days). After a single dose of aspirin, total body platelet activity recovers by 10% per day as a result of new platelets being produced - so approximately, by 5-7 days after the last aspirin dose, the majority of platelet activity would have recovered. Because of this, anti-platelet therapy is usually stopped 5 to 7 days before the scheduled surgery but should be done as directed by the physician. The client should, therefore, discuss this with the physician so that the client will be properly guided as to when the medication should be stopped before surgery. In this case, the nurse needs to reinforce teaching to correct the client's notion. Choices A, B, and D are incorrect. These statements reflect accurate understanding by the client regarding aspirin, and these ideas do not need additional teaching. It is true that the client needs to consult his physician for guidance regarding stopping Aspirin (Choice D). It is true that Aspirin may increase post-operative bleeding risk (Choice A) and can adversely affect the clotting ability (Choice B). Last Updated - 09, Jan 2022

The nurse is caring for a client who is taking prescribed venlafaxine. Which statements made by the client would be highly concerning to the nurse? A. "I have trouble sleeping at night." B. "I experience diarrhea at least once a day." C. "I just cannot go on like this anymore." D. "I am using artificial tears for my dry eyes." Submit Answer

Explanation Choice C is correct. Venlafaxine is a medication that is indicated for depression. Side-effects of venlafaxine include dry eyes/mouth, diarrhea, and sleep disturbances. The client's comment of not wanting to go on anymore should concern the nurse because anti-depressants may cause thoughts of suicide. Thus, the nurse needs to immediately follow up with this client. Choices A, B, and D are incorrect. These statements are not concerning, therefore they are incorrect answers to the question. Last Updated - 15, Feb 2022

The nurse is preparing a client for a breast exam. The nurse should position the client A. supine with arms at the side and a pillow under both knees. B. left lateral with the head resting on a pillow and the arm over the head. C. sitting forward with a pillow behind the shoulder blades with hands on the hips. D. supine, with the arm on the side examined behind the head and a small pillow under the shoulder. Submit Answer

Explanation Choice D is correct. A pillow should also be placed under the client's shoulder on the side that is being assessed. Breast inspection and palpation should be performed on both men and women. The client can be sitting or lying supine. The client should sit erect with arms at the sides or raised overhead. When flat, the client's hand on the examined side is placed under the head, if possible. Examination of the breast and axilla are often performed sequentially with the assessment of the thorax, lungs, and heart. Choices A, B, and C are incorrect. These positions would not facilitate an effective breast exam. Last Updated - 01, Dec 2022

Which of the following meals would you offer your client who practices Orthodox Judaism? A. Chicken parmesan and spaghetti B. Chile con carne topped with queso fresco C. A club sandwich with low sodium ham and cheese D. A cottage cheese salad with fresh fruit

Explanation Choice D is correct. As outlined in the Torah, clients who practice Orthodox Judaism typically consume a kosher diet. Although a few dietary laws are associated with Orthodox Judaism (and discussed below), one of the key aspects required when following a kosher diet is avoiding consuming meat and dairy products in the same meal. Here, offering your client a cottage cheese salad with fresh fruit is acceptable, as the meal does not violate any kosher dietary laws. Choice A is incorrect. Offering chicken parmesan and spaghetti to a practicing Orthodox Jewish client would be unacceptable, as the meal violates kosher dietary law by mixing meat and dairy products in the same meal. Additionally, it is not known if the chicken was slaughtered in a kosher manner. This type of meal is not permitted under the Torah. Choice B is incorrect. Offering chile con carne topped with queso fresco to a practicing Orthodox Jewish client would be unacceptable, as the meal violates kosher dietary law by combining meat and dairy products in the same meal. Additionally, it is not known if the meat was processed in a kosher manner. This type of meal is not permitted under the Torah. Choice C is incorrect. Offering a club sandwich with low sodium ham and cheese to a practicing Orthodox Jewish client would be unacceptable, as the meal violates kosher dietary law by mixing meat and dairy products in the same meal. Furthermore, ham would be inappropriate, as pork consumption would violate kosher dietary law, as a kosher diet does not allow the consumption of pigs' flesh, organs, eggs, or milk. Learning Objective Recognize and implement dietary restrictions of Orthodox Judaism clients. Additional Info The Torah provides the dietary laws for Orthodox Judaism. Most clients who practice Orthodox Judaism do not eat meat with dairy products in the same meal. Orthodox Judaism prohibits food preparation on the Sabbath. Clients who follow Orthodox Judaism typically only consume fish that have scales and fins. Orthodox Judaism only allows for the consumption of Kosher animals. Following this practice, specific regulations specify how animals are slaughtered, specifically so that no blood is consumed.

The nurse cares for a client who has a double-lumen peripherally inserted central catheter (PICC). Which of the following actions would be appropriate for the nurse to take? A. Assign the client to a private room. B. Change the dressing daily using sterile technique. C. Flush heparin prior to discontinuation. D. Aspirate each lumen for blood return and then flush.

Explanation Choice D is correct. Ensuring that the PICC line is patent is essential. This is accomplished by aspirating each lumen for blood return and then flushing each with saline. This measure will help in preventing occlusion. Choices A, B, and C are incorrect. Clients with a central line do not need a private room. This is an inappropriate infection control measure. Dressing changes for a PICC line should be done using an aseptic technique but are not completed daily. Dressing changes for central lines are completed every seven days. A dressing change should occur if the dressing becomes soiled or damp. Heparin is not flushed before discontinuation. Heparin is instilled before removing access to a port - but not a PICC line. Additional Info According to the Centers for Disease Control, (CDC), management of a central line should involve the following - Strict adherence to hand hygiene. Accessing the device with sterile supplies. Scrub the device's hub with an agent such as chlorhexidine or alcohol before instilling medications or fluids. Daily chlorhexidine baths to help reduce the presence of skin microorganisms. Dressing changes are completed with an aseptic technique. Last Updated - 01, Sep 2022

The nurse is performing a head-to-toe assessment of the patient. During the abdominal evaluation, the correct sequence for this assessment is: A. Auscultation, Inspection, Palpation, Percussion B. Inspection, Palpation, Auscultation, Percussion C. Percussion, Auscultation, Palpation, Inspection D. Inspection, Auscultation, Percussion, Palpation

Explanation Choice D is correct. For the abdominal exam, the exact sequence of actions would be inspection, auscultation, percussion, and palpation. The abdominal assessment is an integral part of the evaluation of any patient, but it is critical when the chief complaint is related to intestinal issues. The abdominal assessment should always progress from least intrusive (inspection) to most invasive. All findings should be related to one or more of the four quadrants of the abdomen. For example, a laceration noted in the right upper quadrant might be a documented finding. During the abdominal assessment, the clinician should look at the stomach first, observing for swelling, lacerations or punctures, asymmetry, or other abnormalities. In the second step, auscultation, the clinician is listening for bowel sounds. It is essential to do this before palpation or percussion since any manipulation of the abdomen can change the bowel sounds. If bowel sounds are not immediately auscultated, the clinician should spend 30-60 seconds listening. Palpation should be gentle to determine the amount of discomfort the patient is having. When percussion is needed, it helps the nurse assess the borders of the major organs (especially the liver and spleen). NCSBN Client Need Topic: Health Promotion and Maintenance;Sub-Topic: Physical Assessment Last Updated - 21, Jan 2022

A nurse is taking care of a client undergoing cerebral angiography. Which statement by the client would most warrant additional attention from the nurse? A. "I feel like I'm going to vomit." B. "I hope my results are okay." C. "It's getting a bit hot in here." D. "My throat is getting a bit itchy, and my eyes are getting watery." Submit Answer

Explanation Choice D is correct. Iodinated contrast materials are used during cerebral angiography, potentially causing severe allergic reactions. Here, the client's itchy throat and watery eyes are classic indications of an allergic reaction that may progress to an anaphylactic reaction. Symptoms of a severe anaphylactic reaction include airway compromise due to laryngeal edema or angioedema (stridor), bronchoconstriction (wheezing, cough, and dyspnea), and/or circulatory collapse (shock). This is an extreme emergency, as the client's airway is at risk of compromise. The nurse should promptly assess the client for additional signs of anaphylaxis, notify the health care provider (HCP), and initiate interventions to stop further symptom progression while alleviating the current manifestations. Choice A is incorrect. Nausea is likely a reaction to the administration of contrast material, presumably capable of being alleviated by the administration of a PRN (as needed) intravenous antiemetic medication. While this statement should be of concern to the nurse, this is not the priority concern. The nurse should prioritize airway-related symptoms in this client. Choice B is incorrect. This statement by the client may indicate anxiety or a flushing sensation being experienced by the client. The nurse should address the client's concern; however, it is not prioritized over an airway-related complaint. Choice C is incorrect. A warm, flushed feeling is a benign and anticipated reaction following the intravenous administration of contrast media. The sensation may be felt throughout the body but is often pronounced in certain regions - most clients experience this as a warm sensation around the throat, which gradually moves down to the pelvic area. Learning Objective Understand the need to prioritize airway-related symptoms indicative of a potential allergic reaction, recognizing the urgency to assess the client for symptoms and signs of anaphylaxis. Additional Info Prioritization Airway patency falls under the physiological needs level of Maslow's Hierarchy of Needs. When addressing prioritization questions, physiological needs must be prioritized over all other types of needs. Contrast Agent Allergies Clients with the highest risk of contrast agent allergies are those with a previous history of reactions to contrast media, those taking beta-blockers, and those with heart disease, asthma, and/or renal insufficiency. Research shows that clients with seafood allergies are not at any additional risk if given contrast media. Additionally, clients with allergies to topical iodine preparations or other iodides are also not at increased risk for contrast media reactions. Prevention of Contrast Agent Allergies To prevent contrast media allergies, a prednisone or diphenhydramine medication regimen can often be utilized in clients with a previous history of a contrast allergy. If possible, the risk of contrast reactions can be reduced using nonionic contrast media instead of ionic contrast media. Source : Archer Review Last Updated - 19, Aug 2022

The nurse is about to change a dressing on an older man with a stage 3 pressure ulcer. What should be the nurse's first action? A. Gather all the necessary equipment. B. Use non-sterile gloves to remove the old dressing. C. Explain the procedure to the client. D. Check the medication record to see if pain medications were administered.

Explanation Choice D is correct. Pain associated with pressure ulcers should be appropriately addressed, specifically with dressing changes. The nurse must provide adequate pain medications to the client before the dressing changes. Pressure ulcers ( pressure injuries/ decubitus ulcers/ bed sores) are caused by prolonged pressure on an area of skin that leads to ischemia ( reduced blood supply), skin breaks down, and underlying tissue injury. Usually, these occur over bony prominences. Depending upon the clinical appearance and the degree of damage, pressure-induced skin and soft tissue injuries are staged from stage 1 to stage 4 and unstageable pressure injuries. Stage 3 and stage 4 ulcers are ulcers with full-thickness tissue loss. Management of these deeper injuries involves debridement and covering with appropriate dressings. Generally, pressure ulcers are very painful, and optimal pain medications ( using the WHO analgesic ladder) should be administered to control pain. In stage 3 and 4 ulcers, there is significant tissue damage, and therefore, only a little or no pain may be experienced at the baseline. However, the pain may be worse than the baseline during dressing changes, even with stage 3 ulcers. The nurse should ensure that the client has been given pain medication at least 30 minutes before changing the dressing. Choices A, B, and C are incorrect. The nurse should prepare all the needed equipment for the procedure before attending to the patient and always use non-sterile gloves to remove the old dressing. The nurse should explain the procedure to the client immediately before starting the dressing change process. While all these actions are essential, these are not the first actions. Addressing pain control before dressing change is the nurse's priority action. Last Updated - 15, Feb 2022

Select the classification of cultural beliefs/practices that are accurately paired with an example of it. A. Holistic health beliefs: A pathogen causes infection and this leads to health problems. B. Magical health beliefs: Illness results from disharmony of the body and the mind. C. Scientific health beliefs: The wearing of an amulet to protect health. D. Scientific health beliefs: Compliance with the medical regimen is essential to health.

Explanation Choice D is correct. Scientific health beliefs are grounded in scientific research and evidence-based practice. With research and science, we can know the etiology of diseases and also ways to treat illnesses/disorders. Therefore the clients' compliance and adherence to the medical regimen are essential to health and recovery. Choice A is incorrect. Holistic health beliefs reflect the highly complex interactions of humans and the environment and the whole or integral part of the person. As such, holistic health beliefs create and recreate the harmony and balance of the person within their environment. Choice B is incorrect. Magical health beliefs vary significantly among cultures and religions. The wearing of an amulet and the use of a medicine man are examples of magical health beliefs and practices. Choice C is incorrect. The wearing of an amulet to protect health is an example of a magical health belief. Last Updated - 30, Jan 2022

You are the registered nurse in a multi-ethnic community health department clinic. In this role, you are asked to identify clients with genetic risk factors related to ethnicity to screen them for some commonly occurring diseases. You would identify a client who is of: A. Mediterranean ethnicity for cystic fibrosis B. African American ethnicity for Tay Sachs disease C. British Isles ethnicity for psychiatric mental health disorders D. Saudi Arabian ethnicity for sickle cell anemia Submit Answer

Explanation Choice D is correct. You would identify a client who is of Saudi Arabian ethnicity for sickle cell anemia. Other ethnicities at greatest risk for sickle cell anemia include Africans, Latin Americans, Southern Europeans, and some clients from some Mediterranean nations. Choice A is incorrect. Mediterranean clients are at risk for developing Thalassemia. Choice B is incorrect. African Americans are not at higher risk for Tay Sachs. Clients of Ashkenazi Jewish descent are at risk for Tay Sachs. Choice C is incorrect. African Americans and Native Americans are at risk for psychiatric mental health disorders. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological Adaptation Last Updated - 07, Feb 2022

Place the following steps for starting a peripheral intravenous line in the correct sequential order? Pull the skin taut above the selected vein. Place the tourniquet 1 to 2 inches above the selected vein site. Allow the area to air dry. Inspect and palpate the extremity for a suitable vein. Prep the selected area with an antiseptic wipe. Place a sterile dressing over the IV site. Insert the intravenous catheter at a 15 to 30 degree angle. Stabilize the intravenous catheter. Advance the catheter until a flash of blood is seen. Submit Answer

Explanation The correct sequence of steps to start a peripheral intravenous line are as follows: Inspect and palpate the extremity for a suitable vein. Place the tourniquet 1 to 2 inches above the selected vein site. Prep the selected area with an antiseptic wipe. Allow the area to air dry. Pull the skin taut above the selected vein. Insert the intravenous catheter at a 15 to 30-degree angle. Advance the catheter until a flash of blood is seen. Stabilize the intravenous catheter. Place a sterile dressing over the IV site. NCSBN Client Need: Topic: Reduction of Risk Potential; Sub-Topic: Insert, maintain, or remove a peripheral intravenous line. Last Updated - 23, Oct 2021

The nurse is supervising a new nurse caring for an elderly client. Which of the following statements regarding sensory changes in an older adult, if made by the new nurse, would require follow-up? Select all that apply. A. Increased acuity for high-pitched tones. B. Decreased sensitivity to glare. C. Increased tympanic membrane flexibility. D. Diminished sound discrimination. E. Decreased taste reception. Submit Answer

Explanation Choices A, B, & C are correct. These statements are incorrect regarding changes in the older adult and, therefore, require follow-up by the supervising nurse. Older adults commonly experience a loss of acuity for high-pitched frequencies ( presbycusis) due to changes in the inner ear, such as sclerosis ( Choice A). Glare sensitivity is increased, not decreased. As adults age, changes in the eye, such as smaller pupils and reduced light accommodation, can result in increased sensitivity to glare ( Choice B). Age-related changes in the ear also include a thickening of the tympanic membrane rather than increased flexibility ( Choice C). Choice D & E are incorrect. Sound discrimination is altered in the aging adult, which makes it difficult to hear voices in areas with background noise, such as a television ( Choice D). A decrease in the number of taste buds often causes older clients to have difficulty distinguishing between sweet, sour, and bitter tastes ( Choice E). These answers describe correct changes in the older adult and, therefore, do not require follow-up by the supervising nurse. Learning Objective Understand the age-related physiological sensory changes in an older adult. Additional Info Physiological sensory changes in the older adult include: Eyes: Decreased visual acuity, light accommodation, and increased glare sensitivity due to retinal damage decreased pupil size/slower pupillary reaction, lens opacities, and loss of lens elasticity Presbyopia, a progressive decline in accommodation from near to far vision Ears: Presbycusis, changes in the inner ear bones resulting in decreased ability to hear high-pitched frequencies Thickening of the tympanic membrane increased cerumen build-up Tongue/ taste: Decreased taste due to taste bud atrophy and loss of sensitivity, as well as decreased smell Skin: Decreased touch sensation due to reduces skin receptors Last Updated - 27, Apr 2022

The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure? Select all that apply. A. Blood pressure B. End-tidal carbon dioxide [ETCO2] level C. Respiratory rate D. Blood glucose E. Oxygen saturation

Explanation Choices A, B, C, and E are correct. Moderate sedation is utilized for closed reduction procedures, which involves placing the bone back in alignment without making an incision into the skin. Moderate sedation for a closed reduction of a shoulder is quick, and pain is minimal with the use of moderate sedation. Midazolam, fentanyl, or propofol is commonly used for moderate sedation. The nurse must carefully watch the client's vital signs, end-tidal carbon dioxide, and cardiac rhythm during the procedure. Choice D is incorrect. Blood glucose is not a monitoring parameter associated with moderate sedation. Frequent assessment of the vital signs, end-tidal carbon dioxide, and cardiac rhythm are standard during moderate sedation. Additional Info A procedure involving this type of sedation requires informed consent, and the nurse will serve as a witness. Common medications utilized for moderate (conscious) sedation include fentanyl, midazolam, or propofol. Anesthesia providers, other physicians, dentists, and oral surgeons are qualified to administer conscious sedation, and the nurse does not administer anesthesia intravenously. When this type of sedation is utilized for a closed reduction, it is a quick process that requires close monitoring of the client's vital signs, end-tidal carbon dioxide (normal is 20 and 40 mm Hg), cardiac rhythm, and level of consciousness. Last Updated - 16, Jul 2022

The nurse assists a client with left-sided weakness. Which of the following actions should the nurse perform when assisting this client in ambulating with a cane? Select all that apply. A. Place a gait belt around the client's waist. B. Stand on the client's left side during ambulation. C. Instruct the client to put the cane in the left hand. D. Measure the cane from the client's wrist crease. E. Instruct the client to put the cane in the right hand. F. Instruct the client to look down while ambulating. Submit Answer

Explanation Choices A, B, D, and E are correct. When instructing a client to ambulate with a cane, the nurse should apply a gait belt to the client's waist. The nurse should stand on the client's left (weaker) side if the client has difficulty. The client should have the cane in their right hand (stronger side), and the height of the cane should be measured from the client's wrist crease. Choices C and F are incorrect. The client should have the cane on the unaffected/stronger side. In this question, it would be the right side. Finally, the client should be instructed to look ahead as they ambulate - not down at the ground. Additional Info When a client ambulates with a cane, the nurse should ensure that a gait belt is applied before getting out of bed. The nurse is positioned on the client's affected (weaker) side, slightly behind the client. Measure the height of the cane from the wrist crease or greater trochanter The cane should be held on the unaffected (stronger) side The elbow should be flexed 15-30 degrees The cane should be advanced (6-10 inches) along with the affected (weaker) leg. Remember the mnemonic: COAL - Cane Opposite Affected Leg. Then, the unaffected (stronger) leg should be advanced just past the cane A rubber tip should always be applied to a cane to ensure appropriate traction with the ground. Last Updated - 04, Dec 2022

Which of the following is not a rationale for the nurse to reassess the patient's pain after treatment? Select all that apply. A. To measure the duration of pain B. To pinpoint the location of pain C. To make changes to the patient's pain goal D. To establish the efficacy of medication Submit Answer

Explanation Choices A, B, and C are correct. A: Duration is how long the patient experiences pain. The rationale for the 30-60 minute timeframe for reassessment is to allow the pain medication to take effect. B: Location refers to where the patient is experiencing pain. This is not expected to change in a reassessment. C: The pain goal is negotiated on admission, not during readmission or reassessment. Choice D is incorrect. Reassessment is performed to assess the efficacy of the treatment. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort; Reassessing and Documenting Pain Last Updated - 22, Oct 2021

The nurse is caring for an assigned client. Which prescription requires clarification based on the laboratory data? See the exhibit. Select all that apply. A. Vancomycin 1-gram IVPB Daily B. Furosemide 40 mg PO Daily C. 500 ml of 0.9% Saline IV Bolus x 1 D. Diltiazem XR 120 mg PO Daily E. Ketorolac 15 mg IV Q 8 hours

Explanation Choices A, B, and E are correct. The prescribed vancomycin, furosemide, and ketorolac are all medications that should be clarified with the PHCP based on the BUN and creatinine being elevated. These elevations represent renal insufficiency. All three of these medications are nephrotoxic. Vancomycin is an antibiotic indicated for MRSA infections. Furosemide is used for cardiovascular disorders such as congestive heart failure, and ketorolac is a non-steroidal anti-inflammatory (NSAID) indicated for mild to moderate pain. Choices C and D are incorrect. 500 ml of 0.9% saline bolus would be helpful for this client, considering the labs showing nephrotoxicity. Diltiazem XR is okay to give to a client based on these laboratory findings. Additional Info Elevations of the creatinine (normal: 0.6-1.2 mg/dL for males, 0.5-1.1 mg/dL for females) usually are caused by an offending agent such as an NSAID (ketorolac), antibiotic (vancomycin), or sulfa-based drugs. The elevation of the BUN (normal 10-20 mg/dL) may be caused by dehydration. In this case, it would be detrimental to give the client the furosemide considering existing signs of dehydration and renal insufficiency.

The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply. A. A client who had rectal surgery and a post-operative abscess B. A child who has pneumonia C. An older client who is post-myocardial infarction (MI) D. A teenager with leukemia, a neutrophil count of 500/microliter, and is receiving erythropoietin for anemia E. An adult patient with acute pancreatitis and has disseminated intravascular coagulation (DIC)

Explanation Choices A, C, D, and E are correct. (Choice A) Rectal temperature should not be used in clients with a history of rectal surgery. Because of the risk of disruption of surgical anastomosis, it is preferred to refrain from rectal temperature checks in such clients. Additionally, the rectal temperature should not be used in clients with diarrhea and newborns under 12 weeks. Many healthcare providers prefer axillary temperature screening in newborns because of the theoretical risk of rectal perforation. However, if an accurate temperature reading is desired in a newborn, rectal temperature may be performed because the available evidence does not substantiate the fears of rectal perforation using a rectal thermometer. (Choice C) The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve. Therefore, patients who are post-MI should not have a rectal temperature taken. (Choice D) Assessing a rectal temperature is contraindicated in neutropenic patients. A leukemia client with neutropenia and anemia shouldn't be subjected to rectal temperature checks. A normal absolute neutrophil count should be more than 1500/ microfiber ( 1500/ul). A neutrophil count less than 1500/ul is mild neutropenia, whereas a count less than 500/ul is severe. Neutropenia predisposes to infections, and any invasive procedures with the potential to introduce pathogens into the body must be avoided. (Choice E) Assessing rectal temperature is also avoided in those with certain neurologic disorders and patients with thrombocytopenia (low platelet count). Acute pancreatitis can be complicated with DIC in severe cases. Disseminated intravascular coagulation (DIC) causes consumptive thrombocytopenia. Thrombocytopenia increases the bleeding risk when invasive procedures are performed. Therefore, a client with acute pancreatitis and DIC should not get a rectal temperature assessment. Choice B is incorrect. A child with pneumonia can have a rectal temperature taken. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Temperature Learning Objective While rectal thermometry to confirm fever is one of the most accurate methods, recognize that there are conditions where it is contraindicated. Last Updated - 07, Mar 2022

The nurse is assisting a client to choose food options appropriate for Celiac disease. Which food items would be appropriate to select? Select all that apply. A. Grilled chicken B. Wheat pasta C. Scrambled eggs D. Oatmeal E. Avocado

Explanation Choices A, C, and E are correct. Celiac disease is characterized by an individual's intolerance to gluten. Grilled chicken, scrambled eggs, and avocado are all examples of foods that have no gluten Choices B and D are incorrect. A client with Celiac disease should avoid sources of gluten such as barley, rye, oats, and wheat. Wheat pasta and oatmeal would not be appropriate selections for a client with gluten intolerance. Oats are not gluten-free as when they are transported they come into contact with other gluten-containing products. Additional Info Celiac disease, if untreated, may cause an individual abdominal pain, distention, vomiting, anemia, and diarrhea. A client should be thoroughly educated to avoid foods that contain gluten. Foods allowed include beef, chicken, pork, vegetables, fish, and eggs. Last Updated - 24, Aug 2022

Which statements describe the action of the medications? Select all that apply. A. Diazepam is given to alleviate anxiety. B. Ranitidine is given to facilitate patient sedation. C. Atropine is given to decrease oral secretions. D. Morphine is given to depress respiratory function. E. Cimetidine is given to prevent laryngospasm. F. Fentanyl citrate-droperidol is given to facilitate a sense of calm. Submit Answer

Explanation Choices A, C, and F are correct. A: Sedatives, such as diazepam (Valium), midazolam (Versed), and lorazepam (Ativan), are given to alleviate anxiety and decrease the recall of events related to surgery. C: Anticholinergics, such as atropine and glycopyrrolate (Robinul), are given to decrease pulmonary and oral secretions in order to prevent laryngospasm. F: Neuroleptanalgesic agents, such as fentanyl citrate-droperidol (Innovar), are given to cause a general state of calm and sleepiness. Choices B, D, and E are incorrect. B and E: Histamine-2 receptor blockers, such as cimetidine (Tagamet) and ranitidine (Zantac) are given to decrease gastric acidity and volume. D: Narcotic analgesics, such as morphine, are given to decrease the amount of anesthetic agent needed. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies; Preoperative Medications Last Updated - 09, Nov 2021

Which of the following are concepts or constructs associated with cultural competence? Select all that apply. A. Cultural obedience B. Cultural skills C. Cultural encounters D. Cultural desire E. Cultural awareness F. Cultural knowledge

Explanation Choices B, C, D, E, and F are correct. The five concepts or constructs associated with cultural competence are cultural skills, cultural encounters, cultural desire, cultural awareness, and cultural knowledge. These five concepts put forth by Campinha-Bacote underscore the need for nurses and other healthcare providers to develop the knowledge, skills, and abilities to provide culturally competent care to individuals, families, and the community. Choice A is incorrect. Cultural obedience is NOT one of the concepts or constructs associated with cultural competence. Last Updated - 06, Feb 2022

A nurse is caring for a group of preoperative clients. Which client situation requires follow-up? A client Select all that apply. A. stating that they took their prescribed carbamazepine with a sip of water. B. receiving dextrose 5% in water (D5W) and has a blood glucose of 266 mg/dL. C. reporting that they shaved their abdomen for their scheduled appendectomy. D. reporting difficulty with their last surgery, stating they got 'a really high fever'. E. reporting burning upon urination and increased urinary frequency. Submit Answer

Explanation Choices B, C, D, and E are correct. These clients require follow-up. Preoperative (and postoperative) hyperglycemia is detrimental to optimal outcomes. This client has a glucose of 266 mg/dL, which is hyperglycemia. This client should also have the prescribed infusion of D5W questioned, as this solution would further increase the glucose. Clipping hair at the operative site is the best practice because it reduces the risk of surgical site infection. If shaving has to be done, it is completed immediately before the incision to reduce the chance of postoperative infection. The client stated that they got a high fever after their previous surgery and requires follow-up. This could be a concern for malignant hyperthermia. Although rare, this genetic disorder can be life-threatening when the client is exposed to certain anesthesia. The client reported burning upon urination preoperative and requires follow-up as preoperative infections may cause surgery cancelation as they complicate healing. Choice A is incorrect. This client does not require follow-up. Carbamazepine is an anticonvulsant and is commonly permitted to be taken with a sip of water to prevent seizure activity. Additional Info When performing a preoperative surgical assessment, the nurse assesses the client's physical status and reviews elements such as Adherence to nothing by mouth (NPO) status Preoperative laboratory and diagnostic data Basic understanding of the procedure Discharge planning Postoperative education Last Updated - 23, Nov 2022

Which of the following special considerations should the nurse make when caring for a Hindu patient based on her religion? Select all that apply. A. Provide all vegetarian meals. B. Handle the client's temple garments with care. C. Be sure the bathroom is equipped with a shower and not just a tub. D. Be aware that the patient will likely refuse blood transfusions. E. Arrange for female nursing staff to provide care for the client as much as possible. F. Be aware that the patient will likely refuse pain medication. Submit Answer

Explanation Choices C and E are correct. Hindus prefer to wash in free-flowing water (e.g. a shower instead of a bathtub). If a shower is not available, provide a jug of water for the person to use in the tub. Hindus practice ayurvedic medicine, which encompasses all aspects of life, including diet, sleep, elimination, and hygiene. Most Hindus are lactovegetarians. Most will not eat beef and avoid bovine-derived medications because they believe in the reincarnation of certain gods. Fasting usually means eating only "pure" foods, such as fruit or yogurt, but it is not expected of the sick. Hindu women are modest and usually prefer to be treated by female medical staff (Choice E). Choice A is incorrect. Although some Hindus will eat eggs and even chicken, most are lactovegetarians, consuming milk but no eggs. Choice B is incorrect. Hindus may wear a "sacred thread" or religious jewelry around their body or wrist. Mormons, not Hindus, wear "temple garments". Choice D is incorrect. Jehovah's Witnesses—not Hindus—refuse to accept blood transfusions or blood products, which they view as morally wrong. Choice F is incorrect. Christian Scientists—not Hindus—would be likely to refuse pain medication. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Cultural and Religion Last Updated - 31, Jan 2022

Which of the following examples of documenting care for a patient with appendicitis and order for 10 mg morphine IV every 3-4 hours follows the recommended guidelines? Select all that apply. A. 3/13/20 0945 Morphine 10mg administered IV. The patient's response to pain appears to be exaggerated. M. Dean. RN B. 3/13/20 0945 Morphine 10 mg administered IV. The patient seems to be comfortable. M. Dean. RN C. 3/13/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Dean. RN D. 3/13/20 0945 Patient reports 7 out of 10 pain in the right lower quadrant. Morphine 10 mg administered IV. M. Dean. RN E. 3/13/20 0945 Morphine IV 10 mg will be administered to the patient every 3 to 4 hours. M. Dean. RN F. 3/13/20 0945 Patient states she doesn't want pain medication despite the return of pain. MD notified. M. Dean. RN

Explanation Choices C, D, and F are correct. The nurse should enter information in a complete, accurate, concise, current, and factual manner for each entry. The medication record is a legal document. Recording each dose of medication as soon as possible after it is given provides a documented history that can be consulted if there are any questions about whether the patient received the drug. Nurses should never record medication before it is given. The name of the medication, dosage, route of administration, time administered, and the name of the person giving the medication is noted in the record. If a patient refuses to take a drug that is considered essential to the therapeutic regimen, this should be reported promptly. It is necessary to determine the reason for the refusal and to help the patient accept the needed drugs. If the patient refuses the drugs after a reasonable effort has been made to administer the medication, it is unwise to continue urging the patient. Patients have a legal right to refuse therapy, so nurses must recognize and respect that right. Describe the refusal to take the prescribed medication and how the situation was managed in the patient's record, and report the refusal according to the facility's policy. Choices A, B, and E are incorrect. These answer choices do not reflect how documentation of the refusal of medication should be done correctly. Choice A: The RN documents that "The patient's response to pain appears to be exaggerated." This is subjective and a reflection of the nurse's opinion. The best practice is to only document objective, clear, direct information. The nurse should not chart their opinion about the client's response to pain. Choice B: The RN documents that "The patient seems to be comfortable." This is another example of the nurse documenting their opinion. The best practice is to only document objective, clear, direct information. The nurse should not chart their opinion about the client's response to pain. A more appropriate example would be: "The client reports that their pain was reduced to a score of 2 out of 10 after administration of the morphine." Choice E: In this example, the nurse is documenting actions they plan to take in the future by saying, "Morphine IV 10 mg will be administered to the patient every 3 to 4 hours. M. Dean. RN." Documentation should never take place before the intervention is completed. Additional Info Last Updated - 16, May 2022

The nurse is planning a staff development conference about pain management. Which statement would be appropriate to include? Select all that apply. A. Infants do not have developed pain sensors. B. A lack of behavioral signs of pain negates pain. C. The amount of pain has a positive correlation with the extent of tissue damage. D. Self-report is the most reliable method of pain assessment. E. Analgesics should be administered via the oral route when possible. Submit Answer

Explanation Choices D and E are correct. These statements about pain are appropriate to include. Self-report is considered the most accurate indicator in assessing pain. The oral route is the preferred method of analgesic delivery due to being easiest to administer, better tolerated, and more cost-effective than intravenous medication. Choices A, B, and C are incorrect. These are commonly held misconceptions about pain/pain management. A lack of physiological and behavioral signs of pain does not indicate the absence of pain. Research has shown that infants can experience pain and confirmed that pain does not necessarily equate to tissue damage. Clients may experience intense pain with no significant tissue damage or vice versa. Learning Objective Recognize the commonly held misconceptions about pain. The nurse must recognize and address the pain appropriately in all the clients. Additional Info Effective pain control for all individuals is essential. Key points regarding pain control include - ➢ Self-report is the most important assessment. Although self-reporting is subjective, the nurse must consider the client's perspective on their pain. ➢ Multimodal pain control is an effective way to manage pain. This includes using medications from multiple classes. The advantage of this is that it may decrease reliance on one medication or class. ➢ Providing pain control before certain procedures or activities (dressing change, ambulating) is a good approach. Poor pain control during ambulation may make the client reluctant to participate further. ➢ Valid pain scales should be used when necessary. For example, a non-verbal pain scale may be used if a client is mechanically ventilated. Last Updated - 15, Dec 2022

The nurse inserts a nasogastric tube (NGT). The nurse is correct in performing which of the following sequential actions? Place each step in the correct order. Explain the procedure and place the client in a high-Fowler's position. Insert the tube into the nasopharynx and advance the tube. Confirm placement via abdominal x-ray. Secure the tube Instruct the client to swallow sips of water and advance the tube into the stomach. Measure the length of the tube from the nose to the earlobe to the xiphoid process. Submit Answer

Explanation The correct sequence of nasogastric tube insertion is as follows: The nurse should explain the procedure to the patient. Then, place the client in a high-Fowlers' position and the pillows behind the shoulders. The nurse should then measure the tube length from the nose to the earlobe to the xiphoid process (NEX method). Afterward, the nurse should insert the lubed nasogastric tube into a patent nostril. Once the tube enters the back of the throat, the client should be instructed to take a few sips of water to facilitate the passage of the tube. The tube should then be advanced into the stomach. Once the tube has been inserted to the pre-measured length, it should be secured to the patient's nose with tape. If you send the patient to an X-ray without securing it, there is a potential for the tube to get mobilized to an incorrect position by the time an X-ray is performed. Following this, a confirmation x-ray should be obtained. Obtaining an abdominal x-ray is the best way to confirm the location of the tube, Last Updated - 18, Jul 2022

Which of the following psychological symptoms, occurring at the end of life, is accurately paired with an appropriate intervention that you would incorporate into your client's plan of care? A. Spiritual distress: Diazepam B. Delirium: Lorazepam C. Hallucinations: Dopamine antagonist D. Agitation without delirium: Haloperidol Submit Answer

Explanation Choice C is correct. Hallucinations can be treated with a dopamine antagonist like haloperidol, which is an antipsychotic drug that is also used to treat psychotic disorders such as schizophrenia and bipolar disease. It is also a preferred agent in treating end-of-life delirium. Choice A is incorrect. Spiritual distress should be treated with a referral to the clergy and psychosocial support of the client after assessing the client for the sources of their mental pain rather than diazepam. For example, if the cause of the mental illness is unresolved guilt, the nurse and other members of the healthcare team should educate the client about the purpose of sin, they should facilitate the person's making amends to others, and also advise the client that all humans have faults; nobody is perfect and without errors. Choice B is incorrect. Antipsychotic agents such as dopamine antagonists (haloperidol) are often used as an initial pharmacological treatment in terminal delirium. Benzodiazepines (lorazepam) are not recommended in treating delirium because they may cause paradoxical excitation that worsens delirium. Benzodiazepines (BZDs) are indicated if the dopamine antagonist fails to relieve agitation or if more sedation is desired. BZDs are also used in treating agitation without delirium. Choice D is incorrect. Agitation without delirium is better treated with benzodiazepines (lorazepam) rather than dopamine antagonists (haloperidol). Note that while agitation can be a common symptom of delirium, it can occur without delirium, i.e. patients can be agitated without having acute changes in consciousness. On the other hand, "Terminal agitation" is often associated with anxiety, distress, or restlessness at the end of life. These patients are often delirious. If the patient is in the active dying phase, the use of lorazepam may be limited. In this setting, appropriate alternatives to treat terminal restlessness include haloperidol, midazolam, or chlorpromazine. Haloperidol does not have much sedative effect. If sedation is needed, chlorpromazine and midazolam offer the additional benefit of being sedatives for highly agitated patients. Learning Objective Recognize the medications that are commonly used to treat hallucinations, agitation, and delirium. Understand the differences between delirium and agitation. Additional Info Delirium is an altered sensorium. It is characterized by acute changes in the patient's level of consciousness. Hyperactive delirium is characterized by agitation, restlessness, and emotional lability. Hypoactive delirium is characterized by flat affect, apathy, lethargy, or decreased responsiveness. Causes: Many causes of delirium include medications (dexamethasone, opioid toxicity), nicotine withdrawal, dehydration, uncontrolled pain, constipation, urinary retention, infection, hypoxia, renal failure, hyponatremia, hypercalcemia, hypoglycemia, and emotional distress. Management: Initially, non-pharmacological interventions should be attempted to identify and address reversible etiology and relieve terminal agitation/delirium. For example, address the reversible causes such as treating constipation or discontinuing medications such as dexamethasone, modifying precipitating factors such as sensory deprivation or uncontrolled pain, etc. If no rapidly reversible factors are identified or if the patient is terminal, dopamine antagonists must be used.

The nurse is preparing to administer a unit of packed red blood cells (PRBCs). The nurse should A. obtain a bag of 250 mL of 0.9% saline. B. obtain a bag of 250 mL of Dextrose 5% in water (D5W). C. insert a 22 gauge intravenous (IV) catheter. D. initiate continuous telemetry monitoring.

Choice A is correct. A 250 mL bag of normal saline for infusion, among other things, in preparation for this blood transfusion is necessary. Other items required include an 18 or 20-gauge catheter for the infusion, blood administration set (y-type tubing), IV pole, and intravenous pump or controller. Choices B, C, and D are incorrect. D5W is not compatible with blood or blood products. Another intravenous solution, such as isotonic saline, is used. 0.9% normal saline is isotonic and, therefore, required. A 22 gauge catheter is too small for a blood transfusion and is predisposed to mechanical hemolysis. Continuous telemetry monitoring is not necessary for a transfusion of packed red blood cells. Additional Info The nurse should remain with the client during a transfusion's first fifteen to thirty minutes to observe for a hemolytic or allergic reaction. ➢ A hemolytic blood transfusion may be fatal if not caught promptly. The primary cause of this reaction is the misidentification of the client and the blood product. ➢ Manifestations of a hemolytic reaction include low-back pain, chest pain, tachycardia, hypotension, and a feeling of impending doom. ➢ If a hemolytic reaction is assessed, the nurse should immediately discontinue the transfusion and save the tubing and unit of blood for further analysis. ➢ Immediate client care involves spiking a new bag of isotonic saline (with new tubing) and keeping the intravenous catheter patent.

The nurse is performing a focused physical assessment. Place the steps in correct order to perform a gastrointestinal assessment. Place the steps in the appropriate order. Position the client supine with the knees bent and the arms at their side Inspect the abdomen Auscultate all four quadrants of the abdomen Ask the client to void Palpate the abdomen Place pillows beneath the client's knees Submit Answer

Explanation A gastrointestinal assessment can be complex because of its vascularity and the multiple organs present. To facilitate client comfort, explain the assessment to the client. Ask the client to void before positioning the client for the assessment. Voiding assists with the client's comfort and helps relax the abdominal muscles. The nurse should expose the client's skin but maintain their dignity and privacy by draping their chest and upper legs. The nurse should then position the client supine or in a dorsal recumbent position with the arms at the sides and knees slightly bent. Tense abdominal muscles will not allow for an accurate GI assessment. The nurse should then put pillows under the client's knees to help maintain this position and prevent tightening of the abdominal muscles. The first part of the assessment is the inspection of the client's abdomen. The nurse inspects the skin and assesses for symmetry of the abdomen and any movement or pulsations. The nurse should then proceed to auscultation. Auscultation should occur before palpation because manipulating the abdomen alters the frequency and intensity of bowel sounds. The final portion of the GI assessment is palpation which will determine any areas of tenderness, distention, or masses. Use hand movements that are smooth and do not jab the client. Additional Info The client should be interviewed for an accurate and comprehensive assessment. Assessment questions for a GI assessment include: ✓ Any nausea or vomiting ✓ Bowel habits and stool character ✓ Any laxative use ✓ Previous GI surgery or trauma ✓ Recent weight changes and if it was unintentional or intentional ✓ Ask the client to identify the tender areas and palpate these areas last ✓ Pregnancy status for females ✓ Current medications Last Updated - 19, Jan 2023

The nurse is caring for a patient with chronic liver failure who received a live-donor transplant five days ago. She is taking anti-rejection medication and is experiencing headaches and diarrhea associated with the medication. She wants to know how long she will have to take the anti-rejection medication. The nurse tells her that she will take the medication for: A. The rest of her life B. Until she is discharged from the hospital C. Six weeks D. Six months

Explanation Choice A is correct. An anti-rejection medication will be taken for the rest of her life. This will help to prevent the body from rejecting the donated liver. Survival rates from a live donor seem to be better than from a deceased-donor transplant; however, both groups will receive anti-rejection medication for the rest of their lives. Common anti-rejection or immunosuppressant drugs include cyclosporine, prednisolone, azathioprine, tacrolimus, mycophenolate mofetil, and sirolimus. Unfortunately, these medications suppress the body's reaction to other infection threats, so the liver transplant patient is at high risk for infection. Typically, the dosage of drugs will be decreased over time, so the risk of disease will also decrease. However, the patient with any transplant should be cautioned about the high risk of infection and preventative measures needed. Choices B, C, and D are incorrect. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Expected Actions/Outcomes; Adverse Effects/Contraindications/Side Effects/Interactions Last Updated - 19, Jan 2022

Your client is at the end of life and experiences guilt for past transgressions. After a number of independent and dependent nursing functions, what is an expected outcome for this client? Correct A. The client will articulate the nature of humans in terms of fallibility. [30%] B. The client will go to confession to ask for forgiveness. [26%] C. The client will perform relaxation techniques to dissolve guilt. [33%] D. The client will not express any more feelings at the end of life.

Explanation Choice A is correct. An expected outcome for this client could be that the client will articulate the nature of humans in terms of fallibility. The purpose of guilt is to allow the person to know that they have done something wrong, and it also permits the person, at the end of life, to make final amends to those that they have hurt. Choice B is incorrect. Only a few religions use confession to ask for forgiveness; therefore, unless the client has expressed a desire to practice this religious ritual, this would not be an expected outcome. Choice C is incorrect. Although relaxation techniques may be used by the person to decrease their anxiety related to guilt, relaxation techniques do not dissolve guilt. Choice D is incorrect. The client not expressing any more feelings at the end of life would not be an appropriate outcome; all clients should be encouraged to express their opinions freely and without any judgments. Last Updated - 12, Feb 2022

A nurse is precepting a new graduate nurse. They are working with a client with numerous family members at the bedside. Once they exit the room, the nurse asks the new graduate nurse to define "family." The new graduate nurse is correct when they state: A. "A family is a group of people who care about each other and work together to accomplish common goals or overcome hurdles." B. "A family includes a man and a woman who are married and the children they have together." C. "In order to be considered family, you have to be related through blood, marriage, or adoption." D. "Although there may be extended family elsewhere, the people who live in someone's house are their family members."

Explanation Choice A is correct. Families consist of groups of emotionally connected individuals who function as a unit. Choice B is incorrect. A family consisting of a man, woman, and any children they may have together is known as a nuclear family. Choice C is incorrect. While some benefits require relation through marriage, blood connection, or adoption (i.e., health insurance benefits, tax credits, etc.), these requirements are not mandated to be considered as one's family member. Choice D is incorrect. Although one may reside with members of their immediate family, an individual may also choose to reside alone, with a pet, with a roommate, with a friend, or with a romantic partner. The physical proximity in which one lives with another individual does not affect whether that person is considered family. Learning Objective Define the word "family." Additional Info A family unit is what an individual considers the family to be. As a nurse, encourage clients to verbalize their thoughts regarding their support system. Each family is as diverse as the individuals who comprise them. Unique cultural and ethnic influences often influence the family unit. No two families are alike; each has individual strengths, weaknesses, resources, and challenges. The concept of family is highly individualized and consistently evolving. Never release healthcare information to an individual simply because they are the client's "family member" or "relative." Always verify the individual's identity and check the client's signed Health Insurance Portability and Accountability Act (HIPAA) form to ensure the client has authorized the individual to receive the healthcare information. Last Updated - 29, Jul 2022

The med-surge nurse is caring for a patient who is receiving enteral feedings. What is the most effective method to verify initial tube placement is correct? A. Obtain chest and abdominal x-rays. B. Aspirate the contents to assess pH range. C. Mark tubing at the exit site and record the length of tubing that protrudes. D. Insert 20-30 mL of air into the tube while auscultating the epigastrium. Submit Answer

Explanation Choice A is correct. Getting chest and abdominal x-rays are the gold standard to verify that the enteral tube placement is correct. Choice B is incorrect. Testing pH may help to identify a problem but is not the most specific or reliable way to confirm placement. Respiratory and small intestine secretions have a pH greater than 6. Gastric pH ranges from 1-5 in fasting patients, or up to 6 if on gastric acid-reducing medications. Choice C is incorrect. This may be done, but does not verify or confirm that the initial placement is correct. Choice D is incorrect. This method is subjective and is not considered a reliable way to confirm tube placement. NCSBN Client Need Topic: Skills/procedures, Subtopic: nutrition and oral hydration, diagnosti

Which of the following pharmacological statements is accurate? A. Idiosyncratic side effects to medications are relatively unpredictable and they occur on a highly individual basis. B. Pharmacokinetics addresses the three phases of medications which are the absorption, distribution, and excretion of medications. C. It is possible that isoniazid will more rapidly absorb among Scandinavians when compared to Japanese clients. D. Medications can lead to increased absorption when they have similar metabolic pathways.

Explanation Choice A is correct. Idiosyncratic side effects of medications are relatively unpredictable and they occur on a highly individual basis. Distinctive side effects of medications are peculiar, rare, and unusual side effects of the drug. Choice B is incorrect. Pharmacokinetics addresses the four phases of medications, which are the absorption, distribution, biotransformation or metabolism, and excretion of drugs; not the three phases of medications. Choice C is incorrect. Isoniazid may more slowly, but not more rapidly, absorb among Scandinavians when compared to Japanese clients. Ethnic differences in terms of medications are referred to as ethnopharmacology. Choice D is incorrect. Medications can lead to decreased, rather than increased absorption when they have similar metabolic pathways. Related metabolic pathways can lead to the accumulation of drugs and toxicity when one or more medications share the same metabolic pathway. Last Updated - 16, Oct 2021

The nurse is discussing the use of medications to prevent organ rejection with the health care provider. Which of the following medicines is not used to avoid organ rejection? A. Oxybutynin chloride B. Prednisone C. Tacrolimus D. Cyclosporine

Explanation Choice A is correct. Oxybutynin chloride is an anti-cholinergic medication often used for overactive bladder. This medication is not used to prevent organ rejection. Choice B is incorrect. Prednisone, a glucocorticoid medication, is frequently used in conjunction with other medicines to prevent organ rejection. Choice C is incorrect. Tacrolimus is an immunosuppressive medication used to prevent organ rejection. Choice D is incorrect. Cyclosporine is an immunosuppressive medication used to prevent organ rejection. NCSBN client need Topic: Physiological Integrity, Pharmacological and Parenteral therapies Last Updated - 08, Jan 2022

The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client's clinical data. Which post-procedure data requires immediate follow-up? See the image below. A. Blood Pressure B. Glasgow Coma Scale C. Respirations D. Temperature Submit Answer

Explanation Choice A is correct. The client's post-procedure blood pressure is highly concerning as it reflects clinical hypotension. Medications used in moderate sedation have a vasodilating effect, and the nurse should intervene to increase the client's blood pressure via prescribed intravenous (IV) fluids. Choices B, C, and D are incorrect. The client does have a reduction in the GCS. However, immediately post-moderate sedation, it is common for a client to be lethargic because of the medications administered. The client's respiratory rate is normal, and while it is lower compared to the pre-procedure rate, the client emerging from sedation often has a respiratory rate on the lower end of normal. The client's temperature is within normal limits. Additional Info A procedure involving this type of sedation requires informed consent, and the nurse will serve as a witness. Common medications utilized for moderate (conscious) sedation include fentanyl, midazolam, or propofol. Anesthesia providers, other physicians, dentists, and oral surgeons are qualified to administer conscious sedation, and the nurse does not administer anesthesia intravenously. When this type of sedation is utilized for a closed reduction, it is a quick process that requires close monitoring of the client's vital signs, end-tidal carbon dioxide (normal is 20 and 40 mm Hg), cardiac rhythm, and level of consciousness. Last Updated - 16, Jul 2022

When entering a patient's room to administer medications, what should the nurse's first action be? A. Verify the patient's full name and date of birth. B. Ask the patient to verify any medication allergies. C. See if the patient had breakfast. D. Review medications and potential side effects. Submit Answer

Explanation Choice A is correct. The first nursing action when preparing to administer medications is to identify the correct patient. This helps decrease the risk of errors and is the safest way to administer care. Choices B and D are incorrect. While verifying medication allergies, it is important to know what medications are ordered and their potential side effects. The nurse's first action should be to verify that they have the right patient. Choice C is incorrect. Some medications are recommended to be taken with food. However, verifying if the client has eaten breakfast is not the nurse's first action. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Medication Administration Additional Info Last Updated - 11, Jan 2022

A nurse caring for a client on digoxin therapy receives the client's serum digoxin level taken earlier in the day, noting the result indicating 2.5 ng/mL (3.2 nmol/L). Which of the following should be the nurse's initial response? A. Notify the primary health care provider (PHCP) regarding this laboratory result. B. Review the client's medical record for the most recent pulse rate. C. Record this laboratory value as within the therapeutic range. D. Administer the next dose of digoxin as prescribed. Submit Answer

Explanation Choice A is correct. The therapeutic range for digoxin is 0.5 to 2.0 ng/mL [0.64 to 2.6 nmol/L]). Levels greater than 2.2 ng/mL (2.8 nmol/L) indicate toxicity. The client's most recent digoxin level of 2.5 ng/mL indicates toxicity. The nurse's initial response should be to notify the client's healthcare provider (HCP) of this laboratory value. Following the notification, the nurse should document the notification. Choice B is incorrect. Due to the amount of time that has elapsed since the prior assessment of the pulse rate, the nurse should perform a new assessment of the client's vital signs following the receipt of the digoxin laboratory result. Ideally, following the nurse paging the health care provider (HCP), the nurse could obtain the client's vital signs and relay those to the HCP once the HCP returns the call. Choice C is incorrect. This value is not within the therapeutic range; therefore, it cannot be recorded as such on the client's flow sheet. Choice D is incorrect. Due to the client's serum digoxin level indicating toxicity, all further doses of the medication should be held until further notice, which will include the client's serum digoxin level returning to a therapeutic level. Learning Objective Identify the need to prioritize notifying a client's health care provider (HCP) after receiving an elevated serum digoxin level. Additional Info Digoxin, a cardiac glycoside, is used to increase the force of myocardial contractions and to treat supraventricular arrhythmias. Renal impairment, temporary dehydration, and nonsteroidal anti-inflammatory drug (NSAID) use (all common among older adults) can reduce renal clearance of digoxin, increasing the likelihood of digoxin toxicity in older adults. Clients with digoxin toxicity have levels >2.0 ng/mL. Levels >3.0 ng/mL in adults are strongly suggestive of digoxin overdosage.

The major difference between extravasation and infiltration is that infiltration occurs when: A. A non-vesicant drug enters into the subcutaneous tissue. B. A vesicant drug enters into the subcutaneous tissue. C. A non-vesicant drug enters into the intradermal tissue. D. A vesicant drug enters into the intradermal tissue.

Explanation Choice A is correct. The significant difference between extravasation and infiltration is that infiltration occurs when a non-vesicant drug enters into the subcutaneous tissue, which does not happen with extravasation. Extravasation occurs when a vesicant drug comes into the subcutaneous tissue. Choices B, C, and D are incorrect. Infiltration does not occur when a vesicant drug enters into the subcutaneous tissue; rather, it occurs when a non-vesicant comes into the subcutaneous tissue. Lastly, the affected tissue used to define infiltration and extravasation is subcutaneous tissue, not intradermal tissue. Last Updated - 07, Feb 2022

The nurse is observing a student perform a physical assessment. It will demonstrate appropriate technique if the student assesses for stereognosis by instructing the client to A. close their eyes, place an object in their hand, and ask them to identify it. B. close their eyes with feet together, arms at the sides, and observe for loss of balance. C. walk on their heels and then on their tiptoes for at least ten feet. D. touch the tip of their nose with the index finger and return the arm to an extended position. Submit Answer

Explanation Choice A is correct. This is the correct assessment technique for stereognosis. The concept of stereognosis is for the individual to recognize (or perceive) an object without using vision. For example, having a client close their eyes and placing a toothbrush in their hand can accurately state that it is a toothbrush. Choices B, C, and D are incorrect. The Romberg test is demonstrated in Choice B. This test identifies if the client can maintain balance with closed eyes. A loss of balance makes this test positive and would result in the client falling to the side. Normally the client does not break their stance. Having the client walk on their tiptoes and heels for at least ten feet, along with touching the tip of their nose with the right index finger, is an appropriate assessment for cerebellar function. Additional Info Stereognosis is a sense that allows a person to recognize the size, shape, and texture of an object. For an individual with dementia, this is likely to be failed because of the inability to recognize (or use) the object. This would be agnosia. Last Updated - 30, Jul 2022

The nurse observes a client go up the stairs with a cane. It would indicate effective teaching if the client grabs the handrail and A. places the stronger leg up a step, then simultaneously moves up the weaker leg and cane. B. holds the cane in one hand and hops up each stair using the stronger leg. C. places the cane up a step, then simultaneously moves up the stronger and weaker legs. D. places the weaker leg up a step, then simultaneously moves up the stronger leg and cane. Submit Answer

Explanation Choice A is correct. When a client is ambulating upstairs using a cane, the client will face the stairs and place the cane on the side opposite the handrail. Then, the client will advance the unaffected (stronger) leg up to the next step, then the cane and the affected (weaker) leg simultaneously. This reflects adequate understanding. Remember that the weaker side and the cane share the load and should always move together. Choices B, C, and D are incorrect. These statements require follow-up because they do not follow the correct (and safe) sequence for ambulating with a cane while ascending stairs. Improper usage of a cane may result in falls. Additional Info Walking on a level surface: When walking on a level surface, the client should hold the cane on the same side as the stronger leg. ✓ This helps the client shift the weight to the stronger side as they move. Therefore, the client should move the weaker or injured leg simultaneously while moving the cane. ✓ Always remember that the cane and the injured/ weaker side act as partners - they always move together. By doing this, the cane can share the load with the injured leg. ✓ The client should step with the weak leg as they pick up the cane and press down with the cane again when they step down with their weak leg. B. Using the stairs: " Up with the good, and down with the bad" is a good statement while educating the client regarding cane usage to navigate the stairs. ✓ Up with the good: If the client must ascend stairs, the nurse should instruct the client first to hold the cane on their stronger side. ✓ Then the client should advance the unaffected (good) leg onto the step and, following that, move the affected (weaker) leg and the cane simultaneously onto the step. ✓ The cane and the weaker side should always move together. ✓ Down with the bad: If the client must descend stairs, the nurse should instruct the client to hold the cane on their stronger side. The client should simultaneously place the cane and the affected (weaker) leg down on the next step, followed by the unaffected (stronger) leg. Last Updated - 26, Jan 2023

You are working with geriatric clients in a long-term care facility. What knowledge should you continuously integrate into your role as the nurse administering medications to the aging population? A. The knowledge that the elderly population is more at risk for an accidental overdose than other age groups. B. The knowledge that the elderly population is more at risk for low therapeutic levels of medications than other age groups. C. The knowledge that elderly clients cannot swallow medications, so all these medications should be crushed and placed in apple sauce or pudding before administration. D. The knowledge that elderly clients often reject their medications, so all these medications should be crushed and placed in apple sauce or pudding to conceal them. Submit Answer

Explanation Choice A is correct. You should integrate the knowledge that the aging population is more at risk for an accidental overdose to medications when compared to other age groups. This risk for an unintentional overdose of drugs occurs due to some of the regular changes in the aging process, such as decreased metabolism. Choice B is incorrect. You would not integrate the knowledge that the aging population is more at risk for low therapeutic levels of medications than other age groups because this is not true. Choice C is incorrect. You would not integrate the knowledge that the aging population cannot swallow medications, so all these medications should be crushed and placed in apple sauce or pudding before administration. Some medicines cannot be broken and placed in apple sauce or pudding before administration, and many members of the elderly population can swallow pills and tablets. Choice D is incorrect. You would not integrate the knowledge that the aging population often rejects their medications, so all these medications should be crushed and placed in apple sauce or pudding to conceal them. Although clients have the right to refuse drugs, this is rare; additionally, concealing medications is unethical. Additional Info Last Updated - 04, Dec 2021

The nurse is reviewing laboratory data. Which laboratory data requires follow-up? A. Total Cholesterol 180 mg/dl B. Hemoglobin A1C 7.5% C. Calcium 9.2 mg/dl D. Creatinine 1.0 mg/dl Submit Answer

Explanation Choice B is correct. A hemoglobin A1C of 7.5% is elevated and requires follow-up. The normal hemoglobin A1C is any value less than 5.7% Hemoglobin A1C between 5.7% and 6.4% is considered prediabetes that warrants aggressive lifestyle modification to prevent diabetes. Hemoglobin A1C of 6.5% meets the diagnostic criteria of diabetes. Choices A, C, and D are incorrect. Total cholesterol of 180 mg/dl is normal and does not require follow-up (goal is to maintain it to less than 200 mg/dL). Calcium of 9.2 mg/dl (normal is 9-10.5 mg/dL) is within the normal range and does not require follow-up. Finally, a creatinine of 1.0 mg/dl (normal is 0.6-1.2 mg/dL) is within range. Additional Info Risk factors for type two diabetes include family history, gestational diabetes, being overweight, and being over the age of 45. Racially, diabetes impacts Asian Americans, African Americans, and Native Americans more than other races. Diagnosis for type diabetes mellitus includes a hemoglobin A1C of 6.5% or greater. Normal is a level less than 5.7%. A hemoglobin A1C of 5.7% to 6.4% is concerning for prediabetes. A fasting plasma blood glucose of 126 mg/dl or more (normal is less than 100 mg/dl) is a provisional diagnosis for DM. Last Updated - 16, Feb 202

Pain of short duration with an identifiable cause is referred to as: A. Chronic pain B. Acute pain C. Complex pain D. Neuropathic pain

Explanation Choice B is correct. Acute pain is of short duration. There are several terms used to describe the pain. Definitions of illness emphasize that it is an unpleasant experience. Since pain can be so damaging, it is essential to understand how it is created. Acute pain is meant to warn the body that some type of insult or injury has occurred, whereas chronic pain lasts beyond the average healing period and has no useful role. Choice A is incorrect. Chronic pain lasts more than 3 to 6 months. Choice C is incorrect. Complex regional pain syndrome can develop from acute pain, which is undertreated. Choice D is incorrect. Neuropathic pain results from injury to a nerve related to trauma or diseases (such as diabetes). NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort; Types of Pain Last Updated - 20, Nov 2021

Which of these would be the most appropriate way to document a patient's refusal of medication? A. The patient refused the heparin injection when I tried to administer it. She yelled at me, saying, "I do not want that injection right now!" and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift. B. Subcutaneous heparin injection was attempted to be given to the patient per the physician's order. The patient refused, stating, "I do not want that injection." Potential risks for refusing the medication were reviewed with the patient and the patient verbalized understanding. C. Pt stated she did not want the SQ heparin at this time. Risks of not taking this med were reviewed with the pt and pt verbalized understanding. D. Heparin was refused during the shift. Risks reviewed. Submit Answer

Explanation Choice B is correct. Documentation in healthcare should be objective, thorough, and direct. It should be articulate, with proper grammar and spelling. Legal experts will scrutinize the health record if a dispute about a client's care arises. In court, the health record is relevant evidence of the attention given to a client and is used to judge whether the interventions were timely and appropriate. Expert reviewers look for documentation of the client's baseline status, changes in condition, interpretation of the changes, interventions implemented, and the client's responses to those interventions. The patient has the right to refuse a medication regardless of her reasons and regardless of the consequences, except under certain circumstances (e.g. incompetency). It is up to the nurse to document thoroughly and accurately any patient's refusal. Choice A is incorrect. This answer choice is not direct, although thorough. Additionally, documenting "I will attempt later in my shift" is not the correct form for documentation. Only care/treatments that have been attempted or successfully provided should be documented. Choice C is incorrect. Correct grammar and spelling should be used. When documenting the refusal of care, abbreviations should be avoided. Choice D is incorrect. This option does not provide enough information. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care, Guidelines for Recording Additional Info Last Updated - 15, Feb 2022

The nurse is discussing the risk of wound disruption following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication? A. Diabetes insipidus B. Cushing's syndrome C. Hemophilia D. Inflammatory bowel disease Submit Answer

Explanation Choice B is correct. Excessive corticosteroids characterize Cushing's syndrome. Exposure to the corticosteroid suppresses the production of white blood cells, which inhibits them from migrating to the wound bed. Cushing's also is characterized by high blood glucose levels, which delay healing. An example of a wound disruption would be dehiscence. Choices A, C, and D are incorrect. Diabetes insipidus would not increase the risk of wound disruption, whereas diabetes mellitus would increase the risk of poor wound healing, especially if the diabetes is uncontrolled. Hemophilia is a genetic blood clotting disorder and does not directly cause poor wound healing. Inflammatory bowel disorder is a broad term for Crohn's or Ulcerative Colitis. These conditions do not directly lead to poor wound healing like Cushing's syndrome. Additional Info Last Updated - 26, Jan 2023

The nurse is caring for a client with the following clinical data. Which prescription would the nurse request from the primary healthcare provider (PHCP)? See the exhibit. A. Diphenhydramine B. Lorazepam C. Phenytoin D. Clozapine Submit Answer

Explanation Choice B is correct. Lorazepam is a benzodiazepine used in the management of alcohol withdrawal symptoms. The client is exhibiting these symptoms as evidenced by perspiration on the forehead, nystagmus, coarse tremors, and visual hallucinations. Choices A, C, and D are incorrect. Diphenhydramine is an anticholinergic medication used for insomnia, allergic rhinitis, and other mild to moderate allergic reactions. Anticholinergics worsen delirium and should be avoided. This medication would not assist the client in the reduction of their withdrawal symptoms. Phenytoin is a maintenance anticonvulsant used in epilepsy. This has no clinical utility in alcohol withdrawal. Antipsychotics, such as clozapine, may be useful in alcohol withdrawal. However, clozapine is not used because this medication is reserved for treatment-resistant psychotic disorders. Additional Info Alcohol withdrawal symptoms may manifest as soon as six hours after the last alcohol consumption. The withdrawal symptoms may worsen and cause the client to potentially develop delirium tremens. Mild withdrawal signs and symptoms include irritability, anorexia, nausea, palpitations, and tachycardia. Moderate to severe signs and symptoms include clouded sensorium, tremors, hallucinations, unpredictable behavior, and agitation. The client may be at risk of having a seizure. Medication used in alcohol withdrawal includes benzodiazepines to suppress seizure activity and mitigate the unpleasant withdrawal symptoms. Clonidine to mitigate the adrenergic signs (hypertension) and fluid repletion that may be supplemented with B-complex vitamins. Antipsychotics such as risperidone may be utilized to assist with residual delirium. Last Updated - 16, Feb 2022

You are taking care of a client who is taking warfarin and lovastatin. Which statement about the interaction warfarin and lovastatin should you incorporate into your plan of care? A. Lovastatin decreases the effects of the warfarin. B. Lovastatin increases the effects of the warfarin. C. Lovastatin has no known effects on the warfarin. D. Combining lovastatin and warfarin causes respiratory depression. Submit Answer

Explanation Choice B is correct. Lovastatin increases the effects of warfarin, so the nurse should incorporate this knowledge related to an increased influence of the anticoagulant, warfarin, into the plan of care. Choice A is incorrect. Lovastatin increases the effects of warfarin. Choice C is incorrect. Lovastatin has known effects on warfarin, an anticoagulant medication, so the nurse should consider this when planning care. Choice D is incorrect. Combining lovastatin and warfarin does not cause respiratory depression. Last Updated - 30, Jan 2022

The nurse is preparing to remove a peripheral vascular access device. Which personal protective equipment (PPE) is necessary for this procedure? A. Fluid resistant gown B. Clean gloves C. Surgical mask D. Sterile gloves

Explanation Choice B is correct. PPE necessary to discontinue a peripheral vascular access device includes a pair of clean gloves. Additional PPE may be used if required by the client's clinical condition (if they are in isolation). Choices A, C, and D are incorrect. A fluid-resistant gown, surgical mask, and sterile gloves are not required for removing a peripheral vascular access device. Additional Info The skill of changing and discontinuing a peripheral IV cannot be delegated to unlicensed assistive personnel (UAP). It is appropriate to delegate this task to a licensed practical nurse. Last Updated - 02, Jun 2022

A nurse is instructing a patient about a newly prescribed medication, phenytoin. Which statements, if made by the patient, indicate effective teaching? A. "If my gums get irritated and large, I can stop this medication." B. "I will need laboratory work to monitor the medication level." C. "It is okay for me to increase this medication if I have a seizure." D. "I should take this medication with low protein foods."

Explanation Choice B is correct. Phenytoin is an anticonvulsant and is indicated for epilepsy. Therapeutic levels must be maintained to ensure the effectiveness of the drug. The therapeutic drug levels of phenytoin are 10-20 mcg/mL. Choices A, C, and D are incorrect. Phenytoin is an anticonvulsant medication that requires adherence to prevent seizure activity. The client should not stop the drug because of the side-effect of gingival hyperplasia; instead, the client should report this effect. The client's self-discontinuing the medication increases the risk of a seizure. The client should not increase the drug if they have a seizure. Phenytoin can be taken with or without food. This medication does not have any dietary restrictions. Additional Info Source : Archer Review Phenytoin is an anticonvulsant that requires follow-up drug monitoring. For female clients, education should be provided to utilize appropriate contraception because it may cause fetal defects. Manifestations of phenytoin toxicity include ataxia, nystagmus, and blurred vision. Last Updated - 04, Feb 2022

The nurse is caring for a client who is receiving prescribed lamotrigine. Which of the following findings is highly concerning? A. Abnormal dreams B. Skin blistering C. Dyspepsia D. Xerostomia

Explanation Choice B is correct. Skin blistering associated with lamotrigine therapy is a critical finding to report. This is a feature of Steven-Johnson syndrome (SJS). Lamotrigine has been implicated as causing this adverse finding. Choices A, C, and D are incorrect. Lamotrigine may cause alteration in the mood either intentionally or unintentionally. The indication for this medication is epilepsy or bipolar disorder. Abnormal dreams are a common effect associated with this medication but are not highly concerning compared to skin blistering, which is consistent with SJS. Dyspepsia (painful digestion) and xerostomia (dry mouth) are not priority effects that should be reported as they are not life-threatening. Additional Info Lamotrigine is a mood stabilizer and antiepileptic. This medication may adversely cause SJS, manifested by tender skin lesions that appear as blisters. These skin eruptions may also involve the eyes and mouth. Prompt treatment is necessary because of the risk of sepsis that may consequently occur because of skin erosion. These lesions often spread fast, underlining the necessity of prompt treatment. If this should occur, the offending agent should be withdrawn. Last Updated - 14, Feb 2022

The nurse is preparing to administer medications to a client. The nurse notices that his heart rate is at 51 beats per minute. Which medication should the nurse withhold? A. Amlodipine 5 mg PO B. Diltiazem 60 mg PO C. Ibuprofen 500 mg PO D. Ciprofloxacin 500 mg PO

Explanation Choice B is correct. The client is experiencing bradycardia. Therefore, it is important to withhold medications that may exacerbate bradycardia. Diltiazem is a non-dihydropyridine calcium channel blocker (CCB). Diltiazem is more cardioselective compared to dihydropyridine CCBs. Because of its cardiac depressant (negative chronotropic and negative inotropic) properties, diltiazem reduces the heart rate and contractility. Because of negative chronotropic action, it can cause bradycardia. For this reason, therapeutic uses of diltiazem include atrial arrhythmia and paroxysmal supraventricular tachycardia. When the client has baseline bradycardia, it is important to hold the diltiazem and notify the healthcare provider for further orders or dosage modification. Choice A is incorrect. Amlodipine is a dihydropyridine CCB that is more selective to vascular smooth muscle calcium channels. Therefore, it causes vasodilation and can be used to treat hypertension. Amlodipine does not cause bradycardia. The client is experiencing bradycardia but not hypotension. Amlodipine need not be held if there is asymptomatic bradycardia without hypotension. Side effects of dihydropyridine CCBs (amlodipine, felodipine, nifedipine) include hypotension, flushing, peripheral edema/ ankle edema, headache, and reflex tachycardia. Choice C is incorrect. Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID). NSAIDs do not affect the client's heart rate and can, therefore, be given regardless of their heart rate. Choice D is incorrect. Ciprofloxacin is a fluoroquinolone antibacterial and can be given even if the client's heart rate is low. Ciprofloxacin's most reported cardiac side effects include QTc prolongation and torsades de pointes (ventricular arrhythmias). Bradycardia is unusual. Learning Objective Recognize the differences between non-dihydropyridine and dihydropyridine calcium channel blockers. Diltiazem is more cardio-selective and can cause reduced heart rate and myocardial contractility. Additional Info Calcium channel blockers are classified into two categories: 1. dihydropyridine (amlodipine, felodipine, nimodipine, and nifedipine) 2. non-dihydropyridine (diltiazem, verapamil). Dihydropyridine CCBs are vaso-selective. Therefore, they cause vasodilation. They do not cause reduced contractility or heart rate because of minimal effects on cardiac muscle calcium channels. Consequently, they are safe in congestive heart failure. CCBs like amlodipine are most commonly used to treat hypertension. Because of their vasodilatory properties, their side effects include flushing, headaches, peripheral edema, and reflex tachycardia. Systemic vasodilation can stimulate baroreceptors and cause a reflex increase in the heart rate. Non-dihydropyridine CCBs are more cardio-selective. These include verapamil and diltiazem. Verapamil is purely cardio-selective. Verapamil can be used in atrial tachyarrhythmias. Diltiazem is used for treating both atrial tachyarrhythmias as well as hypertension. Although more cardio-selective than dihydropyridines, diltiazem has some vasodilatory properties as well. For this reason, diltiazem is also used to treat hypertension. Last Updated - 26, Nov 2022

Select the barrier to effective medication use among the elderly population that is accurately paired with an effective corrective nursing intervention. A. Poverty and the lack of health insurance: Discontinue medications and suggest over-the-counter remedies B. Arthritis affecting the hands: Suggest non-child proof medication containers C. Poor fine motor coordination: Suggest an eye examination D. Severe confusion and poor memory: Write up a chart for medications Submit Answer

Explanation Choice B is correct. The barrier to effective medication use among the elderly population that is accurately paired with an effective corrective nursing intervention is suggesting non-childproof medication containers for elderly clients who have arthritis due to their poor manual dexterity and poor fine motor coordination; non-child proof medication containers are very helpful for these patients. Choice A is incorrect. Poverty and the lack of health insurance are not a reason to discontinue medications and suggest over-the-counter remedies; instead, suggest less expensive alternatives to the ordering physician, contact social services, and also contact pharmaceutical manufacturers for assistance. Choice C is incorrect. Poor fine motor coordination interferes with the client's ability to open childproof medication containers and perhaps even take pills or capsules out of them; however, you could suggest an occupational therapist rather than an eye examination. Choice D is incorrect. Writing up a chart for medications is most likely of little use for clients who are affected with severe confusion and poor memory; assistance with drugs should, therefore, be suggested. Last Updated - 15, Feb 2022

A nurse is preparing medications for a client in the intensive care unit (ICU). Which of the following medication orders should the nurse clarify with a health care provider (HCP) prior to administration? A. Warfarin for administration to a client with an international normalized ratio (INR) of 1.8 mg/dL B. Digoxin administration to a client with a serum potassium level of 3.1 mEq/L C. Administration of atenolol to a client with an alanine aminotransferase (ALT/SGPT) of 30 units/L D. Lisinopril for administration to a client with a serum creatinine level of 0.6 mg/dL

Explanation Choice B is correct. The nurse should contact the health care provider (HCP) prior to the administration of the digoxin to this client to clarify the digoxin order. More specifically, digoxin should not be administered to a client with hypokalemia, as this would increase the risk of developing dysrhythmias. The client's potassium level should be corrected prior to resuming digoxin. In the presence of hypokalemia, even lower doses of digoxin can produce serum levels resulting in toxicity. When digoxin toxicity occurs, the medication should be discontinued, and any electrolyte abnormalities should be corrected (intravenously if the abnormalities are severe and toxicity is acute). Choice A is incorrect. The client's international normalized ratio (INR) is not yet within the therapeutic range. The nurse should still administer the warfarin to the client to get the client to a therapeutic level. Choice C is incorrect. The alanine aminotransferase (ALT/SGPT) of this client (i.e., 30 units/L) is at a reasonable level and is within the normal limits of 4-36 units/L; hence, there is no contraindication for atenolol administration. Choice D is incorrect. This client's creatinine level falls within the normal range (i.e., 0.6-1.2 mg/dL for males or 0.5-1.1 mg/dL for females); therefore, the lisinopril should be administered as ordered. Learning Objective Recognize that digoxin administration is contraindicated in clients with hypokalemia (or hypomagnesemia). Additional Info Digoxin toxicity is a concern, especially in clients with renal dysfunction. These clients may need a lower oral dose of digoxin, as may older clients, clients with a low or lean body mass, female clients, and clients concurrently taking amiodarone. Digoxin has a narrow therapeutic window (i.e., 0.5-2 ng/mL). Electrolyte levels should be monitored in patients taking diuretics and digoxin concurrently to prevent abnormalities (if possible); potassium-sparing diuretics may be helpful. Patients with severe toxicity are admitted to a monitored unit, and digoxin immune fab (ovine) is administered if arrhythmias are present or if significant over ingestion is accompanied by a serum potassium of >5 mEq/L (>5 mmol/L). Last Updated - 07, Sep 2022

The nurse prepares a client for a positron emission tomography (PET) scan. Which laboratory data is necessary to obtain before this test? A. Urine specific gravity B. Liver function tests C. Blood glucose D. Creatinine kinase

Explanation Choice C is correct. A PET scan is primarily indicated to detect cancers and their response to treatment. Before a PET scan, the client is instructed to be nothing by mouth (NPO) four to six hours before the exam and have a glucose level below 150 mg/dL. The reasoning is that this exam primarily looks at cancerous tissue, which uses a substantial amount of glucose. If the radioisotope is metabolized in the body, similar to glucose, it will accumulate in the most active areas. Glucose greater than 150 mg/dL or less than 60 mg/dL will alter the results. Choices A, B, and D are incorrect. These tests are not required or relevant before PET imaging. Additional Info PET imaging is primarily used to detect cancers, assess the treatment response, and evaluate the extent of metastasis. F-18 fluorodeoxyglucose (FDG) is used during this exam and emits positrons, and the technique often produces images with higher contrast and spatial resolution. Malignant tissue uses a substantial amount of glucose, and if the radioisotope is metabolized in the body, similar to glucose, it will accumulate in the most active areas. The client is instructed to be NPO 4-6 hours before this exam. The client should be instructed to refrain from vigorous exercise 24- hours before the exam. After the injection of FDG, the client must lie in a quiet room for 60 minutes before the scan. Last Updated - 01, Sep 2022

The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure? A. Nasogastric tube (NGT) B. Bottle of sterile water C. Suction equipment D. Tracheostomy Submit Answer

Explanation Choice C is correct. A cheiloplasty is a procedure to repair a cleft lip (CL). This procedure is typically done by age three to six months. A concern after this procedure is that the child may have excessive secretions that may trigger aspiration. The nurse should have a bulb syringe or some other suction equipment available if the infant begins to choke. While routine suctioning is not done to minimize pain or trauma, this is necessary to have it available to prevent respiratory distress. Choices A, B, and D are incorrect. An NGT is not necessary following this procedure. Following a CL repair, some infants can return to breastfeeding or bottle feeding, where some may have to be fed via a syringe. A bottle of sterile water is necessary if a client has a chest tube and it becomes disconnected from the drainage system. A chest tube is not used in this surgery. A tracheostomy is necessary at the bedside for a client immediately after a thyroidectomy, which may be used if the client gets airway edema. Additional Info ✓ Following a cleft lip repair, some surgeons allow the infant to return to breastfeeding or bottle-feeding, whereas others require syringe-feeding once the child is awake and alert. ✓ The nurse should provide pain management which may include acetaminophen. ✓ The nurse should ensure that no rigid objects are inserted into the mouth that may disrupt the suture line. ✓ After the infant is fed, the suture line may be cleaned with water, and a thin layer of antibiotic ointment may be applied. ✓ Finally, the infant should not be positioned prone and positioned to prevent airway obstruction. ✓ The ideal position is the infant positioned on their back, slightly upright. Last Updated - 23, Jan 2023

Auscultation is one of the most important components of which body systems? A. Pulmonary, gastrointestinal, and neurological B. Reproductive, neurological, and integumentary C. Cardiovascular, pulmonary, and gastrointestinal D. Gastrointestinal, neurological, and reproductive Submit Answer

Explanation Choice C is correct. Auscultation of the heart provides information on rate, rhythm, extra sounds, and murmurs. Auscultation of the lungs includes information on the underlying music and adventitious sounds, which relate to pathology in the alveoli and airways. Gastrointestinal sounds may be absent, hypoactive, or hyperactive. Choices A, B, and D are incorrect. Auscultation plays a minimal role in the reproductive, neurological, and integumentary systems. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Auscultation Last Updated - 20, Nov 2021

The nurse is teaching a client about a vegan diet. Which of the following foods should the nurse recommend for this diet? Select all that apply. A. Legumes B. Tofu C. Almonds D. Prunes E. Baked fish F. Grapefruit Submit Answer

Explanation Choices A, B, C, D, and F are correct. The crux of the vegan diet is that it excludes foods that come from animals, including dairy products and eggs. Foods such as vegetables, nuts, legumes, plant-based oils, and seeds are encouraged. Choice E is incorrect. The vegan diet excludes anything from an animal, including seafood, cheese, eggs, and cream. Additional Info ✓ The vegan diet focuses on no meat or animal fats. ✓ The diet is generally high in fiber. ✓ Foods such as nuts, legumes, tofu, grapefruit, melon, and soy are permitted. ✓ Vegan diet is generally safe during pregnancy but requires appropriate meal planning. ✓ The primary difference between a vegan and a vegetarian diet is that a vegetarian diet includes eggs and dairy. Last Updated - 11, Jan 2023

The nurse is preparing to administer prochlorperazine maleate 10 mg IM and butorphanol 2 mg IM to a patient. Which is the most appropriate nursing action? A. Check the client's respirations and temperature B. Dilute the medications in 5 mL of normal saline C. Draw the medications in separate syringes D. Draw both medications in the same syringe Submit Answer

Explanation Choice C is correct. Prochlorperazine should not be mixed with other medications as it is not compatible. Choice A is incorrect. The nurse does not need to check the respiration and temperature of the patient. Instead, the nurse should monitor the blood pressure and heart rate of the patient. Choice B is incorrect. These medications do not need to be diluted with normal saline. Choice D is incorrect. Prochlorperazine should not be mixed with other medications as it is not compatible. Last Updated - 08, Nov 2021

The nurse is about to prepare the morning medications for clients on the ward. Which medication should the nurse prepare and administer first? A. Prednisolone (Deltsone), a glucocorticoid, to a client with inflammatory bowel disease. B. Rivastigmine (Exelon), an anticholinesterase inhibitor, to a client with dementia. C. Sucralfate (Carafate), a mucosal barrier agent, for a client with a duodenal ulcer. D. Enoxaparin (Clexane), an anticoagulant, to a client on bed rest after surgery. Submit Answer

Explanation Choice C is correct. Sucralfate is a mucosal barrier agent that must be given 30 minutes before the client's meal. This medication must be given first to achieve its effect. Choice A is incorrect. This medication can be given 30 minutes before and after the scheduled time. This medication does not have to be the first medication given. Choice B is incorrect. Exelon can be given within a 30 minute time frame of the scheduled time. This medication does not have to be given first. Choice D is incorrect. Clexane can be given within a 30 minute time frame of the scheduled time. This medication does not need to be administered first. Last Updated - 08, Feb 2022

The best and most effective way to evaluate your adult client's response to non-pharmacological comfort interventions is to: A. Use the PQRST pain assessment method to measure comfort. B. Ask the client if they feel better after the comfort intervention. C. Compare pre- and post-intervention data using a numerical pain rating scale. D. Compare pre- and post-intervention data using the NIPS pain rating scale Submit Answer

Explanation Choice C is correct. The best and most effective way to evaluate your adult client's response to non-pharmacological comfort interventions is to compare pre- and post-intervention data using a numerical pain rating scale that is typically a scale from 0 to 10 with 0 being the absence of pain, 1 is the presence of minimal pain, and 10 is the greatest pain imaginable. Choice A is incorrect. The PQRST pain assessment method is used to assess pain and not to measure comfort levels. PQRST stands for precipitating events, quality of the pain, region or area of the pain, severity of the pain, and triggers that cause the pain. Choice B is incorrect. Asking the client if they feel better after the comfort intervention is not the best and most effective way to evaluate your adult client's response to non-pharmacological comfort interventions because this open-ended question elicits only a yes or no response and no other objective data about the level of intensity of the pain. Choice D is incorrect. Comparing pre and post-intervention data using the NIPS (Neonatal Infant Pain Scale) pain rating scale to evaluate your adult client's response to non-pharmacological comfort interventions is not a way to evaluate your adult client's response to non-pharmacological comfort interventions because the NIPS scale is used to assess pain among the neonate and not the adult population of clients. Last Updated - 12, Feb 2022

The client in the unit is expressing to the nurse that his son's complaining is making him feel anxious. He asks the nurse if she will talk to his son during his visit later in the day. Which is the most therapeutic response by the nurse? A. "Tell me about your son's complaints." B. "What do you think are the reasons for his complaints?" C. "Let's talk about how you can bring this up later when he arrives." D. "He's your son, why do you want me to talk to him?"

Explanation Choice C is correct. The nurse should assist the client in communicating directly with his son about his behavior. Such an approach helps the client practice how to confront the situation directly. Choice A is incorrect. Asking about the son's specific complaints distracts the client from the focus of the conversation. Ethically, the nurse should not explore the son's complaints in his absence. The client should be encouraged to talk about it with his son present in the room. Choice B is incorrect. Digging up reasons for the son's complaints distracts the client from the focus of the conversation. This focuses on his son, who is not in the room. The client should talk about it with his son present. Choice D is incorrect. Asking why the nurse should talk to the son on his behalf shifts the focus from dealing with the client's problem to reasoning with the client. This is inappropriate. Last Updated - 11, Dec 20

The nurse is assisting a client of the Orthodox Jewish faith while serving lunch. A kosher meal has been delivered to the client. What is the next appropriate action to perform with this client? A. Substitute plastic utensils with metal utensils B. Unwrapping the eating utensils for the client C. Carefully transferring the food from a styrofoam tray to a ceramic plate D. Allow the client to unwrap the utensils and prepare his own meal

Explanation Choice D is correct. A person of the Orthodox faith should be able to unwrap the utensils and prepare his meal. Choices A, B, and C are incorrect. The nurse should not assist or touch the kosher meal in any way. NCSBN client need Topic: Fundamentals; SubTopic: Culture and Spirituality Last Updated - 14, Dec 2021

Which of the following sacred religious symbols would be most analogous to the rosary beads often utilized by followers of the Roman Catholic faith? A. A sari for a female Hindu believer B. A sari for a female Buddhist believer C. A mala for a practicing Muslim D. A mala for a practicing Hindu

Explanation Choice D is correct. A mala is a Hindu rosary of prayer beads. Although there are various ways in which practicing Hindus may utilize a mala, the most common method is to hold the bead similar to how Roman Catholics hold rosary beads while reciting specific mantras (also known as Sanskrit prayers) in sets of 108 repetitions as a form of meditation. Additionally, Hindu mala is also sometimes referred to as "Japa mala beads." Choice A is incorrect. Unlike the sacred religious symbol of rosary beads which are carried by some members of the Roman Catholic faith, a sari (also spelled saree) is specific attire that a female Hindu believer wears. More specifically, a sari is either a six-yard or a nine-yard piece of brightly colored fabric wrapped around the body, fastened to the waist, and draped over one shoulder and often the head. In Hindu culture, wearing a sari symbolizes the woman's virtue. Choice B is incorrect. Unlike the sacred religious symbol of rosary beads which are carried by some members of the Roman Catholic faith, a sari (also spelled saree) is specific attire that a female Buddhist believer wears. Similar to a sari of the Hindu faith (discussed above), a Buddhist sari consists of one long piece of brightly colored fabric wrapped around the woman's body, fastened to the waist, and draped over one shoulder and often the head. Various colors have different meanings. Choice C is incorrect. Although some members of the Muslim faith do utilize a form of prayer beads, Islamic prayer beads are called misbaha (or subḥah), not mala. Additionally, unlike Roman Catholics' rosary beads, misbaha often comes in a string whose units (100, 25, or 33) represent the names of Islamic Gods. Learning Objective Correlate a mala used by a practicing Hindu as the sacred religious symbol most analogous to the rosary beads often utilized by a practicing Roman Catholic. Additional Info Prominent religions and their respective symbols have been identified below: Baha'i: The nine-pointed star is the symbol of the faith. Buddhism: In addition to the above discussion, Buddhists use the Lotus flower, Bodhi tree, Dharma wheel, and Two Golden Fish. Christian Science: The Bible is central to Christian Science. It is interpreted in the Christian Science textbook, Science, and Health, the authoritative guide for adherents. Church of Jesus Christ of Latter-day Saints (Mormon): King James Version of the New and Old Testaments the Bible, the Book of Mormon, and scriptures. Eastern Orthodox: Pray by making the sign of the cross. Hinduism: Sacred writings and objects include candles, fresh flowers, incense, prayer beads, and sandalwood. Islam: Only symbols include the Holy Quran with some women required to wear a burqa. Jehovah's Witness: None Judaism: Sabbath Candles are used. Protestant: Bible and Cross are utilized. Roman Catholicism: Observing sacraments and praying the rosary beads to aid in prayers. Seventh-day Adventist: An ill person is anointed with oil. Sikhism: A turban is worn as a symbol of personal sovereignty and symbolizes responsibility to others. Additional symbolic objects include a cloth around the chest, an iron bracelet, and a wooden comb. Spirituality (Native American): Prayer accompanied by the burning of cedar, sage, sweetgrass, or tobacco. Last Updated - 16, Dec 2022

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence the way people see and behave within the world is defined as: A. Society B. Community C. Spirituality D. Culture

Explanation Choice D is correct. Culture is defined as the customs, arts, social institutions, and achievements of a particular nation, people, or another social group. Choice A is incorrect. Society is defined as the people who live in a country or region, their organizations, and their way of life. Choice B is incorrect. A community is defined as all the people living in an area or a group or groups of people who share common interests. Choice C is incorrect. Spirituality is defined as the quality of being concerned with the human spirit or soul as opposed to material or physical things. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Cultural Assessment and Cultural Competency Last Updated - 20, Jan

The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include? A. Sterile gloves should be used to perform urinary catheter care. B. Urinary specimens may be collected from a catheter bag. C. You may irrigate a catheter with warm water for poor outflow. D. Daily use of soap and water should be used around the urinary meatus.

Explanation Choice D is correct. Daily cleaning of the urinary meatus with soap and water is recommended for catheter care. Sterile gloves do not need to be used for this process as it is a clean procedure. Soap and water is an acceptable practice for daily catheter care as alcohol, CHG, and other antiseptics may be highly irritating to the urinary meatus. Choices A, B, and C are incorrect. It is not necessary to utilize sterile gloves for catheter care as this is a waste of resources. Urinary specimens should not be collected from the catheter bag as this sample will be contaminated. If irrigating a urinary catheter is required, normal saline should be used as it is sterile. Water should not be used as it is not sterile and will cause cystitis. Additional Info When managing a client with an indwelling urinary catheter, the nurse should - Evaluate the reasoning for the indwelling catheter. The insertion of an indwelling catheter is invasive, so other measures such as external devices should be considered. Minimize the amount of time that a client has the device. Urinary catheters are directly implicated in catheter-associated urinary tract infections (CAUTIs). Perform meticulous hand hygiene before the insertion of the device. Aseptic technique during the insertion of the device is imperative. Ensure system patency by decreasing kinks and loops in the tubing. The catheter should always be below the bladder and catheters with anti-reflux valves are highly preferred. Last Updated - 15, Feb 2022

The nurse is caring for a client who has type 2 diabetes mellitus and hypertension. The client is nothing by mouth status (NPO) before a scheduled surgery. Which of the following prescribed medications should the nurse question? A. Metoprolol B. Phenytoin C. Levothyroxine D. Glipizide

Explanation Choice D is correct. Glipizide is a sulfonylurea and is given to the client with meals to manage blood glucose. This medication will lower blood glucose and could potentially cause hypoglycemia. The client is NPO and will not receive any food. Thus, the nurse should question the administration of this medication to prevent the client from developing hypoglycemia. Choices A, B, and C are incorrect. Endocrine medications (steroids, thyroid hormone), anticonvulsants, and beta-blockers are okay to give with a sip of water. Beta-blockers are given to clients with a sip of water before surgery to prevent intra- and post-procedure cardiac dysrhythmias. Additional Info Drugs for cardiac disease, respiratory disease, seizures, and hypertension are commonly allowed with a sip of water before surgery. Clients at risk for intra- and post-procedure cardiac dysrhythmias and hypertension are typically prescribed a presurgical beta-blocker to prevent this complication. Before administering a beta-blocker, the nurse should obtain the client's pulse and blood pressure. Last Updated - 04, Dec 2022

The primary objective in identifying similarities and differences among cultural beliefs of a patient is to: A. Communicate with the family B. Make sure the proper diet is ordered C. Perform a spiritual consult D. Avoid making assumptions

Explanation Choice D is correct. Making assumptions or generalizations about a patient's spiritual needs based on ethnic or religious affiliation is almost sure to be an oversimplification. The nurse should be able to identify similarities and differences among the cultural beliefs of the patients. Just because a patient belongs to a certain culture or ethnicity, it is incorrect to generalize their spiritual needs. Choices A, B, and C are incorrect. Ordering a specific diet as per the patient's specific cultural or religious preference is certainly warranted. However, generalizations cannot be made here either, and knowing the patient's specific preference will help the nurse cater to the patient's dietary or spiritual needs. Communicating with the family and performing a spiritual consult should also be done at the patient's request. While identification of cultural similarities and differences among the patients can help guide these processes, these are not the primary objectives. The primary objective is to avoid making assumptions. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Characteristics of Culture Last Updated - 09, F

The nurse is taking care of a client that is suffering from orthostatic hypotension. The client's health care provider is contemplating prescribing an alpha-adrenergic agonist. Which alpha-adrenergic agonist is most likely to be administered? A. Clonidine B. Phenylephrine C. Ephedrine D. Midodrine

Explanation Choice D is correct. Midodrine is an oral drug that is used to treat orthostatic hypotension in patients who do not respond to traditional therapy. It causes peripheral vasoconstriction and an increase in vascular tone and blood pressure. Choice A is incorrect. Clonidine is an alpha 2 receptor agonist that is used to treat essential hypertension. Choice B is incorrect. Phenylephrine is a potent vasoconstrictor that is used in many cold and allergy products. Choice C is incorrect. Ephedrine is an adrenergic agonist that is used for the chronic management of asthma and allergic rhinitis. Last Updated - 04, Feb 2022

The nurse is caring for a patient with a nasogastric tube. Irrigation should be performed every 4 hours to assess for NG tube patency. The nurse should instill how many milliliters of water or normal saline? A. 15 - 25 mL B. 20 - 30 mL C. 20 - 40 mL D. 30 - 50 mL

Explanation Choice D is correct. NG tubes should be watered every 4 hours with 30 - 50 mL of water or normal saline. Choices A, B, and C are incorrect. These are the inaccurate measurements necessary. NCSBN client need Topic: Basic Care and Comfort: Nutrition Last Updated - 06, Nov 2021

A client with a history of confusion has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? A. "Good morning. Do you remember where you are?" B. "Hello, my name is Susan Jones and I am your nurse for today." C. "How are you today? Remember, you're in the hospital." D. "Good morning. You're in the hospital. I am your nurse, Susan Jones." Submit Answer

Explanation Choice D is correct. This option gives the patient information about where he is and who is caring for him. It does not require him to answer questions or risk increasing his agitation if he does not know the answers. When a client is experiencing confusion, the nurse needs to provide a calm, predictable environment. Greeting the patient and stating where he is, who you are, and any pertinent information (without overwhelming him) will help prevent increased anxiety, which could lead to worsening confusion. Choices A and C are incorrect. The patient is confused and most likely does not know where he is. Asking him what he remembers may cause increased anxiety. Instead, the nurse should explain where the patient is and why to help ease his frustration. Choice B is incorrect. Although introducing yourself is essential, the client needs more information than merely the nurse's name. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Interventions for Confused Clients Last Updated - 31, Jan 2022

The nurse is caring for a client with a sodium level of 130 mEq/L. Which of the following medications may cause this abnormality? Select all that apply. A. Spironolactone B. Hydrochlorothiazide C. Prednisone D. Sodium polystyrene E. Tolvaptan

Explanation Choices A and B are correct. Spironolactone is a diuretic that retains potassium but causes the loss of water and sodium. Hydrochlorothiazide is a thiazide diuretic that may contribute to hyponatremia because while it does raise serum calcium levels, it depletes every other electrolyte. Choices C, D, and E are incorrect. Prednisone is a corticosteroid used for inflammatory conditions. This drug causes an increase in aldosterone, which increases sodium and water retention. Sodium polystyrene is used for individuals with hyperkalemia, and its use will not only lower potassium but may also raise sodium. Tolvaptan is a medication used to treat syndrome of inappropriate antidiuretic hormone (SIADH). It depletes the water but not the sodium. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Adverse effects/Contraindications/Side Effects/Interactions Question Type: Analysis Additional Info Hyponatremia is sodium less than 135 mEq/L. The cause of hyponatremia is multifactorial and may include diuretics, lithium, alcoholism, and certain forms of dehydration. For severe hyponatremia, the nurse should institute seizure precautions. Source : Archer Review Source : Archer Review Last Updated - 02, Feb 2022

Which of the following drugs is associated with photosensitivity? Select all that apply. A. Ciprofloxacin B. Sulfonamide C. Norfloxacin D. Sulfamethoxazole and Trimethoprim E. Isotretinoin F. Nitro-Dur patch Submit Answer

Explanation Choices A, B, C, D, and E are correct. Photosensitivity is an extreme sensitivity to ultraviolet rays from the sun and other light sources. A type of photosensitivity called phototoxic reactions are caused when medications in the body interact with UV rays from the sun. Choice F is incorrect. Nitro-Dur patches are not associated with photosensitivity. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies; Tetracyclines Last Updated - 30, Jan 2022

The nurse is caring for an assigned client. Which prescription requires clarification with the primary healthcare provider (PHCP) based on the laboratory data? See the exhibit. Select all that apply. A. Furosemide 40 mg PO Daily B. Metformin 1-gram PO Daily C. Ibuprofen 800 mg PO Daily PRN Pain D. Citalopram 20 mg PO Daily E. Lisinopril 20 mg PO Daily Submit Answer

Explanation Choices A, B, C, and E are correct. Furosemide, Metformin, Ibuprofen, and Lisinopril are all medications that may lead to nephrotoxicity. The laboratory data showed hypokalemia and an increase in creatinine which should prompt the nurse to clarify the prescriptions with the PHCP. Choice D is incorrect. Citalopram is an antidepressant that does not cause nephrotoxicity. This medication should be okay to administer to the client based on the laboratory data. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Adverse Effects/Contraindications/Side Effects/Interactions Question Type: Analysis Additional Info Elevations of the creatinine (normal: 0.6-1.2 mg/dL for males, 0.5-1.1 mg/dL for females) usually are caused by an offending agent such as an NSAID (ibuprofen), antibiotic (vancomycin), ACE inhibitors (lisinopril), and sulfa-based drugs. In this case, the client had elevated creatinine and low potassium, which support the clarification of the furosemide. Last Updated - 24, Nov 2021

The nurse assists a client with cystic fibrosis pick out items on a menu. It will indicate effective teaching if the client selects which food items? Select all that apply. A. Chicken breast B. Almonds C. Fat free yogurt D. Orange slices E. French fries Submit Answer

Explanation Choices A, B, D, and E are correct. A client with cystic fibrosis requires a well-balanced diet, rich in calories, high in protein, dense in vitamins, and unrestricted in fat. These food choices reflect one of these requirements. Chicken breast - high in protein Almonds - high in vitamin A Orange slices - high in vitamin C French Fries - high in sodium and fat Choice C is incorrect. The client will benefit from yogurt with milk fat. Because the client commonly has malabsorption, it is recommended that dietary items be rich in fat. Yogurt with fat would be a good choice because of the vitamins it offers, along with calcium. Additional Info Collaboration with a dietician is recommended in the management of cystic fibrosis. General dietary guidelines include - Pancrelipase is taken with snacks and meals to enable the absorption of nutrients. The diet should be rich in vitamins, fat, and protein. Because a client with CF often excretes high amounts of sodium, dietary items rich in sodium are usually not restricted. Blood glucose levels should be periodically monitored if diabetes mellitus should develop. DM is a common comorbidity associated with CF. Height and weight should be monitored at every exam. Last Updated - 06, Nov 2022

When caring for an Amish patient, what does the nurse know to be true? Select all that apply. A. They use traditional and alternative health care. B. Funerals are conducted in the home. C. The authority of women and men are equal. D. Many choose to live without health insurance. E. Health is believed to be a gift from God. Submit Answer

Explanation Choices A, B, D, and E are correct. Amish live a life that is generally strictly separate from society. While women are highly respected and valued, men hold the authority in the home. Traditional and alternative health care is appreciated, although many live without insurance. Health is believed to be a gift from God. Choice C is incorrect. Women are respected in Amish society but do not hold authoritative power. NCSBN client need Topic: Psychosocial Integrity / Cultural Awareness Last Updated - 27, Oct 2021

Which of the following are the steps of blood glucose level monitoring? Select all that apply. A. Hold the finger downward so the blood will drop by gravity. B. Use sterile gauze to wipe off the first drop of blood before testing. C. Collect the second blood drop on the test strip. D. Use a lancet to prick the pad of the finger. Submit Answer

Explanation Choices A, B, and C are correct. The procedure for checking the client's blood glucose levels in the correct sequential order are as follows: Verify and confirm that the code strip corresponds to the meter code. Disinfect the client's finger with an alcohol swab. Prick the side of the finger using the lancet. Turn the finger down so the blood will drop with gravity. Wipe off the first drop of blood using sterile gauze. Collect the next drop on the test strip. Hold the gauze on the client's finger after the specimen has been obtained. Read the client's blood glucose level on the monitor. Choice D is incorrect. The side of the finger should be pricked with the lancet, not the pad. Finger pads are not recommended for pricking because they are the thickest part of the finger, so one will have to prick deeper to get the required amount of blood NCSBN Client Need Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential Last Updated - 28, Oct 2021

Which forms of nonverbal communication can be viewed differently among members of different and diverse cultures? Select all that apply. A. Silence B. A smile C. Eye contact D. Touch E. Bodily posture

Explanation Choices A, C, D, and E are correct. Silence, eye contact, touch, and bodily posture are all forms of nonverbal communication that can be viewed and perceived differently among members of different and diverse cultures. Some cultures can see silence to be a lack of attention, while others can perceive silence as a compassionate way that understanding is conveyed. Some view eye contact as aggressive and hostile while other cultures see eye contact as connectedness with others. Some cultures perceive touch as inappropriate and invasive while others recognize touch as a sign of caring and compassion. Lastly, many bodily postures and gestures differ significantly among various cultures. A smile is a relatively universal sign of joy and happiness. Choice B is incorrect. A smile is a relatively universal sign of joy and happiness among all, if not most, cultures. Therefore this is the incorrect answer to the question. Last Updated - 21, Apr 2021

Which of the following fall under the right time of the 8 rights of medication administration? Select all that apply. A. Have a second nurse independently calculate the medication dosage. B. Double-check the last time that the medication was administered. C. Verify the frequency with which the medication is ordered. D. Document the pertinent vital signs.

Explanation Choices B and C are correct. B is correct. Double-checking the last time that the medication was administered is a part of the right time step in the 8 rights of medication administration. This is important because the nurse needs to verify that she is giving the dose at the correct time and that it is not being administered too frequently based upon the previous administration. C is correct. Verifying the frequency with which the medication is ordered is a part of the right time step in the 8 rights of medication administration. The nurse needs to verify that the frequency with which the medication is being ordered will be safe not just for this dose, but for the cumulative dosage if the medication is being administered more than once. For example, with acetaminophen, one dose of 1,000 mg may be appropriate, but administering this dosage every 4 hours would result in a daily intake of 6,000 mg of acetaminophen, far above the maximum of 4,000 mg. This is why the right frequency is a part of the right time step in the 8 rights of medication administration. Choice A is incorrect. Having a second nurse independently calculate the medication dosage is an important part of verifying the right dose. This check ensures that two nurses both calculate the dosages and come up with the same answer, decreasing the chance of an error in calculation. However, this is not a part of the right time check. Choice D is incorrect. Documenting the pertinent vital signs is part of the right documentation step to the 8 rights of medication administration, not the right time. The nurse must always document pertinent vital signs when administering medication. For example, if giving an antihypertensive, blood pressure should be documented. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological adaptation, Fundamentals - Medication Administration Additional Info Last Updated - 16, Feb 2022

The nurse is reinforcing education with a nursing student about how to bathe a newborn correctly. Which of the following statements by the student indicates a need for further instruction? Select all that apply. A. Always cover the newborn during the bath, except for the part of the body being washed. B. Clean their eyes from the outer canthus to the inner canthus C. Start with the body and work your way up to the face for the bath. D. Be sure to support the weight of the newborn's head during the bath. Submit Answer

Explanation Choices B and C are correct. B is correct. This statement is incorrect and demonstrates a need for further instruction. The newborn's eyes should be washed from the inner canthus to the outer canthus to prevent infection, not vice versa, as the student stated. C is correct. This statement is incorrect and demonstrates a need for further instruction. The nurse should start with the face, wash the baby's body, and move to the diaper area last. Choice A is incorrect. This statement demonstrates understanding by the student and does not indicate a need for further instruction. It is crucial to always cover the newborn during the bath, except for the part of the body being washed. The newborn cannot yet regulate its temperature and may quickly become too cold if fully exposed during a bath. Choice D is incorrect. This statement demonstrates understanding by the student and does not indicate a need for further instruction. It is always crucial to support the weight of the newborn during the bath. The nurse should place her hands under the infant's head and neck, as they cannot yet support their weight. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Infection control and safety; Fundamentals - Prioritization, delegation, and leadership Last Updated - 01, Jan 2022

The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct to identify which of the following medications that can increase the risk for falls? Select all that apply. A. Naproxen B. Alprazolam C. Bumetanide D. Verapamil E. Allopurinol F. Thiamine Submit Answer

Explanation Choices B, C, and D are correct. Medications that may hasten the risk for falls and included benzodiazepines such as alprazolam. This medication causes drowsiness and may impair judgment. Bumetanide is a loop diuretic; this medication may cause a client to experience orthostatic hypotension and the urgency to use the bathroom. Both of which pose a fall hazard. Verapamil is a calcium channel blocker and is utilized in the management of migraines and hypertension. This medication causes vasodilation; therefore, it will allow the client to become orthostatic if they do not shift positions slowly. Choices A, E, and F are incorrect. Naproxen is an anti-inflammatory medication and is not implicated in raising the risk of falls. Allopurinol is indicated to lower uric acid levels and would not increase the risk for falls. Thiamine is a water-soluble vitamin indicated for alcoholism. Additional Info Medications that may raise the risk for falls include any agents that may cause drowsiness (benzodiazepines, opioids), shifts in blood pressure (diuretics, beta-blockers), or alterations to the sensorium (melatonin). The nurse should diligently work to ensure a safe environment for the client and assess their risk for falls. Last Updated - 14, Feb 2022

Which of the following patients should have their temperature measured orally? Select all that apply. A. A 61-year-old woman who had oral surgery. B. A 44-year old man with chest pain on oxygen via nasal canula. C. An 83-year-old woman with diarrhea. D. A 29-year-old patient with an earache. Submit Answer

Explanation Choices B, C, and D are correct. There is no contraindication for oral temperature measurement in any of these patients. The oral temperature is measured with the probe placed under the tongue and the lips closed around the instrument. Oxygen delivered by nasal cannula does not affect the accuracy of the measurement. Choice A is incorrect. Oral surgery may falsely increase the local temperature by causing surgery-related inflammation. Oral temperature measurement is contraindicated in: Patients who have altered mental status because they may not cooperate fully. Those who are mouth breathers. Mouth breathing can affect the accuracy of oral temperature. Those who have had a recent oral intake of cold or hot foods/drinks Those who have recently smoked Those who have recently undergone oral surgery NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Temperature Last Updated - 14, Jan 2022

Select the complications of intravenous therapy that are accurately paired with its possible treatment after the intravenous line is discontinued. A. Mechanical phlebitis: the application of ice B. Superficial thrombophlebitis: lowering the extremity below the level of the heart C. Extravasation: the application of manual pressure to the site D. Site ecchymosis: elevation of the extremity and applying cold compresses E. Catheter embolus: placing a tourniquet above the site to limit blood flow and catheter particles migration F. Suppurative thrombophlebitis: the injection of a thrombolytic directly into the IV Submit Answer

Explanation Choices D and E are correct. Site ecchymosis ( Choice D) can be treated with the elevation of the extremity and applying cold compresses to the site. Catheter embolus ( Choice E) refers to the migration of catheter fragments following a fracture/ rupture of the catheter. Catheter rupture may occur due to excessive pressure when flushing the line. Excessive force should not be applied if the catheter does not flush easily. Catheter embolism can be managed by placing a tourniquet above the site to limit blood flow and catheter particle migration. The other common intravenous therapy complications and recommended interventions are as follows: Mechanical phlebitis (Choice A is incorrect): Phlebitis refers to the inflammation of the vein. Phlebitis due to catheter-related injury/ irritation is called "mechanical" phlebitis. Signs and symptoms include tenderness, erythema, and edema. If phlebitis is accompanied by thrombosis of the superficial veins, it is called "superficial thrombophlebitis" or superficial venous thrombosis. If it becomes infected, it is referred to as "suppurative thrombophlebitis." Treatment of phlebitis is aimed at reducing inflammation. Mechanical phlebitis is treated with the application of warm, moist compresses along with the administration of non-steroidal anti-inflammatory agents. Superficial Thrombophlebitis (Choice B is incorrect): Treatment should be aimed at reducing the swelling and symptoms. Elevation of the limb minimizes the swelling. The affected extremity should be elevated, not kept below the heart level. Ambulation should be encouraged. The physician may order a venous doppler to exclude concomitant deep vein thrombosis. Extravasation (Choice C is incorrect): Manual pressure should not be applied to the extravasated site. Management is focused on the elevation of the affected limb to help reabsorb the extravasated infiltrate. Septic (suppurative) Thrombophlebitis (Choice F is incorrect): Septic thrombophlebitis is characterized by the presence of a thrombus with inflammation and pus formation (suppuration). Clinical features include fever, redness, tenderness, a palpable cord, and purulent drainage at the affected venous site. If pus drainage is present, culture is necessary. Treatment includes catheter removal and broad-spectrum antibiotics as prescribed. Learning Objective Understand the various local complications of intravenous therapy and recommended management principles. Last Updated - 27, Jul 2022

The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect? Select all that apply. A. Nausea and vomiting B. Constipation C. Pruritus D. Urinary retention E. Nystagmus Submit Answer

xplanation Choices A, B, C, and D are correct. Fentanyl is an opioid analgesic used in the management of acute and chronic pain. Common effects associated with this drug include nausea and vomiting, constipation, pruritus, and urinary retention. Choice E is incorrect. Nystagmus is not associated with fentanyl. Ophthalmic effects associated with fentanyl include blurred vision and miosis. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Adverse Effects/Contraindications/Side Effects/Interactions Question Type: Knowledge/Comprehension Additional Info Source : Archer Review Fentanyl is an opioid medication that may be given in a variety of routes, including intravenous, intramuscular, transdermal, intranasal, and buccal. Prior to the administration of an opioid, the nurse should assess the client's pain level, blood pressure, and respiration. The fentanyl patch should be applied no greater than 72 hours. Source : Archer ReviewSource : Archer Review Last Updated - 19, Dec 2022

What characteristics best describe physical changes occurring in the aging adult? Select all that apply. A. Fatty tissue is redistributed B. The skin is drier and wrinkles appear C. Cardiac output increases D. Muscle mass increases E. Hormone production increases F. Visual and hearing acuity diminishes

Explanation Choices A, B, and F are correct. Physical changes occurring with aging include fatty tissue redistribution, the skin is drier with the appearance of wrinkles, and also the visual and hearing acuity diminishes. Choice C is incorrect. Cardiac output decreases with age. Choice D is incorrect. Muscle mass decreases with age. Choice E is incorrect. Hormone production decreases, causing menopause and andropause. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Age-Related Changes Last Updated - 28, Dec 2021

Upon assessment, the nurse noticed that the site of a client's peripheral intravenous (IV) catheter was red, warm, painful, and slightly edematous near the insertion point of the IV catheter. After taking the appropriate steps to address the issue and provide care for the client, the nurse documents in the medical record that the client experienced which of the following? A. Hypersensitivity to an IV solution B. Infiltration of the IV line C. Phlebitis of the vein D. Allergic reaction to the IV catheter material Submit Answer

Explanation Choice C is correct. The pH of IV solutions is a measure of acidity or alkalinity and usually ranges from 3.5 to 6.2. Extremes of both osmolarity and pH can cause vein damage, leading to phlebitis. The signs of phlebitis include warmth, tenderness, erythema, and swelling in the affected region. If this occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. Choice A is incorrect. Hypersensitivity reactions to IV solutions occur on a continuum, with anaphylaxis being considered the most severe type of hypersensitivity reaction. The more rapid the occurrence of the hypersensitivity, the more likely it is to be a true anaphylaxis and increase in severity. This is different from what is occurring in this client. Choice B is incorrect. Infiltration occurs when an IV solution leaks into the tissues around the vein. Early signs of infiltration include swelling, coolness, tingling, or redness. Choice D is incorrect. Allergic reactions to the materials utilized within IV catheter materials are so rarely seen that accurate numbers documenting this phenomenon are difficult to ascertain. When an "allergic reaction" does occur, the reaction is more likely to occur in response to a dressing or antiseptic material utilized to prepare the skin prior to initiating the IV site. Learning Objective Correctly identify the red, warm, painful, and slightly edematous region located near the insertion point of a client's IV catheter as phlebitis. Additional Info Currently, there are no specific established timeframes for which peripheral catheters are recommended to remain in place (i.e., dwell). The recommendations from both the Centers for Disease Control and Prevention (CDC) and the Infusion Nurses Society are that the IV catheters should be removed and/or rotated to a different site based on clinical indications (e.g., signs of phlebitis [warmth, tenderness, erythema, or edematous swelling], infection, or malfunction). This process requires conscientious and frequent assessment of the site. The Infusion Nurses Society recommends assessment of an IV site at least every 4 hours, every 1 to 2 hours for vulnerable patients, and every 4 hours for continuous infusions for outpatient and home care patients. For all other clients, site assessment should be performed once daily. Last Updated - 24, Sep 2022

Which of the following is a neurological complication that may occur when a vest restraint is too tight around a patient's body? A. Skin breakdown B. Strangulation C. Changes in skin pallor D. Numbness Submit Answer

Explanation Choice D is correct. The neurological complication can occur when a vest restraint is too tight around the client's body causing numbness and tingling that, unless corrected, can lead to neurological damage. Choices A, B, and C are incorrect. Skin breakdown, strangulation, and changes in skin pallor can occur when the restraint is too tight. These complications are usually related to the integumentary, respiratory, and circulatory systems, rather than neurological system complications. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential Last Updated - 23, Jan 2022

The nurse has received the following prescriptions for newly admitted clients. Which prescription should the nurse administer first? A. Aspirin to a patient experiencing an acute myocardial infarction B. Lisinopril to a patient with essential hypertension C. Risperidone to a patient with schizophrenia D. Levodopa-carbidopa to a patient with Parkinson's disease

Explanation Choice A is correct. A client experiencing a myocardial infarction is an acute emergency that requires immediate intervention. The standard treatment includes (in no order) morphine, oxygen, nitroglycerin, and aspirin. Choices B, C, and D are incorrect. Lisinopril for a patient with hypertension, risperidone for a patient with schizophrenia, and levodopa-carbidopa for an individual with Parkinson's disease are all maintenance medications for chronic conditions. Myocardial infarction is an acute event requiring acute interventions such as aspirin administration. Additional Info A client with a myocardial infarction requires immediate intervention, including establishing a large-bore intravenous catheter, continuous cardiac monitoring, and prescribed medications such as nitroglycerin and aspirin. Last Updated - 13, Feb 2022

The purpose of a health assessment is to: A. Obtain subjective and objective data B. Outline appropriate care C. Determine whether interventions are effective D. Intervene to correct difficulties Submit Answer

Explanation Choice A is correct. A health assessment is a method by which nurses gather both subjective and objective data. A health assessment is "gathering information about the health status of a patient, analyzing and synthesizing that data, making judgments about nursing interventions based on the findings, and evaluating patient care outcomes." A health assessment includes both a health history and physical evaluation. While a registered nurse performs the initial admissions assessment, LPN/LVNs will assess clients each shift and, if needed, more frequently. Choices B, C, and D are incorrect. While all of these options are things that are done in implementing and evaluating the plan of care, the health assessment is used to gather the data necessary to create the plan of care. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care Last Updated - 08, Feb 2022

You are caring for an elderly client of the Orthodox Judaism faith. Which meal would you most likely offer this client? A. Cottage cheese and fruit B. Beef lasagna C. Hamburger and milk D. Pork cutlet parmigiana

Explanation Choice A is correct. As outlined in the Torah, clients who practice Orthodox Judaism typically consume a kosher diet. Although a few dietary laws are associated with Orthodox Judaism (and discussed below), one of the key aspects required when following a kosher diet is avoiding consuming both meat and dairy products concurrently during the same meal. Here, offering your client a meal consisting of cottage cheese with fresh fruit is an acceptable option, as this meal would not violate any kosher dietary laws. Choice B is incorrect. Offering beef lasagna to a practicing Orthodox Jewish client would be unacceptable, as the meal violates kosher dietary law for numerous reasons. First, consuming meat and dairy products during the same meal violates the kosher diet. Second, even if the lasagna was a dairy-free product, it is unknown if the cow was slaughtered in a kosher manner. In order for the beef to be considered kosher, the animal would have to have been killed individually and in a precise way by a specially trained Jewish individual known as a shochet. Based on one or both of these reasons, this meal is not permitted under the Torah for a practicing Orthodox Jewish client. Choice C is incorrect. Similar to Choice B, offering a hamburger and milk to a practicing Orthodox Jewish client would be unacceptable, as the meal violates kosher dietary law for numerous reasons. First, consuming meat and dairy products during the same meal violates the kosher diet. Second, even if the milk was a dairy-free product such as soy milk, it is unknown if the cow used for the hamburger was slaughtered in a kosher manner. In order for the beef to be considered kosher, the animal would have to have been killed individually and in a precise way by a specially trained Jewish individual known as a shochet. Based on one or both of these reasons, this meal is not permitted under the Torah for a practicing Orthodox Jewish client. Choice D is incorrect. Offering pork cutlet parmigiana to a practicing Orthodox Jewish client would be unacceptable, as this would violate kosher dietary law by mixing meat and dairy products during the same meal for reasons discussed in Choice B and Choice C. Additionally, the consumption of pork would violate kosher dietary law, as the Torah does not permit the consumption of animals "that do not chew the cud and do not have cloven hoofs" such as pigs. Learning Objective Based on the client's Orthodox Judaism faith, recognize the client will need to be served a Kosher diet, therefore mandating specific dietary requirements. According to this client's Kosher diet, identify that the client may consume the cottage cheese and fruit meal, as all other options are prohibited due to the consumption of meat and dairy during the same meal in violation of the client's faith and/or other dietary restrictions. Additional Info The Torah provides the dietary laws for Orthodox Judaism. Orthodox Judaism prohibits food preparation on the Sabbath. Most clients who practice Orthodox Judaism do not eat meat with dairy products in the same meal. Orthodox Judaism only allows for the consumption of Kosher animal products. Following this practice, specific regulations specify the manner in which animals are slaughtered. "Prohibited foods that may not be consumed in any form include all animals (and the products of animals) that do not chew the cud and do not have cloven hoofs (e.g., pigs and horses); fish without fins and scales; the blood of any animal; shellfish (e.g., clams, oysters, shrimp, crabs, etc.) and all other living creatures that creep; and those fowl enumerated in the Bible (e.g., vultures, hawks, owls, herons, etc.)." Last Updated - 16, Dec 2022

The nurse is performing medication reconciliation for a patient in the respiratory clinic recently prescribed with terbutaline. Which medication should the nurse be concerned about? A. Atenolol B. Furosemide C. Cefuroxime D. Omeprazole

Explanation Choice A is correct. Atenolol is a beta-blocker that can interfere with the action of terbutaline due to its antagonistic effect on the beta receptor cells in the bronchi. The nurse should talk to the prescribing physician regarding shifting the atenolol to another drug class. Choice B is incorrect. Furosemide is a loop diuretic. It blocks the reabsorption of water and sodium in the loop of Henle, leading to diuresis. It does not cause any drug-drug reaction with terbutaline. Choice C is incorrect. Cefuroxime is a second-generation cephalosporin that does not produce any reaction with terbutaline. Choice D is incorrect. Omeprazole is a proton pump inhibitor. It does not produce any undesirable drug interactions with terbutaline. Last Updated - 28, Jan 2022

This nurse is caring for a client who is receiving prescribed cilostazol. Which of the following findings would indicate a therapeutic response? A. Absence of pain while ambulating B. Decreased total cholesterol C. Increased visual acuity D. Improved focus and attention Submit Answer

Explanation Choice A is correct. Cilostazol is a phosphodiesterase inhibitor approved to treat peripheral arterial disease. Its action mechanism decreases platelet aggregation and promotes vasodilation, allowing a client to ambulate distances without pain. Choices B, C, and D are incorrect. Cilostazol is not utilized to mitigate total cholesterol levels. Further, this medication does not improve visual acuity or attention. Additional Info Cilostazol is an effective treatment for a client with peripheral arterial disease (PAD). Manifestations of PAD include pain while walking (claudication), decreased peripheral pulses, and painful ulcers. Common side effects of this medication include diarrhea and headache. Under no circumstances should this medication be given to a client with heart failure. Last Updated - 28, Apr 2022

While working in the emergency department, the nurse attends to a client who has overdosed on lorazepam. Which of the following medications does she expect the healthcare provider to order? A. Flumazenil B. Phenylephrine C. Epinephrine D. Naloxone

Explanation Choice A is correct. Flumazenil is the antidote for benzodiazepine (BZD) overdose. Lorazepam (Ativan) is a benzodiazepine, so the nurse expects to administer Flumazenil to this patient with BZD overdose. Choice B is incorrect. Phenylephrine is a decongestant that is used to treat stuffy nose and sinus congestion caused by the common cold, hay fever, or other allergies. There is no indication to give this medication in the case of a benzodiazepine overdose. Choice C is incorrect. Epinephrine is a catecholamine that increases the heart rate and blood pressure. There is no indication to give epinephrine in a benzodiazepine overdose. Choice D is incorrect. Naloxone is the antidote for opioid overdose. Lorazepam is a benzodiazepine, not an opioid. Naloxone would be used in the overdose of morphine, fentanyl, oxycodone, or other opioid medications. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Fundamentals - Medication Administration

A client that recently died of a car accident was sent to the coroner for autopsy. The client's family became concerned about the autopsy since they are of the Jewish religion. The nurse's approach to the family must be guided by the fact that: A. All body parts removed during autopsy must be buried along with the client. B. The client can donate his body parts with the consent of his next of kin. C. Judaism supports organ donation. D. An autopsy can only be allowed upon approval of a rabbi.

Explanation Choice A is correct. In Orthodox Judaism, all body parts removed during autopsy must be buried with the body because it is believed that the entire body must be returned to the earth. Choice B is incorrect. In Orthodox Judaism, organ donation may not be decided by family members. Choice C is incorrect. It is not allowed in Orthodox Judaism to donate organs since they believe that all of the client's organs must be buried with the dead. Choice D is incorrect. The rabbi can approve of organ transplantation, but not organ removal or organ donation. Last Updated - 18, Jan 2022

Which of the following is the best approach for a nurse on the Quality Improvement (QI) team working on a project to reduce medication errors? A. Ensure that all staff members are educated on how to appropriately fill out an incident report if they make a medication error. B. Ensure the staff has been educated on the five rights of medication administration. C. Track the incident reports for repeating offenders and report findings to the next chain in command. D. Have an in-service to supervise staff members during medication administration to determine if further education needs to be given.

Explanation Choice A is correct. Reporting errors is fundamental to preventing errors. One crucial way to have a successful continuing quality improvement project is to have a procedure to file organized, accurate incident reports. This enables tracking of when, how, and why errors occurred, thus helping prevent future mistakes. Problems in the systems can be detected through incident reports of errors (errors that may or may not have harmed the patients). Even "near misses" must be reported. Reporting a near miss (i.e. an event where harm to the patient was avoided) can provide beneficial information for proactively reducing errors. Analysis of such reported errors often reveals many deviations/near misses that point to system vulnerabilities. Such vulnerabilities may eventually cause patients harm. Fixing such systems' problems is the idea behind quality improvement (QI) projects. Choices B, C, and D are incorrect. The question here is about the goals of a "Quality Improvement (QI)" committee in reducing medication errors. Such projects aim to reduce future errors and errors in the entire hospital system. Educating a single nurse or staff member about medication rights alone or supervising certain staff members is not considered a "quality improvement" project because these interventions do not address entire system problems. There are many reasons why an error can occur. Preventing those needs "knowledge" regarding what led to an error. The single most proven method to reduce future medication errors has been filing an "incident report" because it helps the QI committee identify "what" caused the error. Once the cause is identified, the QI committee can put in place protocols to prevent the recurrence. Additional Info Last Updated - 27, Jan 2022

The nurse is precepting a new graduate nurse. They are working with a client who has many family members present at the bedside. The nurse knows family dynamics are an important component of management of care, and asks the new graduate to define family. The new graduate nurse is correct when they state: A. A unit comprised of members who are related or not related. B. A unit comprised of blood-related relatives. C. A dyad of a male and female. D. A dyad of heterogeneous or homogeneous genders.

Explanation Choice A is correct. The most accurate definition of the family is a unit comprised of members who can be related or not related and bound legally or in a nonlegal manner. Choice B is incorrect. Families do not necessarily consist of only blood relatives; the traditional family has a man and a woman who are not blood relatives. Choice C is incorrect. Families do not necessarily consist of males and females; some families are gay or lesbian couples and others can have more than two people like a commune. Choice D is incorrect. Families do not necessarily consist of only a dyad of heterogeneous or homogeneous genders; they can consist of many members, such as communal families and extended families. Last Updated - 29, Jul 2022

The home health nurse is visiting an elderly client for the first time in his home. Upon assessment of the client, the nurse notices that the client has been taking 12 prescription medications and five over the counter medications. What is the nurse's most appropriate action? A. Check for drug interactions. B. Check for side effects from the medications. C. Check for any medication duplication. D. Ask the client if there are family members helping him with his medications.

Explanation Choice C is correct. Checking for any duplication in medication should be the first action of the nurse to eliminate the risk of adverse effects on the client. Choice A is incorrect. Checking for drug interactions should be done after determining if there is any duplication of medications. Choice B is incorrect. The identification of side effects from medications can be made after the duplication of drugs is determined. Choice D is incorrect. Asking about family members helping with his medications is irrelevant to the problem of polypharmacy as of the moment. Last Updated - 17, Jan 2022

The nurse is preparing to give an intramuscular (IM) injection into the client's vastus lateralis. It would indicate the correct technique if the nurse A. palpates to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third. B. locates acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion. C. locates the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers. D. displaces the skin by pulling the skin down or to one side about 1 inch with the nondominant hand before administering the injection. Submit Answer

Explanation Choice A is correct. This is the appropriate anatomical landmark for giving an IM in the vastus lateralis. To locate the vastus lateralis, palpate to find greater trochanter and knee joints; divide vertical distance between these two landmarks into thirds; inject into middle third. Choices B, C, and D are incorrect. Locating the acromion process is a landmark involved with giving an IM in the deltoid muscle. Locating greater trochanter, iliac tubercle, and iliac crest is involved in giving an IM ventrogluteal. Displacing the skin by pulling the skin down or to one side about 1 inch is relevant to the Z-track technique which is commonly used when giving an IM injection. Additional Info A key advantage of using the vastus lateralis is that an intramuscular (IM) injection may be given if the client is supine, side-lying, or sitting. Aspiration for routine injections into deltoid or vastus lateralis is not indicated because there are no large blood vessels in these locations. Last Updated - 27, May 2022

The nurse is observing a client ambulate with crutches. It would require follow up by the nurse if the client is observed A. with the crutches placed 2 inches in front of and 4 inches to the side of each foot. B. placing weight on the crutch and then steps up the first step of stairs with the unaffected leg. C. placing the crutch down to the step below and then moves the affected leg down. D. with both of their elbows flexed between 15 and 30 degrees.

Explanation Choice A is correct. This observation requires follow-up because it is inappropriate. The basic crutch stance is the tripod position, formed when the crutches are placed 6 inches in front of and 6 inches to the side of each foot. Choices B, C, and D are incorrect. These observations are correct and do not require follow-up. When the client goes up the stairs, the client leads with the stronger leg. When going downstairs, the client should lead with the affected leg. The elbows should be flexed between 15-30 degrees, and the client should report that the hand grips support their weight.

Your client has been taking medication to promote sleep for the last 19 days. This medication was discontinued three days ago. The client is now complaining about their insomnia ever since the drug was discontinued. You would respond to this client's concern by stating: A. "It is likely that you are affected with insomnia rebound which often occurs when a sleeping medication is discontinued." B. "It is likely that you are affected with REM rebound which often occurs when a sleeping medication is discontinued." C. "I am going to talk with your doctor about re-ordering your medication because this insomnia will, again, interfere with your necessary sleep." D. "I am going to talk with your doctor about re-ordering another sleeping medication because this insomnia will, again, interfere with your necessary sleep." Submit Answer

Explanation Choice A is correct. You would respond to this client's concern by stating, "It is likely that you are affected with insomnia rebound, which often occurs when a sleeping medication is discontinued." This rebound typically affects clients, therefore sleeping medications should be used for only a brief period and only when alternatives have been tried but failed. Choice B is incorrect. You would not respond to this client's concern by stating, "It is likely that you are affected with REM rebound, which often occurs when a sleeping medication is discontinued" because REM rebound can affect the client's increased dreaming, but does not induce insomnia. Choice C is incorrect. You would not respond to this client's concern by stating, "I am going to talk with your doctor about re-ordering your medication because this insomnia will, again, interfere with your necessary sleep" because this rebound will only occur again, therefore sleeping medications should be used for only a brief period and only when alternatives have been tried but failed. Choice D is incorrect. You would not respond to this client's concern by stating, "I am going to talk with your doctor about re-ordering another sleeping medication because this insomnia will, again, interfere with your necessary sleep" because this rebound will only occur again, therefore sleeping medications should be used for only a brief period and only when alternatives have been tried but failed. Last Updated - 15, Oct 2021

Parenting styles are most similar to whose theory of leadership? A. Bass B. Lewin C. House D. Fiedler

Explanation Choice B is correct. Kurt Lewin's theory of leadership is the most similar to the styles of parenting. Lewin describes the leadership styles as the autocratic, participative, democratic, and laissez-faire styles of leadership, which are the same as the different parenting styles. All these styles of leadership and parenting styles have their distinct advantages and disadvantages. Choice A is incorrect. Bass developed the transformational leadership style, which is not similar to the parenting styles of authoritarian parenting, participative parenting, democratic parenting, and laissez-faire parenting. Choice C is incorrect. House developed the Path-Goal situational leadership theory, which is not similar to the parenting styles of authoritarian parenting, participative parenting, democratic parenting, and laissez-faire parenting. Choice D is incorrect. Fiedler is credited with the Contingency situational leadership theory, which is not similar to the parenting styles of authoritarian parenting, participative parenting, democratic parenting, and laissez-faire parenting. Last Updated - 26, Jan 2022

The nurse identifies that one of her clients will need education on caring for their stoma and education on how to self-catheterize by three weeks post-op. Based on this information, which of the following urinary diversion methods does this client have? A. Vesicostomy B. Kock Pouch C. Ileal Conduit D. Condom Catheter

Explanation Choice B is correct. Postoperatively, the client will have an indwelling urinary catheter in place to drain urine continuously until the pouch has healed. This catheter will require irrigation. Clients will then perform self-catheterization every 4 to 6 hours for urinary diversion. Choice A is incorrect. Clients do not perform self-catheterization with a vesicostomy. Instead, urine empties through a stoma into an externally placed collection pouch. Choice C is incorrect. Clients do not perform self-catheterization with an ileal conduit. Instead, an externally placed collection pouch is used for urinary diversion, as urine flows into the conduit and is continually propelled out through the stoma by peristalsis. Choice D is incorrect. Clients do not perform self-catheterization with a condom catheter. A condom catheter is a non-invasive device placed externally on the male penis. When the man urinates, gravity propels the urine through a tube to a collection bag. Learning Objective Utilize the objective information provided to determine which urinary diversion method the client has in place. Additional Info The urinary diversion methods contained within the table above may be utilized due to bladder removal (usually from cancer), interstitial cystitis, painful bladder syndrome, incontinence after trauma or surgery, neurogenic bladder, congenital anomalies, strictures, bladder trauma, chronic bladder inflammation, etc. Last Updated - 28, Jul 2022

The nurse is caring for a client with a Sengstaken-Blakemore tube. The nurse performs safety checks at the beginning of the shift and ensures which priority item is readily available at the bedside? A. Trach kit B. Scissors C. Obturator D. Yaunker Submit Answer

Explanation Choice B is correct. Scissors must be kept at the bedside of any client with a Sengstaken-Blakemore tube. The nurse should check for this essential item at the beginning of the shift to ensure safety of the client. Scissors are necessary for this client, because if the Sengstaken-Blakemore tube were to rupture, the tube would move upward and could obstruct the airway. This is an emergency, and the nurse would need to act immediately so that the balloon can be cut. Choice A is incorrect. An extra trach kit does not need to be at the bedside of a client with a Sengstaken-Blakemore tube, rather this is a priority item for a client with a tracheostomy. Choice C is incorrect. An obturator does not need to be at the bedside of a client with a Sengstaken-Blakemore tube, rather this is a priority item for a client with a tracheostomy. Choice D is incorrect. A Yaunker suction catheter is kept at the bedside of most clients in the event that they need oral suctioning. While this is an appropriate item to keep at the bedside, it is not the priority for this client. NCSBN Client Need Topic: Reduction of Risk Potential, Subtopic: Potential for Complications of Diagnostic Tests/Treatments/Procedures - Safety Last Updated - 07, Feb 2022

The nurse is educating a client about their prescribed full-liquid diet. It would reflect client understanding if the client selects A. Gelatin B. Tea C. Custard D. Apple juice

Explanation Choice C is correct. A full-liquid diet includes food items such as plain ice cream, strained soups, sherbet, milk, pudding, custard, breakfast drinks, refined cooked cereals, and strained vegetable juices. Custard is under the full liquid diet specification and is the correct answer. Choices A, B, and D are incorrect. These dietary items reflect choices on a clear liquid diet. A clear liquid diet consists of relatively transparent foods. The client has been advanced to a full-liquid diet, and custard would be an appropriate choice. Additional Info A full liquid diet is used after a client has tolerated a clear liquid diet. A key difference in this diet is that the client may have liquid dairy products. For example, the client may have coffee on a clear liquid diet, but now on the full liquid diet, they may have coffee with cream. Last Updated - 04, Nov 2022

The nurse is teaching a client about the proper administration of liquid iron. The teaching has been effective if the client reports an intention to take the medication with which of the following? A. Milk B. Antacid C. Orange juice D. Water Submit Answer

Explanation Choice C is correct. Acids, such as orange juice, facilitate iron absorption and are recommended to be taken with liquid iron. Choice A is incorrect. Milk interferes with the absorption of iron (liquid and tablet forms). Choice B is incorrect. Antacids interfere with the absorption of iron (liquid and tablet forms). Choice D is incorrect. Water is not contraindicated when taking liquid iron, but orange juice has numerous benefits compared to water, including increased absorption of liquid iron and decreased dental staining. Learning Objective Correlate the administration of liquid iron with orange juice, as the latter increases the medication's absorption. Additional Info Liquid iron is ideally given on an empty stomach (i.e., one hour before or two hours after a meal) to ensure absorption, but may be provided with meals if gastrointestinal upset occurs. Liquid iron is also offered through a straw to prevent teeth staining. Last Updated - 15, Feb 2022

Which of the following meals would be the most appropriate dinner for a nurse to provide to a client of Orthodox Judaism faith on a kosher diet? A. Pork belly roast, rice, vegetables, mixed fruit, 2% milk, iced water B. Crab salad on a croissant, potato salad, vegetables with dip, 2% milk, iced water C. Sweet and sour chicken with rice and vegetables, assorted fruits, sweet tea, iced water D. Fettuccini alfredo with shrimp and vegetables, salad, mixed fruit, sweet tea, iced water

Explanation Choice C is correct. As outlined in the Torah, clients who practice Orthodox Judaism typically consume a kosher diet. Although a few dietary laws are associated with Orthodox Judaism (and discussed below), one of the fundamental aspects required when following a kosher diet is avoiding consuming meat and dairy products during the meal. Here, offering your client sweet and sour chicken with rice and vegetables, assorted fruits, sweet tea, and iced water is acceptable, as the meal does not violate any kosher dietary laws. Choice A is incorrect. Offering pork belly roast and 2% milk to a practicing Orthodox Jewish client would be unacceptable, as this would violate kosher dietary law by mixing meat and dairy products in the same meal. Additionally, pork consumption would violate kosher dietary law, as a kosher diet does not allow the consumption of pigs' flesh, organs, eggs, or milk. Choice B is incorrect. Offering crab salad to a practicing Orthodox Jewish client would be unacceptable, as crab is not kosher. For fish or seafood to be considered kosher, it must have fins and scales (i.e., salmon, bass, or trout). Sea creatures that do not have fins and scales are not considered kosher (i.e., shellfish, crab, shrimp, and lobster) and, thus, not permitted to be consumed under the Torah. Crab fail to meet these criteria, rendering this type of meal prohibited under the Torah. Choice D is incorrect. Offering fettuccini alfredo with shrimp to a practicing Orthodox Jewish client would be unacceptable, as shrimp is not considered kosher. For fish or seafood to be considered kosher, it must have fins and scales (i.e., salmon, bass, or trout). Sea creatures that do not have fins and scales are not considered kosher (i.e., shellfish, crab, shrimp, and lobster) and, consequently, not allowed to be consumed under the Torah. Shrimp do not meet these criteria, rendering this type of meal prohibited under the Torah. Learning Objective Recognize various aspects of the kosher diet, specifically the dietary restrictions on various seafoods and pork. Additional Info The Torah provides the dietary laws for Orthodox Judaism. Orthodox Judaism prohibits food preparation on the Sabbath. Most clients who practice Orthodox Judaism do not eat meat with dairy products in the same meal. Orthodox Judaism only allows for the consumption of Kosher animals. Following this practice, specific regulations specify how animals are slaughtered so that no blood is consumed. Last Updated - 14, Sep 2022

The nurse is caring for a post-operative client at high risk for pneumonia. Which intervention would be most effective in the prevention of this complication? A. Passive range of motion B. Sequential compression devices (SCDs) C. Early ambulation D. Prophylactic antibiotics Submit Answer

Explanation Choice C is correct. Early ambulation is beneficial because it prevents venous thromboembolism (VTE) and respiratory complications such as hypostatic pneumonia. Ambulation increases ventilation and mobilizes secretions, both of which help prevent the development of pneumonia. Choices A, B, and D are incorrect. Passive range of motion would help with joint mobility but would not mobilize respiratory secretions. The client needs early ambulation. SCDs would be helpful to prevent VTE - not pneumonia. Prophylactic antibiotics are invasive, expensive, and could lead to resistance. This is not an effective remedy for preventing pneumonia. Surgical clients may get antibiotics, but they intend to prevent surgical site infections. Additional Info Early ambulation in the post-operative period is highly effective in the prevention of venous thromboembolism and pneumonia. Other measures that should be implemented include frequent hand hygiene and incentive spirometry. Last Updated - 23, Jul 2022

A 16-year-old was rushed to the emergency department after falling off his motorcycle earlier in the day. He sustained a closed head injury but is still conscious. The physician in the ED orders a set of medications for the client. Which medication should the nurse question? A. Ranitidine 50 mg IV B. Docusate sodium 50 mg PO C. Morphine sulfate 10 mg IM D. Promethazine 25 mg IM

Explanation Choice C is correct. Morphine sulfate is a narcotic analgesic. Narcotic analgesics should not be given to patients with a head injury as it masks signs of increased intracranial pressure. Choice A is incorrect. Ranitidine is an H2 receptor antagonist; it reduces gastric acid production, preventing gastric ulcers. Choice B is incorrect. Docusate sodium is a stool softener. It is beneficial for clients on bed rest to have a stool softener to prevent constipation related to immobility. Choice D is incorrect. Promethazine is an H1 receptor blocker, used as an antiemetic. Last Updated - 15, Feb 2022

The nurse is performing community health screenings. A client tells the nurse that they smoke two packs a day of cigarettes and have smoked for six years. The nurse should document this finding as how many pack years? A. 3.5 pack years B. 3 pack years C. 12 pack years D. 6 pack years

Explanation Choice C is correct. Pack-years are calculated by multiplying the number of packs smoked per day by the years the client has smoked. Pack-years (PY) = number of packs of cigarettes per day (P) x number of years of smoking (Y) In this client, twelve is the correct amount of pack-years. The client has smoked two packs of cigarettes for six years (PY = two packs x six years = twelve pack-years). Choices A, B, and D are incorrect. None of these calculations are accurate when two is multiplied by six. Learning Objective Understand that "pack-year" is a terminology used to quantify lifelong smoking. It is a value obtained by multiplying the number of cigarette packs/day by the number of years. Additional Info The smoking history should include the number of cigarettes smoked daily, the duration of the smoking habit, and the client's age when smoking started, even for clients who are not current smokers. Record the smoking history in pack-years (the number of packs smoked per day multiplied by the number of years the client has smoked). For example, one pack year equals smoking one pack per day for one year, two packs per day for half a year, and so on. An occasional smoker's risk profile differs from a lifelong, heavy smoker. Some client's may have smoked heavily but later quit or cut back on smoking. Without using common terminology to quantify the "lifelong" use, it is difficult to estimate the client's risk for lung problems. Therefore, screening for smoking in "pack years" helps the health care providers with a common terminology to quantify lifelong smoking. Last Updated - 20, Nov 2022

The nurse is providing discharge teaching to a patient receiving sulfamethoxazole. Which of the following instructions should be given during this teaching? A. Discontinue taking this medication when symptoms are alleviated B. Restrict fluid intake to prevent hypertension C. Drink plenty of fluids D. Go to the emergency department if the urine turns a dark brown or yellow

Explanation Choice C is correct. Sulfamethoxazole (SMX) is used to treat urinary tract infections and should be taken with plenty of water. Each dose should be taken with a full glass of water. Choice A is incorrect. Antibiotics should not be discontinued until the entire prescribed course is completed. Choice B is incorrect. This medication should be taken with plenty of fluids to prevent adverse effects. Choice D is incorrect. Dark brown urine is a common side effect of using sulfamethoxazole and does not warrant a visit to the emergency department. NCSBN client need Topic: Physiological Integrity, Pharmacological and Parenteral therapies

The nurse prepares to insert a peripheral IV into the basilic vein of the right arm. Based on the diagram, indicate where the nurse would attempt this puncture. See the exhibit. Incorrect Correct Answer(s): C A. In the center of the antecubital fossa [19%] B. Not shown in the diagram [6%] C. Medial aspect of the forearm [38%] D. Lateral aspect of the arm

Explanation Choice C is correct. The basilic vein is the third site of choice for venipuncture and IV insertion in the arm. The basilic vein (labeled in the image below) is located medial to the other major veins of the arm ( ulnar side of the arm). The basilic vein is a less preferred venipuncture site than the median cubital vein and the cephalic veins because it is not as superficial, typically not well anchored, and tends to roll. This makes it difficult to access with a needle and poses a greater risk of injury to the adjacent median nerve and brachial artery. Therefore, the basilic vein should only be used if the median cubital vein and the cephalic veins are not accessible or usable. Choices A, B, and D are incorrect. The median cubital vein ( antecubital vein) is located in the center of the antecubital fossa ( Choice A, the area in front of the elbow). It connects the cephalic vein with the basilic vein. The median cubital vein is the most preferred ( first choice) for venipuncture in the arm because it is well anchored ( less likely to roll), large, and closer to the skin surface. It is easily accessible, away from the median nerve, and poses the least risk of injury to the nerves/arteries. The cephalic vein is located on the lateral aspect of the forearm ( Choice D), traverses along the radial ( lateral) side of the antecubital fossa, the arm, and terminates by draining into the axillary vein. The cephalic vein is the second choice for venipuncture in the arm.

While performing morning rounds, a nurse assesses a client's fat emulsion infusion and notes the infusion is one hour behind the scheduled time. Which of the following is the best nursing action? A. Adjust the infusion rate to make up the difference over the next hour, then revert the infusion rate back to the prescribed rate. B. Increase the infusion rate to ensure that the infusion finishes at the correct time. C. Ensure the fat emulsion infusion rate is infusing at the prescribed rate and maintain the rate at the prescribed rate. D. Stop the infusion and inform the health care provider (HCP). Submit Answer

Explanation Choice C is correct. The nurse should confirm the fat emulsion infusion is infusing at the prescribed rate and subsequently maintain the prescribed rate until the infusion is complete. Choice A is incorrect. Fat emulsions, parenteral nutrition (PN), or any other intravenous fluid should not be infused faster than the rate at which they are ordered. Doing so places the client at risk for fluid and/or fat overload. Choice B is incorrect. Similar to the above answer, fat emulsions, parenteral nutrition (PN), or any other intravenous fluid should be infused at the rate at which they are ordered, as deviations from the ordered rate place clients at risk for fluid and/or fat overload. Infusion rates should not be expedited in order to complete an infusion that is running behind schedule. Choice D is incorrect. Based on the information contained within the question, there is no need to stop the infusion or contact the health care provider (HCP) at this point. Additionally, similar to parenteral nutrition, fat emulsions should not be discontinued abruptly. Learning Objective Recognize the need to confirm the prescribed infusion rate of a client's fat emulsion infusion and maintain the prescribed rate until the infusion is complete after identifying the infusion is behind schedule. Additional Info Typically, lipids (i.e., one fat emulsion infusion bag) should never hang for more than 12 hours. Hospital policy should be checked to ensure compliance. In hospitalized patients, lipid emulsions are an integral part of balanced parenteral nutrition. Last Updated - 23, Sep 2022

When a hospice patient tells the nurse, "I feel no real connection with God," what is the nurse's most appropriate response? A. Give the patient a hug and tell her that her life still has meaning B. Arrange for a spiritual adviser to visit the patient C. Ask the patient if she would like to talk about her feelings D. Call in a close friend or relative to talk with the patient

Explanation Choice C is correct. When caring for a patient who is in spiritual distress; the nurse should listen to the patient first. Goals and expected outcomes for patients in spiritual distress need to be individualized and may include a patient achieving some of the following: Exploring the origin of spiritual beliefs and practices Identifying factors in life that challenge spiritual beliefs Exploring alternatives given these challenges: denying, modifying, or reaffirming beliefs, developing new beliefs Identifying spiritual supports Reporting or demonstrating a decrease in spiritual distress after successful intervention Choice A is incorrect. A hug and false reassurances do not address the diagnosis of spiritual distress. Choice B is incorrect. After listening to the patient, the nurse can ask if the patient would like a consultation with a spiritual adviser. However, the nurse should not arrange for a spiritual adviser to visit without the patient's consent. Choice D is incorrect. Talking to friends or relatives may be helpful, but should only be done if the patient expresses wishes to do so. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Spirituality Last Updated - 10, Jan 2022

The nurse is caring for an older adult client undergoing bowel prep for a scheduled colonoscopy. Which nursing diagnosis is the priority to integrate into the care plan? A. Deficient knowledge B. Altered elimination pattern C. Impaired skin integrity D. Risk for falls

Explanation Choice D is correct. A bowel prep will cause the client to ambulate to the bathroom frequently. The client is an older adult, and being an older adult is a risk factor for falls. The nurse should consider using a bedside commode to shorten the ambulation distance, mitigating the fall risk. Choices A, B, and C are incorrect. Deficient knowledge is common for any procedure, and the nurse should reinforce any education regarding the procedure and bowel prep process to the client. The bowel prep will likely cause loose stools, altering the elimination pattern. Frequent elimination may cause skin breakdown from the wiping of the peri region. These aspects are pertinent to the care plan but do not prioritize the client's safety regarding falls. Additional Info Polyethylene glycol 3350 is an osmotic laxative administered pre-procedurally to cleanse the bowel. This powder should be dissolved in water or Gatorade® and may chill in the refrigerator to increase palatability. The bowel prep is typically performed one day before the scheduled colonoscopy. Last Updated - 17, Dec 2022

What is the most appropriate nursing response when a Muslim patient requests that a basin of water on her bedside table not be emptied? A. Tell her that the water is a health hazard B. Talk with her about why she should not have it there C. Empty it because it could spill and wet the bed D. Support and accommodate her preference

Explanation Choice D is correct. A devout Muslim patient may request to turn their bed to face Mecca, change their hospital gown, and place a basin of water near their bed for ritualistic handwashing before praying. Choices A, B, and C are incorrect. The health risks associated with having the basin of water on the bedside table are minimal compared with the benefit of supporting the patient's spiritual needs. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Cultural Assessment Last Updated - 08, Nov 2021

An expected outcome that is appropriate for the recipient of respite care is: A. The terminally ill client will be free of any physical, psychological, or spiritual distress. B. The terminally ill client will be free of any pain or discomfort at the end of life. C. The primary caregiver will be free of any physical, psychological, or spiritual distress. D. The primary caregiver will be physically and emotionally rested. Submit Answer

Explanation Choice D is correct. An expected outcome that is appropriate for the recipient of respite care is that "the primary caregiver will be physically and emotionally rested." Respite care provides time off for the primary caregiver of the ill client so that the caregiver gets to rest with the opportunity to renew and restore their strengths during this stressful period as they serve as the primary caregiver. Choice A is incorrect. An expected outcome that is appropriate for the recipient of respite care is not that "the terminally ill client will be free of any physical, psychological, or spiritual distress." This is an expected outcome of the end of life care and hospice care, but not respite care. Choice B is incorrect. An expected outcome that is appropriate for the recipient of respite care is not that "the terminally ill client will be free of any pain or discomfort at the end of life." This is an expected outcome of the end of life care and hospice care, but not respite care. Choice C is incorrect. An expected outcome that is appropriate for the recipient of respite care is not that "the primary caregiver will be free of any physical, psychological, or spiritual distress." This is not a feasible goal. Last Updated - 29, Jan 2022

A nurse is preparing the plan of care for a client with stage 2 ovarian cancer who is a Jehovah's Witness. The client has been told that surgery is necessary. After discussing the client's religious preferences with the client, the nurse documents which of the following while creating the care plan? A. Religious sacraments and traditions are unimportant B. Medication administration is not allowed for this client C. Surgery is strictly prohibited for this client D. Administration of blood or blood products is not allowed for this client based on religious beliefs Submit Answer

Explanation Choice D is correct. For Jehovah's Witnesses, surgery is allowed, but the administration of blood and blood products is forbidden. Choice A is incorrect. Sacraments are traditionally associated with the Roman Catholic faith, not Jehovah's Witnesses. Choice B is incorrect. In general, the administration of medication is acceptable for Jehovah's Witnesses. The only exception is the administration of blood products or any item or medication containing a blood product. Choice C is incorrect. Jehovah's Witnesses are allowed to undergo surgery so long as the surgery does not involve the transfusion of blood or blood products. Learning Objective In general, recognize that the members of the Jehovah's Witness faith are forbidden from receiving a transfusion of blood or blood products. Additional Info Jehovah's Witnesses believe it is against God's will to receive blood or blood products; therefore, they will often refuse these transfusions, even if it is their own blood. The willing acceptance of blood transfusions by Jehovah's Witnesses has in some cases led to expulsion from and ostracisation by their religious community. However, a minority of Jehovah's Witnesses do not agree that the Bible prohibits blood transfusions, and will therefore accept transfusions. Some Jehovah's Witnesses may also believe that it is acceptable to receive blood plasma fractions or the reinfusion of their own blood. Given the divergent beliefs about receiving blood amongst followers of the religion, it is imperative that the view of each individual Jehovah's Witness client on this aspect be carefully canvassed by the treating health care provider (HCP). Last Updated - 12, Sep 2022

The nurse is caring for a client with the following clinical data. Based on the laboratory tests, which medication would the nurse clarify with the primary healthcare provider (PHCP) prior to administration? See the below exhibits. Incorrect Correct Answer(s): D A. Bupropion 150 mg XL PO Daily [33%] B. Clonidine 0.1 mg PO Daily [17%] C. Albuterol 2.5 mg via nebulizer Daily [11%] D. Lisinopril 40 mg PO Daily

Explanation Choice D is correct. Lisinopril is an ACE inhibitor used to manage heart failure and hypertension. While this medication may be nephroprotective, it can become nephrotoxic. While a client is taking an ACE inhibitor, the creatinine and the GFR need to be watched closely. Elevations of the creatinine and a decrease in the GFR are reportable findings to the PHCP. Choices A, B, and C are incorrect. Bupropion is an antidepressant and not a nephrotoxic medication. Clonidine is indicated for hypertension and ADHD; this medication is also not nephrotoxic. Albuterol is a beta-adrenergic agonist indicated for both acute and chronic respiratory illnesses. Additional Info Elevations of the creatinine (normal 0.6-1.2 mg/dl) usually are caused by an offending agent such as an NSAID (ibuprofen), antibiotic (vancomycin), ACE inhibitors (lisinopril), and sulfa-based drugs. Last Updated - 26, Nov 2022

Which of these medications can be mixed in the same syringe without the risk of any incompatibility? A. Dexamethasone and midazolam B. Haloperidol and ketorolac C. Hydrocortisone and midazolam D. NPH and regular insulin

Explanation Choice D is correct. NPH insulin and regular insulin can and are often mixed in the same syringe without the risk of incompatibility. Choice A is incorrect. Dexamethasone and midazolam cannot be mixed in the same syringe because they are not compatible. However, dexamethasone and other medications such as metoclopramide are compatible and can be mixed in the same syringe. Choice B is incorrect. Haloperidol and ketorolac cannot be mixed in the same syringe because they are not compatible. However, haloperidol and other medications such as hydromorphone can be mixed in the same syringe. Choice C is incorrect. Hydrocortisone and midazolam cannot be mixed in the same syringe because they are not compatible. However, hydrocortisone and other medications such as metoclopramide are compatible and can be mixed in the same syringe. Additional Info Source : Archer Review Last Updated - 22, Nov 2022

The nurse is preparing to administer dopamine (Intropin) to a client intravenously. All of the following are precautions to be taken when administering the medication, except: A. Use caution in calculating and preparing doses of the drug. B. Monitor the patient's response slowly (blood pressure, ECG, urine output, cardiac output). C. Dilute the drug before use if it is not prediluted. D. Have phenylephrine on standby in case extravasation occurs. Submit Answer

Explanation Choice D is correct. This is not the precaution a nurse needs to take because it represents an erroneous statement, therefore this is the correct answer to the question. Phentolamine should be on standby to save the vein in case of infiltration, not phenylephrine. Phentolamine is an antidote that counteracts the effects of dopamine, vasopressin, norepinephrine, and phenylephrine by causing vasoconstriction via alpha-receptor stimulation. Dopamine-induced extravasation can cause tissue injury with blanching and hematoma. Subcutaneous injection of phentolamine has been proven to be clinically effective in preventing tissue injury in the case of dopamine or vasopressin extravasation. Choice A is incorrect. This is the precaution that the nurse should take. The nurse should use extreme caution when calculating and preparing doses of the drug because even small errors could have serious effects. Choice B is incorrect. This is the precaution that the nurse should take. Monitoring the patient's response to the medication ensures that the most benefit is achieved with the least amount of toxicity to the client. Choice C is incorrect. This is the precaution that the nurse should take. Diluting the drug prevents tissue irritation on injection. Last Updated - 18, Oct 2021

The nurse supervises a nursing student administering a purified protein derivative (PPD) skin test. Which action by the student requires follow-up by the nurse? A. Inserts the needle, bevel up at a 15-degree angle B. Instructs the client that the test will be read in 48-72 hours C. Selects a site 3 to 4 finger widths below the antecubital space D. Administers the test using a 20-gauge needle, 2 inches long Submit Answer

Explanation Choice D is correct. When administering a PPD, the nurse should administer the test intradermal at an angle of 15-degrees. The appropriate gauge and length of the needle should be 25- to 27-gauge, ½- to 5⁄8-inch. Choices A, B, and C are incorrect. These observations do not require follow-up because these observations are appropriate. It is appropriate for the nurse to administer this test at an angle of 15-degrees with the bevel up. PPD testing is read within 48-72 hours and is administered 3 to 4 finger widths below the antecubital space. Additional Info A positive PPD intradermal skin test result does not necessarily mean the client has active tuberculosis (TB). A positive result indicates the client has been exposed to TB and only confirms the presence of antibodies. A client who tests positive for this test would need additional testing to confirm or rule out tuberculosis. A sputum culture will need to be performed to determine if a client has active pulmonary tuberculosis. A positive PPD for an individual who is immunocompetent is an induration of 10-15 mm. A positive PPD for an individual who is immunocompromised is 5 mm. Last Updated -

The nurse is caring for a 4-year-old child who is being hospitalized due to complications from an autoimmune disorder, frequent infections, and a low white blood cell count. This child is very nervous about being in the hospital. Which intervention should the nurse implement to address this child's fears? A. Provide the child with a private room B. Encourage them to play with other children in the common area C. Advise the parents to only visit during visiting hours D. Allow the parents to stay as much as they'd like Submit Answer

Explanation Choice D is correct. While most preschoolers can manage to be away from their parents for school, illness adds another stressor, making separation increasingly tricky. Parents should be encouraged to stay with their children as much as possible. Choice A is incorrect. Staying in a private room may be more anxiety-producing for a child separated from their healthy life. Choice B is incorrect. Because this patient is immunocompromised, they should not be spending time in the commons area with other children, as this may lead to developing infections. Choice C is incorrect. Parents should be encouraged to visit their children as much as possible. NCSBN client need Topic: Health Promotion and Maintenance, Developmental Stages Last Updated - 28, Jan 2022

The nurse is caring for a client receiving a continuous heparin infusion. Which of the following laboratory data should the nurse monitor? Select all that apply. A. Partial thromboplastin time (PTT) B. Platelet count C. Prothrombin time (PT) D. Neutrophil count E. International normalized ratio (INR)

Explanation Choices A and B are correct. A client receiving a heparin infusion will need their aPTT and platelet count monitored closely. Heparin prolongs the aPTT (goal is 1½ to 2½ times the control value) and should be observed frequently. Platelet counts that decrease approximately 50% may indicate heparin-induced thrombocytopenia, which should be reported. Choices C, D, and E are incorrect. PT and INR are significant if the client takes warfarin rather than heparin. The neutrophil count is irrelevant in this case; this would be appropriate to monitor if the client was also: Experiencing infection Taking certain drugs that may affect neutrophil levels, such as clozapine or chemotherapy agents Known to have neutropenia, an abnormally low count of neutrophils in the blood Additional Information: Intravenous heparin is typically administered as a bolus dose first, then as a continuous infusion to achieve therapeutic aPTT. The aPTT levels are drawn daily and 6 hours after the first dose and 6 hours following any dose adjustments. It is considered a critical value if the aPTT level rises above 70 seconds (or per facility policy). Platelets should also be monitored for clients receiving heparin, as it is expected for a slight reduction to occur. This usually resolves with continued anticoagulation therapy. Platelet counts of less than 150,000 may indicate heparin-induced thrombocytopenia (HIT), a medical emergency placing the client at high risk for clotting. All clients on anticoagulation therapy should be assessed for signs of bleeding, such as: Hematuria Blood in the stool Ecchymosis Petechiae Altered level of consciousness Pain NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Parenteral/IV Therapies Question Type: Application Additional Info Source : Archer Review Last Updated - 11, Jan 2022

You are working in the emergency department. Your adult patient has an endotracheal tube (ETT) in place and a team member is providing assisted ventilation. Which of the following medications can be instilled in the ETT? Select all that apply. A. Morphine B. Lidocaine C. Epinephrine D. Atropine Submit Answer

Explanation Choices B, C, and D are correct. According to the American Heart Association, lidocaine, epinephrine, and atropine can all be given via the ETT. It is essential to know that the dosage of a medication given via the endotracheal tube will usually be higher than if provided via the IV or IO routes. An easy way to remember what medications you can give via the ETT is by remembering the NAVEL mnemonic: N = Naloxone, A = Atropine, V = Vasopressin, E = Epinephrine, and L = Lidocaine. In the pediatric population, do not give vasopressin via an ETT. Choice A is incorrect. Medications other than these can damage the airways if instilled into the tube. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-Topic: Medication Administration

Select the normal physiological changes associated with the aging process that can adversely affect the excretion and elimination of medications in the human body. Select all that apply. A. Diminished glomerular filtration B. Decreased enzyme functioning C. Decreased peristalsis D. Lower pH of the gastric secretions E. Increased acidity of the gastric secretions F. Low functioning nephrons Submit Answer

Explanation Choices A and F are correct. As people age, several physiological changes occur. Many of these changes impact the pharmacokinetics and pharmacodynamics of medications. The regular physiological changes associated with the aging process that can adversely affect the excretion and elimination of drugs in the human body are the aging population's low functioning nephrons and diminished glomerular filtration. These changes can lead to the accumulation of medications in the body because they are not properly eliminated. Choice B is incorrect. Decreased hepatic enzyme functioning slows down the metabolism of medications, but not the excretion and elimination of medications in the human body. Choice C is incorrect. Decreased peristalsis slows down the absorption of medications, but not the excretion and elimination of drugs in the human body. Choice D is incorrect. Increased pH of the gastric secretions, rather than lower pH, slows down the absorption of medications, but not the excretion and elimination of drugs in the human body. Choice E is incorrect. Increased alkalinity, not acidity, slows down the absorption of medications, but not the excretion and elimination of drugs in the human body. Last Updated - 18, Oct 2021

The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home? Select all that apply. A. Positive gag reflex B. Hypoactive bowel sounds C. Blood pressure 90/60 mm Hg D. Incisional pain '2' on a scale of 0 to 10 E. Urinary output of 240 mL since surgery

Explanation Choices A, B, D, and E are correct. This client data reflects that the client is ready for discharge home. The client has a positive gag reflex, adequate urinary output for the postoperative time frame (30 mL/hr), positive bowel sounds, and minimal pain. Hypoactive bowel sounds immediately following anesthesia is expected because anesthesia decreases peristalsis. Absent bowel sounds would be a concerning finding. The client's pain is minimal and does not inhibit their ability to be discharged. Choice C is incorrect. This blood pressure is clinical hypotension and requires correction before discharge. It would be unsafe to discharge the client with this low blood pressure. The nurse should report this finding to the primary healthcare provider. Additional Info For a client to be discharged following a surgery, the following criteria must be met: ➢ Return to baseline neurological status ➢ Adequate urinary output (30 mL/hr) ➢ Return of reflexes (cough, gag, swallow) ➢ Bowel sounds present in all four quadrants ➢ Ability to ambulate ➢ Vital signs within normal limits ➢ Ability to tolerate oral fluids ➢ Minimal nausea and vomiting ➢ Adequate pain control Last Updated - 22, Nov 2022

The nurse performs a physical assessment on a client. Which of the following would the nurse recognize as a technique of inspection? Select all that apply. A. Ecchymosis to sacral area. B. Foul odor noted to urine. C. Jugular veins distended. D. Abdomen is tympanic. E. Bowel sounds hyperactive.

Explanation Choices A, B, and C are correct. Assessing that the client has bruising over the sacral area is achieved by visually inspecting the skin. Noting the presence of a foul odor is an example of inspection that uses the sense of smell. The nurse would inspect the client's neck to note visible jugular vein distension. Choices D and E are incorrect. Assessment of tympany in the abdomen is obtained through percussion and is typically observed over areas of air-filled organs such as the intestines. Assessment of the bowel sounds is obtained through auscultation with a stethoscope. NCLEX Category: Health Promotion and Maintenance Related Content: Techniques of Physical Assessment Question Type: Application Additional Info Inspection is the first step in a physical assessment and describes the process of obtaining purposeful observations about a client using the senses of vision, hearing, and smell. Auscultation involves listening to areas of the client's body (such as lungs, heart, and bowel sounds) with a stethoscope. Palpation and percussion are methods that use the sensation of touch and are performed by using the hands or fingers to tap or feel areas of the client's body. Palpation gives information about aspects such as the skin temperature, turgor, moisture level, tenderness, and the presence of any edema. Percussion provides information about whether an area is filled with air, an organ, bone, or other solid masses.

The nurse is caring for a client with advanced cirrhosis of the liver. Which of the following medications would the nurse clarify with the primary healthcare provider (PHCP) prescribe? Select all that apply. A. Isoniazid B. Valproic Acid C. Amiodarone D. Lithium E. Thiamine Submit Answer

Explanation Choices A, B, and C are correct. Isoniazid, valproic acid, and amiodarone are extensively metabolized by the liver and have been implicated in causing hepatotoxicity. Thus, the nurse should clarify these medications with the PHCP if the client has an existing hepatic injury such as advanced cirrhosis. Choices D and E are incorrect. Lithium is a salt and not metabolized by the liver. This medication would not aggravate the client's existing cirrhosis of the liver and would be safe. Lithium raises the concern for nephrotoxicity. Thiamine is a water-soluble vitamin and is not implicated in worsening hepatic injury. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Contraindications Question type: Knowledge/comprehension Additional Info Medications that may be hepatotoxic include, but are not limited to: Acetaminophen Antifungals (ketoconazole) Antiepileptics (valproic acid) Antituberculins (isoniazid) Statins (atorvastatin) Anabolic steroids Antiarrhythmics (amiodarone) Source : Archer Review Last Updated - 03, Dec 2022

The nurse has provided medication instructions to a client who has been prescribed a fentanyl transdermal patch. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply. A. "I may still need pain medication while this patch is applied." B. "If the patch comes loose, I may reinforce it with a piece of tape." C. "I can apply heat to the patch site to increase the pain relief." D. "I should remove this patch while I am sleeping." E. "The patch will need to be changed every 72 hours." Submit Answer

Explanation Choices A, B, and E are correct. Fentanyl can be delivered by a variety of routes, including transdermal patches. This patch is effective for around-the-clock pain control, but the client may still experience breakthrough pain requiring a more immediate release type of pain control. The client may reinforce the patch with tape if it starts to loosen. The fentanyl patch should be changed every 72 hours, with a new patch applied to a new site. Choices C and D are incorrect. Heat should not be applied to a fentanyl patch. This may result in the medication being rapidly discharged and could cause the client to experience opioid toxicity. The fentanyl patch is intended to provide around-the-clock pain control, and thus, it would be inappropriate for the client to remove it while they are sleeping. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Medication Administration Question Type: Knowledge/Comprehension Additional Info Fentanyl is an opioid that can be delivered in a variety of preparations (intravenous, transdermal, buccal). The transdermal patch is effective for providing a client with continuous pain control for 72 hours. This medication will take 24-hours to reach its peak effect, and the nurse should anticipate the client to experience breakthrough pain. Fentanyl patches should be applied to a clean area with minimal hair. Hair may be clipped but not shaven to ensure appropriate adhesion to the skin.

The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled? Select all that apply. A. Tachypnea B. Bradycardia C. Nausea D. Mydriasis E. Increased blood glucose

Explanation Choices A, C, D, and E are correct. A client experiencing acute pain will have activation of the sympathetic nervous system, therefore, causing signs and symptoms such as: Nausea, vomiting Diaphoresis Increased pulse Tachypnea Increased blood glucose Increased blood pressure Dilated pupils (mydriasis) Choice B is incorrect. The activation of the sympathetic nervous system is associated with acute pain. Bradycardia is not a finding consistent with this system's activation, as tachycardia would be the likely finding. Additional Info Pain is a subjective symptom that must be taken seriously. A thorough assessment of a client's pain includes the location, intensity, quality, onset and duration, aggravating factors, and the effects pain has caused, such as psychosocial distress. Client self-report is the most reliable indicator of pain, but the nurse must be aware of the non-verbal assessment findings supporting the presence of pain. Last Updated - 06, Dec 2022

The nurse is assisting a client to pick out food options appropriate for Dumping Syndrome. Which food items would be appropriate to select? Select all that apply. A. Rice cereal B. Pastries C. Chicken breast D. Cola E. Scrambled eggs Submit Answer

Explanation Choices A, C, and E are correct. Dumping syndrome is characterized by rapid peristalsis, especially with foods that are simple carbohydrates (refined sugars). Rice cereal, chicken breast, and scrambled eggs reflect foods that are not simple carbohydrates. Foods recommended for clients with dumping syndrome include complex carbohydrates, high protein, and high fiber. Choices B and D are incorrect. Clients with Dumping Syndrome should avoid simple carbohydrates (refined sugars). These foods include candy, cookies, pastries, cola, and anything with concentrated sugars. Pastries and cola have a high amount of sugar and are not recommended for a client with or at risk for dumping syndrome. Additional Info Dumping syndrome is a common complication following gastric bypass surgery. Early dumping syndrome has a rapid onset, usually within 15 minutes. It is the result of rapid emptying of food into the small bowel. Due to the hyperosmolality of the food, rapid fluid shifts from the plasma into the bowel occur, resulting in hypotension and a sympathetic nervous system response. Clients often present with colicky abdominal pain, diarrhea, nausea, and tachycardia. At worst, the client runs the risk of hypoglycemia. Last Updated - 30, Nov 2021

The nurse is discussing possible causes of sleeping difficulties in an older patient. Which of the following statements. If reported by the client indicates a need for further teaching? A. "I used chewing gum to help me quit smoking." B. "I take my dog for walks through the park two or three times a week." C. "Reading before bedtime helps calm me down." D. "I enjoy a cup of English tea before bed." Submit Answer

Explanation Choice D is correct. Since this client is experiencing insomnia, they should be advised to cut out stimulating drinks and food from their diet. English tea is a black tea that contains caffeine and may result in a lack of quality sleep. Choices A, B, and C are incorrect. Quitting smoking will help the patient sleep. Exercise and reading are both excellent ways to relax and sleep more effectively. NCSBN client need Topic: Health Promotion and Maintenance: Aging Process Last Updated - 11, Feb 2022

When assessing self-perception, the nurse should ask the client which of the following? A. "How would you describe yourself?" B. "What gives you hope when times are troubled?" C. "Is your normal way of dealing with stress helpful to you?" D. "Are you having difficulty handling any family problems?" Submit Answer

Explanation Choice A is correct. Assessment of self-perception focuses on how the patient thinks of himself/herself. Choices B, C, and D are incorrect. Role addresses the daily duties or tasks. Values address important big concepts of life and death. Coping is in response to a stressor. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care Last Updated - 13, Feb 2022

The nurse assists a client with cystic fibrosis pick out items on a menu. It will indicate effective teaching if the client selects meals that are A. High in fat B. Low in sodium C. Low in calories D. Low in protein Submit Answer

Explanation Choice A is correct. Cystic fibrosis is a multisystem disorder that may cause an individual to develop vitamin and mineral deficiencies because of dietary malabsorption. The recommended diet for a client with cystic fibrosis is a well-balanced, high-protein, high-calorie diet with high fat (impaired intestinal absorption). Dietary items rich in sodium are also encouraged because of the salt loss through the skin. Choices B, C, and D are incorrect. A diet rich in sodium is recommended (popcorn, chips). Dietary items low in protein and calories would be detrimental to managing CF. Additional Info Collaboration with a dietician is recommended in the management of cystic fibrosis. General dietary guidelines include - Pancrelipase is taken with snacks and meals to enable absorption of the nutrients. Blood glucose levels should be periodically monitored if diabetes mellitus should develop. DM is a common comorbidity associated with CF. Height and weight should be monitored at every exam. Last Updated - 24, Aug 2022

The first bodily area to be washed with a complete bed bath is the: A. Inner canthus of the right eye B. Cheeks C. Forehead D. Chin Submit Answer

Explanation Choice A is correct. The first bodily area to be washed with a complete bed bath is the inner canthus of either eye, including the right or left eye. The washing is done from the inner to the outer canthus of the eye. The next steps for the bath are the rest of the face, the upper chest, the arms, and hands, after which you would proceed downward on the body from the head to the toes. Choice B is incorrect. Although the cheeks are washed near the beginning of a complete bed bath, washing either cheek is not the first bodily area to be washed. Choice C is incorrect. Although the forehead is washed near the beginning of a complete bed bath, washing the forehead is not the first bodily area to be washed. Choice D is incorrect. Although the chin is washed near the beginning of a complete bed bath, washing the chin is not the first bodily area to be washed. Last Updated - 15, Jan 2022

While reviewing various pain scales, the nurse understands pictorial pain assessment scale, like the Wong-Baker scale, has some advantages compared to a numerical pain intensity assessment scale. One of these advantages of pictorial scale over logarithmic scale is that the logarithmic pain intensity assessment scale cannot be used when: A. A client is confused and disoriented B. A client is in severe pain because these numerical pain intensity assessment scales are only able to measure mild to moderate pain and not severe pain. C. A client is in minimal pain because these numerical pain intensity assessment scales are able to measure only mild to moderate pain and not minimal pain. D. A client is deeply lethargic and unable to follow instructions.

Explanation Choice A is correct. The primary advantage of a pictorial pain assessment scale, like the Wong-Baker scale, when compared and contrasted to a numerical pain intensity assessment scale is that the logarithmic pain intensity assessment scale cannot be used when a client is confused and disoriented. However, this type of client would be able to use a pictorial pain assessment scale like the Wong-Baker FACES range of pain assessment. Choice B is incorrect. This is inaccurate. Logarithmic pain intensity assessment scales can be used to assess the continuum of pain intensity from the absence of all suffering to the most significant and highest level of severe pain. Choice C is incorrect. This is inaccurate. Logarithmic pain intensity assessment scales can be used to assess the continuum of pain intensity from the absence of all suffering to the most significant and highest level of severe pain. Choice D is incorrect. This is inaccurate because a client who is deeply lethargic and unable to follow instructions cannot be assessed with either a numerical or pictorial pain assessment scale since they are not able to follow instructions. For these clients, the nurse should use a pain behavior assessment. Last Updated - 05, Feb 2022

The nurse notes that her patient arriving from the emergency department has increased intracranial pressure and is planning to adjust the bed to accommodate them. At what angle should the nurse elevate the head of the bed? A. 25 degrees B. 30-40 degrees C. 10-20 degrees D. 5-10 degrees Submit Answer

Explanation Choice B is correct. A patient with increased intracranial pressure should have the head of the bed elevated at 30 or 40 degrees. Nurses should also be sure to avoid Trendelenburg and prevent the patient's neck from flexing. A standard ICP is about 5 to 15 mmHg. Choice A is incorrect. 25 degrees is too low and could increase intracranial pressure. Choice C is incorrect. 10 to 20 degrees is too low and could increase intracranial pressure. Choice D is incorrect. 5 to 10 degrees is too low and could increase intracranial pressure. NCSBN client need Topic: Physiologic integrity, alterations in body systems Last Updated - 15, Feb 2022

The nurse is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside? A. Air humidifier B. Inner cannula C. Nasal cannula oxygen D. Tracheostomy brush

Explanation Choice B is correct. An inner cannula of the tracheostomy size and one smaller must be kept at the bedside. This is essential in case the inner cannula becomes dislodged. Choices A, C, and D are incorrect. An air humidifier is recommended for a client with a tracheostomy but is not required. This is useful to help prevent the hardening of the secretions since the oropharynx is bypassed. Nasal cannula oxygen is inappropriate to have at the bedside because the oropharynx is bypassed. A trach collar should be used to deliver oxygen to a client with a tracheostomy. A tracheostomy brush is useful for tracheostomy care but not necessary. This brush is only used to loosen up hardened secretions. Additional Info When caring for a client with a tracheostomy, the nurse should have the necessary safety equipment at the bedside, and this includes - Two extra inner cannulas - one fitting the client and one smaller size. Obturator Suction equipment Oxygen source/tank Last Updated - 12, Feb 2022

The nurse observes unlicensed assistive personnel (UAP) give a bed bath using 4% chlorhexidine (CHG). Which observation requires follow-up? A. Uses one washcloth for washing each major body part B. Rinses the skin after bathing with the CHG solution C. Washes the client's face with warm water and mild soap D. Allows the CHG solution to dry on the client's skin

Explanation Choice B is correct. CHG is an effective antimicrobial agent that inhibits bacterial growth for 24 hours. The solution should not be rinsed off once it is applied, as it will leave a sticky residue. The sticky residue (sensation) is normal. Choices A, C, and D are incorrect. These observations do not require follow-up because they are appropriate. When using CHG in a bath basin of water, use one washcloth to wash each major body part. Then dispose of the cloth and use a new cloth for the next body part. CHG should not be applied to the face or the eyes. Only use warm water or mild soap, and water should be used on the face. CHG should be allowed to dry on the client's skin and should leave a residue-type sensation. Additional Info When using CHG in a bath basin of water, use one washcloth to wash each major body part. Then dispose of the cloth and use a new cloth for the next body part. Dipping cloth back into the basin contaminates the solution and makes CHG less effective. Do not rinse after bathing with CHG solution. Allow CHG to dry on the skin to achieve antimicrobial effects. CHG is safe to use on the perineum and external mucosa. However, cleansing of the urinary meatus is best performed with soap and water Last Updated - 11, Jun 2022

You are caring for a client who has severe burns on her right arm and is in extreme pain, despite receiving a potent analgesic. You decide to rub the client's uninjured left arm to relieve pain in the right. This approach is known as which of the following? A. Massage B. Contralateral stimulation C. TENS D. Acupressure Submit Answer

Explanation Choice B is correct. Contralateral stimulation involves stimulating the skin in an area opposite to the painful site. The stimulation may be in the form of scratching, rubbing, or applying heat or cold. This intervention is especially helpful if the affected area is painful to touch, under bandages, or in a cast. Choice A is incorrect. By providing cutaneous stimulation and relaxing the muscles, massage helps to reduce pain. Massage can be used as a type of contralateral stimulation. Choice C is incorrect. A transcutaneous electrical nerve stimulator (TENS) is an externally worn battery-powered device consisting of electrode pads, connecting wire, and a stimulator. The pads are directly applied to the painful area. Due to the burns, the TENS unit is not an appropriate answer. Choice D is incorrect. Similar to the ancient art of acupuncture, acupressure stimulates specific sites in the body. However, instead of needles, fingertips provide a firm, gentle pressure over the various pressure points. It is not recommended for a patient with burns. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care & Comfort Last Updated - 15, Feb 2022

Which percussion sound would indicate further assessment is needed? A. Dull tone over the spleen B. Hyperressonance over an adult's lung tissue C. Flat tone over bone D. Hyperressonance over a child's lung tissue

Explanation Choice B is correct. Hyperressonance is an abnormal finding over adult lung tissue. It indicates an abnormal increase in the amount of air present, such as with emphysema. Choice A is incorrect. Soft, short, muffled "dull" sounds are normal over dense organs such as the liver and spleen. Choice C is incorrect. Bones produce a "flat" percussion sound in normal healthy adults. Choice D is incorrect. Adult lung tissue should create a "resonant" sound during percussion, but hyperresonance is a normal finding in children's lung tissue. NCSBN Client Need Topic: Pathophysiology, Subtopic: Skills/procedures Last Updated - 14, Feb 2022

The nurse has instructed a client who is being discharged with a cane about going upstairs. Which statement by the client would indicate a correct understanding of the teaching? A. "I should move my cane up, then my weaker leg, then my stronger leg." B. "I should move my stronger leg up, then my cane and the weaker leg simultaneously." C. "I should move my stronger leg up, then my cane, followed by my weaker leg." D. "I should move my cane up, then my stronger leg, then my weaker leg." Submit Answer

Explanation Choice B is correct. When a client is ambulating upstairs using a cane, the client will advance the unaffected (stronger) leg up to the next step, then the cane and the affected (weaker) leg simultaneously. This reflects adequate understanding. Remember that the weaker side and the cane share the load and should always move together. Choices A, C, and D are incorrect. These statements require follow-up because they do not follow the correct (and safe) sequence for ambulating with a cane while ascending stairs. Improper usage of a cane may result in falls. Learning Objective Recognize that the correct sequence of ambulating upstairs while using a cane is moving the good leg first and then the cane and the bad leg together. Additional Info Education regarding cane usage: A. Walking on a level surface: When walking on a level surface, the client should hold the cane on the same side as the stronger leg. This helps the client shift the weight to the stronger side as they move. Therefore, the client should move the weaker or injured leg simultaneously while moving the cane. Always remember that the cane and the injured/ weaker side act as partners - they always move together. By doing this, the cane can share the load with the injured leg. The client should step with the weak leg as they pick up the cane and press down with the cane again when they step down with their weak leg. B. Using the stairs: " Up with the good, and down with the bad" is a good statement while educating the client regarding cane usage to navigate the stairs. Up with the good: If the client must ascend stairs, the nurse should instruct the client first to hold the cane on their stronger side. Then the client should advance the unaffected (good) leg onto the step and, following that, move the affected (weaker) leg and the cane simultaneously onto the step. The cane and the weaker side should always move together. Down with the bad: If the client must descend stairs, the nurse should instruct the client to hold the cane on their stronger side. The client should simultaneously place the cane and the affected (weaker) leg down on the next step, followed by the unaffected (stronger) leg.

You ask your 32-year-old female client about her hobbies. The client tells you that they thoroughly enjoy reading, making pottery, hiking, and rock climbing in the mountains. Which of these interests would you primarily focus on and encourage? A. Making pottery because this avocation is relaxing and not hazardous. B. Hiking because this avocation is a good and low-impact exercise. C. Reading because this avocation is relaxing and not hazardous. D. Rock climbing because this avocation is a good and low-impact exercise. Submit Answer

Explanation Choice B is correct. You would primarily focus on and encourage hiking because hiking is not only a hobby and interest for the client, but it is an excellent form of exercise that is low impact and relatively safe in comparison to other hazardous hobbies like rock climbing. Choice A is incorrect. Making pottery is not the activity or hobby that you would focus on and encourage because pottery is a sedentary and solitary activity; not one that provides enjoyable outdoor exercise and social interactions with others. However, it can be relaxing and with minimal hazards. Choice C is incorrect. Reading is not the activity or hobby that you would focus on and encourage because it is a sedentary and solitary activity; not one that provides any exercise and social interactions with others, although it can be relaxing. Choice D is incorrect. Rock climbing is not the activity or hobby you would focus on and encourage because rocking climbing is exceptionally hazardous, although it is an excellent and high-impact exercise. Last Updated - 21, Jan 2022

A patient is scheduled for an IV pyelogram. He asks the nurse what he needs to do to prepare for the test. The correct response is: A. "You need to have a full bladder for the test to be successful." B. "You need to alert the technician if you feel any burning after the dye is injected." C. "You will receive a bowel preparation before the test can be performed." D. "You must lie on your back for four hours after the test is performed." Submit Answer

Explanation Choice C is correct. Bowel prep is necessary to make sure the x-rays are bright and bowel contents do not obstruct viewing of urinary structures. An IV pyelogram is an x-ray that is used to view the urinary structures. Choice A is incorrect. A full bladder is unnecessary for the test to be successful. Choice B is incorrect. Although the technician should be alerted if any uncomfortable sensations occur, allergies should be checked before the test is administered. Choice D is incorrect. It is not necessary to lie down after the test is performed. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential Last Updated - 15, Feb 2022

The nurse is educating a client who has stomatitis on oral care. Which of the following recommendations would be appropriate? A. Recommend the client swish and spit alcohol mouthwash. B. Provide lemon glycerin swabs in between meals. C. Recommend the client swish and spit saline mouthwash. D. Instruct the client to cleanse their mouth with chlorhexidine.

Explanation Choice C is correct. For a client with stomatitis (inflammation of the oral mucosa), the client must avoid anything acidic or irritating to the oral mucosa. Saline mouthwashes or saline mouthwashes with sodium bicarbonate are recommended. Choices A, B, and D are incorrect. Acidic rinses and swabs are discouraged because of their irritating effects on the oral mucosa. Products such as chlorhexidine, alcohol, and lemon should be avoided. Additional Info Stomatitis may be caused by an array of medications, including chemotherapy. The nurse should advise the client to avoid products such as - commercial mouthwashes which contain alcohol chlorhexidine povidone-iodine hydrogen peroxide lemon glycerin swabs What is recommended are rinses with saline or saline mixed with sodium bicarbonate.

The nurse is preparing to prime a new line of IV tubing. They understand that priming intravenous tubing is crucial because it prevents which dangerous treatment complication? A. Medication toxicity B. Infiltration C. Air embolism D. Extravasation Submit Answer

Explanation Choice C is correct. Priming new intravenous tubing is done to prevent a medical emergency known as an air embolism. This condition occurs when a blockage of blood supply caused by an air bubble results in breathing problems, chest pain, or cardiac arrest. Choice A is incorrect. A worry over medication toxicity is not the reason for priming new IV tubing. Choice B is incorrect. Infiltration occurs when fluids from IV parenteral therapy enter surrounding tissues. This is not prevented by priming new IV tubing. Choice D is incorrect. Extravasation is the leaking of harmful IV fluids into the tissue surrounding an IV site. This is not the primary concern when priming new IV tubing. NCSBN client need Topic: Pharmacologic and Parenteral Therapies: Parenteral/Intravenous Therapies Last Updated - 26, Oct 2021

The definition of a "nonverbal" client in the context of pain assessment can include the clients: A. Reluctance to report pain. B. Inability to speak because of intubation. C. Absence of consciousness. D. Expressive verbal aphasia. Submit Answer

Explanation Choice C is correct. The absence of consciousness is a part of the definition of "nonverbal" in the context of pain assessment. The description of "nonverbal" in the context of pain assessment is the inability to self-report pain, the failure to be adequately assessed using a numerical pain scale, and the inability to be adequately evaluated using a pictorial pain assessment scale; "nonverbal" clients have to be assessed by the nurse in terms of their nonverbal, behavioral indications of pain such as facial expressions. In addition to unconsiousness, other conditions that render the client "nonverbal" in the context of pain assessment include the very young, confused clients, comatose clients, and others. Choice A is incorrect. The client's reluctance to report pain is not part of the definition of "nonverbal" in the context of pain assessment. The client can be verbal and can communicate, but they do not do so because of their reluctance to report pain. The definition of "nonverbal" in the context of pain assessment is the inability to self-report pain, the failure to be adequately assessed using a numerical pain scale, and the inability to be adequately evaluated using a pictorial pain assessment scale. "Nonverbal" clients have to be assessed by the nurse in terms of their nonverbal, behavioral indications of pain such as facial expressions. Choice B is incorrect. An inability to speak because of intubation is not part of the definition of "nonverbal" in the context of pain assessment. The client can be assessed with a pictorial pain scale, so they are not considered "nonverbal" in the context of pain assessment. Choice D is incorrect. Expressive verbal aphasia is not part of the definition of "nonverbal" in the context of pain assessment. The client can be assessed with a pictorial pain scale, so they are not considered "nonverbal" in the context of pain assessment. Last Updated - 12, Jan 2022

The primary care physician has ordered an enema for a patient with fecal impaction. The nurse would be correct in placing the client in which position before administration? A. Trendelenburg's position B. Semi-Fowler's position C. Left Sims' position D. Right-side with the head of the bed lowered

Explanation Choice C is correct. When administering an enema for fecal impaction, the nurse should place the patient in the left Sims' position. This allows the medicine to move naturally throughout the colon. Choice A is incorrect. Trendelenburg's position would not allow the fluid from the enema to flow throughout the colon. Choice B is incorrect. Semi-fowler's position works against gravity when giving an enema. Choice D is incorrect. Lowering the head of the bed is not necessary and would not be appropriate during this procedure. NCSBN client need Topic: Pharmacological Therapies, Medication Administration Last Updated - 15, Nov 2022

Parts of a pain assessment entail the subjective comments of the client in terms of their sensory and affective/emotional comments that can indicate the quality and intensity of their pain. Select the type of pain that can be shown with the client's emotions of "nagging and tender". A. Hurting pain B. Pain C. Somatic pain D. Aching pain

Explanation Choice D is correct. Aching pain in terms of affective/emotional descriptors can include the client's subjective comments that include "nagging and tender." Other personal affective descriptors can consist of "troublesome," "annoying," and "tiring". Ache is the least intense, hurt is the next level of intensity, and pain is the most intense. Choice A is incorrect. Hurting pain in the client can describe pain with affective/emotional descriptors such as "robbing", not "nagging and tender." Choice B is incorrect. Pain, in contrast to other intensity pain, is considered the highest level possible; its affective/emotional descriptors include comments such as "agonizing," suffocating" and "unbearable". Choice C is incorrect. "Nagging and tender" are not sufficient, emotional descriptors of bodily pain. Last Updated - 11, Feb 2022

The client is admitted to a long term care facility. The nurse in charge is encouraging autonomy in the client. Which activity should the nurse introduce to the client? A. Have the client plan her meals. B. Let the client decorate her room. C. Make the client in charge of setting her appointment with the hair dresser. D. Let the client choose social activities she would like to join. Submit Answer

Explanation Choice D is correct. Choosing social activities in the facility promotes the client's freedom of choice and does not risk her safety. Choice A is incorrect. The client cannot do meal planning on her own and needs the assistance of a nutritionist or dietician. Choice B is incorrect. Having the client decorate her room may pose a risk to both the client and others as the client may arrange things in a way that is conducive to trips and falls. Choice C is incorrect. The client may find it difficult to contact the hairdresser and set an appropriate appointment. Last Updated - 05, Jan 2022

While caring for a child who is six weeks old, the LPN checks their temperature and notes that it is 38.7 degrees C. Which of the following diagnostic tests does she expect the provider will order? Select all that apply. A. Blood culture B. Urine culture C. Echocardiogram D. MRI Submit Answer

Explanation Choices A and B are correct. An infant of 6 six weeks who presents with a fever must be worked up for infectious causes of the heat immediately. Since infants are at an increased risk of developing sepsis from any infectious process, a blood culture should be ordered (Choice A). Since infants are at an increased risk for urinary tract infections, a urine culture should be ordered. The health care provider might also request a urinalysis to look for any signs of infection while the urine culture processes (Choice B). Choice C is incorrect. An echocardiogram is an ultrasound used to assess the function of the heart. This would be used in heart failure, infants with congenital heart disease, or after a cardiothoracic surgical procedure - but it is not indicated in this febrile infant. Choice D is incorrect. MRI, or magnetic resonance imaging, is an advanced radiologic imaging process used for many different reasons. However, for the febrile infant where the infection is the first suspicion, an MRI is not immediately indicated. NCSBN Client Need Topic: Effective, safe care environment, Subtopic: Coordinated care - Pediatrics Last Updated - 03, Aug 2021

The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? Select all that apply. A. Place a small pillow between the client's knees. B. Places the client's arms at their side. C. Fanfold a drawsheet along the backside of the client. D. Instruct the client to laterally flex the neck during the turn. E. Roll the client as one unit in a smooth, continuous motion. Submit Answer

Explanation Choices A, C, and E are correct. These actions are appropriate during the process of log rolling a client. It is appropriate for a client who is to be log rolled to have a pillow placed between the client's knees to prevent tension on the spinal column and adduction of the hip. Fanning out a draw sheet under the client enables staff to have strong handles to grip without slipping. The purpose of log rolling a client is to move the client in one smooth, continuous motion to prevent twisting of the spinal column. Choices B and D are incorrect. To prevent a client from injuring their arms, the client should cross their arms across their chest during the repositioning. Instructing the client to laterally flex the neck would defeat the purpose of log rolling as this causes twisting of the spinal column. Additional Info Logrolling a client is utilized to keep the spinal column in straight alignment to prevent further injury. This turning technique is commonly used for clients with spinal cord injuries or who are recovering from neck, back, or spinal surgery. A minimum of three individuals is necessary to perform log rolling safely. The procedure of logrolling a client: Place a small pillow between the client's knees. Cross the client's arm on their chest. Position two nurses on the side where the client is to be turned and one nurse on the side where pillows are to be placed behind the patient's back. Fanfold drawsheet along the backside of the client. One nurse should grasp the drawsheet at the lower hips and thighs, and the other nurse grasping the drawsheet at the client's shoulders and lower back and roll the client as one unit in a smooth, continuous motion. The nurse on the opposite side of the bed places pillows along length of client for support. Gently lean the client as a unit back toward pillows for support. Last Updated - 09, Jun 2022

The nurse is caring for a client experiencing pain. What barriers would the nurse recognize that the client may have in terms of reporting pain? Select all that apply. A. A feeling that the nursing staff will not answer their call for complaints of pain. B. Not wanting to be viewed as a complainer or drug seeker. C. A cultural bias. D. An ethnic bias. E. Fears about incurring more healthcare costs. Submit Answer

Explanation Choices B, C, D, and E are correct. Barriers that clients may have in terms of them reporting pain to the nursing staff include: Fears revolving around addiction and dependence on pain medications Not wanting to be viewed as a complainer or drug seeker A cultural bias An ethnic bias Fears about incurring more healthcare costs Choice A is incorrect. Although some clients may have a feeling that the nursing staff will not answer their call bell for complaints of pain, this is not a client barrier to them reporting pain to the nursing staff; it is, however, a nursing barrier to effective pain management and control. Additional Info Pain is often not adequately addressed across most healthcare settings. Clients most at risk for inadequate treatment of pain include: Older adults, especially in nursing homes Clients with a history of substance use Clients with a language barrier Unrelieved pain can result in a prolonged stress response, physiological changes (such as increased heart rate, blood pressure, and oxygen demand), reduced GI motility, delayed healing and immune response, and increased risk for chronic pain issues. Clients need nurses to assess and intervene to manage their pain, and nurses should consider factors that may inhibit reporting of pain. Last Updated - 12, Jun 2022

Which procedures necessitate the use of surgical asepsis techniques? Select all that apply. A. Intramuscular medication administration B. Central line intravenous medication administration C. Wearing gloves in the operating room D. Neonatal bathing E. Foley catheter insertion F. Emptying a urinary drainage bag Submit Answer

Explanation Choices B, C, and E are correct. Surgical asepsis is used when managing central line intravenous medication administration, when wearing sterile gloves in the operating room, and when inserting an indwelling Foley catheter. Asepsis is the freedom from disease-causing microorganisms. To decrease the possibility of transferring microbes from one place to another, an aseptic technique is used. The two basic types of asepsis are medical and surgical. Medical asepsis includes all practices intended to confine a specific microorganism to a particular area, limiting the number, growth, and transmission of microorganisms. In medical asepsis, objects are referred to as clean, which means the absence of almost all organisms; or dirty (soiled, contaminated), some of which may be capable of causing infection. Surgical asepsis, or sterile technique, refers to those practices that keep an area or object free of all microorganisms; it includes practices that destroy all microorganisms and spores (microscopic dormant structures formed by some pathogens that are very hardy and often survive common cleaning techniques). Surgical asepsis is used for all procedures involving the sterile areas of the body. Sepsis is the condition in which acute organ dysfunction occurs secondary to infection. Choices A, D, and F are incorrect. Medical asepsis, or clean technique, is used to administer an intramuscular injection, bathing a neonate, and emptying a urinary drainage bag. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control, Types of Asepsis Last Updated - 12, Jan 2022

The nurse is supervising a new graduate place an intravenous catheter. Select all the nursing interventions that have been proven effective in terms of beginning and maintaining intravenous access. Select all the apply. A. Not attempting an intravenous start more than one time B. Using the shortest length catheter as possible C. Using the smallest size catheter as possible D. Reviewing the medical history to determine any previous untoward effects of IV access E. Using the most distal hand veins when possible F. Applying warm compresses to the site for 10 minutes Submit Answer

Explanation Choices B, C, and F are correct. Using the shortest length catheter as possible, using the smallest size catheter as possible, and applying warm compresses to the site for 10 minutes for vasodilation are three effective nursing interventions for beginning and maintaining intravenous therapy. Other effective nursing interventions include: Not attempting to start an intravenous line more than two times. Reviewing the client's medical history to determine if there are any contraindications to a specific IV site, like a history of mastectomy or prior lymph node dissection. To use the most distal veins of the arm, not the hand. Hand veins should be avoided whenever possible to prevent inadvertent nerve damage. Choice A is incorrect. Intravenous attempts can be attempted more than one time. It is preferred to keep the attempts to two or less. Choice D is incorrect. Although the nurse should review the medical history, the purpose of this review is to determine if there are any contraindications to a specific IV site, like a mastectomy. The purpose of this review is not to identify any previous untoward effects of IVs. For example, if the client had an IV site infection or superficial thrombophlebitis with a prior IV site, it is irrelevant to the current IV access. Choice E is incorrect. It is not appropriate to use the most distal hand veins. Distal hand veins should be avoided whenever possible to prevent inadvertent nerve damage. Last Updated - 25, Oct 2021

The nurse places a patient with hypovolemia in the position depicted in the Exhibit. Which of the following positions does it represent? A. The prone position. B. The supine position. C. The Trendelenburg position. D. The Sims' position.

Explanation Correct Answer is C. This picture shows the Trendelenburg position. In this position, the body is laid supine or flat on the back on a 15-30 degree incline with the feet elevated above the head. This position increases the venous blood return to the heart when a client is affected by hypotension, hypovolemia, or shock. It is also used to improve the effects of spinal anesthesia and also to prevent air embolism during central venous cannulation. Choice A is incorrect. The prone position is when a patient is placed in a horizontal position with the face oriented down. A prone position is often used during surgical procedures, especially for those needing access to the spine and the back. It is also used to increase oxygenation in patients with respiratory distress. A Prone position is depicted in the image below: Choice B is incorrect. The supine position is when a patient is placed in a horizontal position with the face oriented up. A supine position is often used during surgical procedures, especially for those needing access to the thoracic area/ cavity. A Supine position is depicted in the image below: Choice D is incorrect. A Sim's position is when a patient lies on his/her left side, left hip and lower extremity straight, and right hip and knee bent. It is also called a lateral recumbent position. Sim's status is usually used for rectal exams, treatments, and enemas. A Sims position is shown below: Additional Info Fowler's position is another position an RN needs to be aware of since it has many implications during nursing care. This is when a patient is seated in a "semi-sitting" position when the head of the bed is elevated at a 45 to 60 degrees angle. There are variations in Fowler position: Low ( 15-30 degrees), Semi-Fowler (30-45 degrees), Standard (45-60 degrees), and High Fowler's (60-90 degrees). Fowler's position is depicted in the image below: Fowler has been used as a way to help with peritonitis. Fowler's can be used:- To promote oxygenation during respiratory distress because it allows maximum chest expansion and relaxation of abdominal muscles. E.g., infants with respiratory distress. To increase comfort during eating and other activities. To improve uterine drainage in post-partum women. To minimize the risk of aspiration in patients with oral or nasal gastric feeding tubes. Fowler's position aids Peristalsis and swallowing by the effect of gravitational pull.

The nurse observes a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Which of the following should the nurse assess in the patient? A. Pain B. Anxiety C. Depression D. Fluid volume deficit

Explanation Choice A is correct. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior. The transmission of information without the use of words is termed nonverbal communication. It is also known as body language. Nonverbal communication helps nurses to understand subtle and hidden meanings in what a patient is trying to say verbally. Additionally, nonverbal communication is reflected in a person's actions, such as the way he/she walks or uses facial expressions. Nurses must be aware of nonverbal messages that they send and the ones they receive from patients so they can identify patients who are suffering from or at risk of certain conditions. Choices B, C, and D are incorrect. The nonverbal expressions of stooped gait and gasping sounds do not indicate anxiety, depression, or fluid-volume deficit. Nonverbal signs associated with generalized anxiety (Choice B) disorder include tenseness, difficulty sleeping, and stomach problems. Nonverbal expression of depression (Choice C) may include head and lips in the downwards expression, adaptive hand gestures, social withdrawal, frowning, crying, and decreased levels of eye contact and smiling. Nonverbal expression of fluid-deficit (Choice D) may include slowed responses and agitation. Last Updated - 20, Sep 2021

You have an adult client who has abnormally heightened responses to minor pain like the pain from sitting on a bedpan or a small skin tear. What would you suspect that this client is affected by? A. Hyperpathia B. Drug seeking behavior C. Equianalgesia D. Dysesthesia Submit Answer

Explanation Choice A is correct. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is most likely affected with hyperpathia. Hyperpathia is synonymous with hyperalgesia and is defined as the abnormal pain processing that can lead to the appearance of neuropathic pain. Choice B is incorrect. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is most likely affected with a disorder other than drug-seeking behavior. Choice C is incorrect. Equianalgesia is the mathematically calculated relationship between different opioid medications and parenteral morphine. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is not affected with equianalgesia. Choice D is incorrect. Dysesthesia is a cutaneous symptom; i.e. pruritis, burning, stinging, tickling, crawling, cold sensation, tingling, etc. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is not affected with dysesthesia. Last Updated - 10, Feb 2022

The nurse is preparing ephedrine nasal spray for a client in the medical ward. The nurse understands that ephedrine is contraindicated in which of the following patients? A. A client with pheochromocytoma B. A client with bronchial asthma C. A client with allergic rhinitis D. A client with hypotension due to sepsis Submit Answer

Explanation Choice A is correct. A pheochromocytoma is a small vascular tumor of the adrenal medulla, causing irregular secretion of epinephrine and norepinephrine. Clinical manifestations of pheochromocytoma include paroxysmal hypertension, episodic headache, sweating, and palpitations. Ephedrine is an adrenergic agonist and is often, used as a nasal decongestant. It is also used to prevent low blood pressure during spinal anesthesia. In pheochromocytoma, there is a systemic overload of catecholamines. Ephedrine is contraindicated in clients with pheochromocytoma because it may lead to further exacerbation of adrenergic activity which could be fatal. Choice B is incorrect. Ephedrine is indicated in bronchial asthma as it stimulates the dilation of the bronchial muscles by activating the beta receptors found in the bronchus. Choice C is incorrect. Ephedrine is used in allergic rhinitis because it may serve as a nasal decongestant due to its vasoconstrictive effects. Choice D is incorrect. Adrenergic agonists such as ephedrine are used in hypotension due to their sympathomimetic effects on the body leading to increased blood pressure. Ephedrine is often used to prevent low blood pressure during spinal anesthesia. Last Updated - 10, Feb 2022

The nurse is caring for a client who is a Native American. Which of the following actions would be necessary for the nurse to take? A. Avoid excessive direct eye contact. B. Ensure that the nurse is of the same gender. C. Refer healthcare decisions to the male. D. Allow time for meditation to a shrine of Buddha.

Explanation Choice A is correct. Caring for a client who is Native American requires the nurse to be culturally competent and sensitive. One of the cultural norms is avoiding direct eye contact, as excessive eye contact may be seen as disrespectful. Choices B, C, and D are incorrect. Cultural norms for Native Americans do not require the nurse to be the same gender as the client. A patriarchal family structure is consistent with the Amish culture - not Native American. Healthcare decisions are made independently. Allowing time for meditation in a shrine of Buddha is a religious practice for Buddhism. Additional Info When caring for a client who is Native American, the nurse should practice cultural competence and sensitivity. Cultural norms for Native Americans include utilizing silence as a sign of respect, avoiding direct eye contact, and providing ample personal space. As stated previously, this is a cultural norm and the client's individual preferences should be respected during care. Last Updated - 29, Jan 2022

A nurse is precepting a new graduate nurse. They are working with a client with numerous family members at the bedside. Once they exit the room, the nurse asks the new graduate nurse to define "family." The new graduate nurse is correct when they state: A. "A family is a group of people who care about each other and work together to accomplish common goals or overcome hurdles." B. "A family includes a man and a woman who are married and the children they have together." C. "In order to be considered family, you have to be related through blood, marriage, or adoption." D. "Although there may be extended family elsewhere, the people who live in someone's house are their family members." Submit Answer

Explanation Choice A is correct. Families consist of groups of emotionally connected individuals who function as a unit. Choice B is incorrect. A family consisting of a man, woman, and any children they may have together is known as a nuclear family. Choice C is incorrect. While some benefits require relation through marriage, blood connection, or adoption (i.e., health insurance benefits, tax credits, etc.), these requirements are not mandated to be considered as one's family member. Choice D is incorrect. Although one may reside with members of their immediate family, an individual may also choose to reside alone, with a pet, with a roommate, with a friend, or with a romantic partner. The physical proximity in which one lives with another individual does not affect whether that person is considered family. Learning Objective Recognize that a family consists of emotionally connected individuals who function as a unit. Additional Info A family unit is what an individual considers the family to be. As a nurse, encourage clients to verbalize their thoughts regarding their support system. Each family is as diverse as the individuals who comprise them. Unique cultural and ethnic influences often influence the family unit. No two families are alike; each has individual strengths, weaknesses, resources, and challenges. The concept of family is highly individualized and consistently evolving. Never release healthcare information to an individual simply because they are the client's "family member" or "relative." Always verify the individual's identity and check the client's signed Health Insurance Portability and Accountability Act (HIPAA) form to ensure the client has authorized the individual to receive the healthcare information.

While scheduling a client for thoracentesis, the nurse understands which of the following is the most preferred position for the procedure? A. Sitting up, leaning over a bedside table, and feet supported on the ground or stool. B. The head of the bed flat with the patient lying on the unaffected side. C. Prone position with both arms extended above the head. D. The head of the bed elevated 45 degrees, and the patient lying on the affected side

Explanation Choice A is correct. The patient should be sitting up, leaning over a bedside table with arms rested, feet supported on the ground, or stool so the needle can be inserted appropriately. Usually, only sufficient fluid to lubricate the pleura is present in the pleural cavity. However, excessive fluid can accumulate as a result of injury, infection, or other pathology. In such a case of pleural effusion or pneumothorax, the physician may perform a thoracentesis to remove the excess fluid or air to ease breathing. Thoracentesis is also used to introduce chemotherapeutic drugs intrapleurally. The nurse assists the client in assuming a position that allows easy access to the intercostal spaces. Two different client-positioning options are used for the thoracentesis procedure. An upright position is the most preferred approach and it allows access to the posterior approach to thoracentesis. In patients unable to sit up, the supine position is preferred. The preferred upright position is usually a sitting position with the arms above the head, which spreads the ribs and enlarges the intercostal space. The client leans slightly forward resting the head over the pillow. To ensure that the needle is inserted below the fluid level when fluid is removed (or above any liquid if the air is to be removed), the physician will palpate and percuss the chest and select the specific site for insertion of the needle. A place on the lower posterior chest is often used to remove fluid and a section on the upper anterior chest is used to remove air. A chest x-ray before the procedure helps to identify the best insertion site. In an anteroposterior view of chest x-ray, pleural effusions become visible as blunting of the lateral costophrenic angle at a volume of 150-200 mL. On a lateral view of chest x-ray, even 50 mL of fluid may be directed as blunting the posterior costophrenic angle. Choice B is incorrect. The supine position is used for thoracentesis only in patients unable to sit up (e.g. patient on a ventilator). This position is similar to the one used for chest tube placement. The patient lies in a lateral position on his unaffected side, so the side to be drained (affected) is on the top. The head of the bed should be elevated to about 45 degrees (Fowler's position) to allow the pleural fluid to move inferiorly and accumulate closer to the location of the needle placement. An ultrasound is often used to localize pleural fluid in this position. Choice C is incorrect. The prone position is commonly used for several surgical procedures such as spinal surgeries and lumbar puncture, not thoracentesis. A prone position allows good access to the spinal column but will not allow easy access to intercostal space and pleural fluid. Choice D is incorrect. Thoracentesis can not be performed with the patient lying on the affected side. A lateral recumbent position with the head of the bed raised to 45 degrees may be used for those patients that can not sit up for thoracentesis, but the patient should be lying on the unaffected side. Learning objective: While two different positions are used for thoracentesis, the most preferred one is the upright position with the patient sitting up and leaning forward. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Basic Care and Comfort Additional Info Last Updated - 08, Feb 2022

The nurse is caring for assigned clients with newly received prescriptions. Which prescription should the nurse administer first? See the exhibit. A. Levofloxacin 750 mg IVPB Q12 hours B. 0.9% Saline 125 ml/hr C. Metoclopramide 10 mg IV Push Q8 hours D. Ketorolac 15 mg IV Push Q8 hours

Explanation Choice A is correct. Levofloxacin should be promptly administered for this client with pneumonia. Critical pathways call for prompt initiation of antibiotics for pneumonia as the condition may worsen to acute respiratory distress syndrome (ARDS) and/or sepsis. The diagnosis of pneumonia is also prioritized as it is a breathing impediment and requires prompt follow-up. Choices B, C, and D are incorrect. Gastroenteritis consists of symptoms such as nausea, vomiting, diarrhea, and fever. All of which leads to dehydration. While this is important to initiate fluid repletion, this is a circulation issue that does not prioritize antibiotic administration for pneumonia. Metoclopramide is commonly used in DKA because of its amelioration on gastroparesis. This does not prioritize the respiratory need of the client with pneumonia. Urolithiasis requires prompt pain control with anti-inflammatories such as ketorolac. This medication helps with the urinary colic that the client experiences. Additional Info Prompt initiation of antibiotics for CAP is essential to ensure positive patient outcomes. Other medications that may be used in the management of community-acquired pneumonia (CAP) include bronchodilators and fluids. The nurse should encourage coughing and deep breathing. Incentive spirometry may be utilized as well. Last Updated - 11, Feb 2022

When planning care for a patient in the post-anesthesia care unit, the nurse should first assess the client's: A. Respiratory status B. Level of consciousness C. Level of pain D. Ability to move the extremities

Explanation Choice A is correct. Respiratory status should always be given priority in any assessment. Care in the PACU involves assessing the postoperative patient, with emphasis on preventing complications from anesthesia and the surgery. Assessments are continuous, using preoperative and intraoperative data as bases for comparison. The estimates made in the PACU include respiratory status (airway, pulse oximetry), cardiovascular status (blood pressure), temperature, central nervous system status (level of alertness, movement, shivering), fluid status, wound status, GI status (nausea and vomiting), and general condition. These assessments are initially made every 10 to 15 minutes. Choices B, C, and D are incorrect. Although all of these answer options are issues that should be addressed, the nurse's priority is that of stable respiratory status. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential - Immediate Postoperative Assessment and Care Last Updated - 16, Nov 2021

The RN performs palpation and percussion in a head-to-toe assessment. Over what organ would he/she expect to hear tympany when percussed? A. Stomach B. Liver C. Normal lung tissue D. Tympany is an abnormal finding Submit Answer

Explanation Choice A is correct. Tympany refers to a high, loud, drum-like tone that can be heard with percussion over air-containing organs. The stomach and intestines would produce tympany in a healthy adult. Choice B is incorrect. Dense organs such as the liver and the spleen produce "dull" tones upon percussion. Dull tones are soft, short, and high; they sound like a muffled thud. Choice C is incorrect. Percussion of healthy lung tissue produces a "resonant" sound that is medium to loud, low, clear, and hollow sounding. Choice D is incorrect. Tympany is a normal finding over organs with air inside. NCSBN Client Need Topic: Pathophysiology, Subtopic: Skills/procedures Last Updated - 10, Jan 2022

The nurse is observing a newly hired nurse insert a nasogastric tube (NGT). Which action by the newly hired nurse requires follow-up? A. Advances the tube during the client's inspiration. B. Hands the client a cup of water and straw. C. Positions the client's head-of-bed at 90 degrees. D. Washes the client's bridge of nose with soap and water. Submit Answer

Explanation Choice A is correct. This observation requires follow-up because it will likely enter the respiratory tract if the nasogastric tube ( NGT) is advanced as the client takes a breath. The preferred method is gently advancing the NGT each time the client swallows until the desired length is reached. One can feel the characteristic tug on the tube as the epiglottis closes during swallowing. During the advancement of the tube, if the client begins coughing or becomes cyanotic, the nurse should pull the tube back until the client breathes normally again. Cyanosis and severe coughing during tube insertion can indicate accidental positioning of the tube in the respiratory tract ( trachea and bronchi). Choices B, C, and D are incorrect. These actions are appropriate and do not require follow-up. A cup of water and straw are supply items utilized to insert an NGT. The client is instructed to take short sips of water and swallow during the tube insertion. This facilitates the passage of the tube. The head-of-bed ( HOB) should be positioned at 90 degrees with the pillow behind the shoulders to allow neck flexion and extension. Washing the bridge of the nose with soap and water (or alcohol) is recommended because this removes skin oils and promotes adherence to the tape to the nose. Additional Info A nasogastric tube (NGT) should be measured from the tip of the nose to the earlobe to the xiphoid process of the sternum. Once this is established, a small piece of tape should be placed around the tube. An NGT is used to decompress the stomach, feed a client, administer medications, and irrigate the stomach. Last Updated - 30, May 2022

A 90-year-old woman has been bedridden at home for two weeks. Which of the following is not an expected finding due to immobility? A. A decrease in bone density B. Loss of short-term memory C. Atelectasis D. High serum calcium level

Explanation Choice B is correct. Loss of short-term memory is not an expected complication of prolonged immobility and warrants further assessment. Short-term memory loss may indicate medication effects, Alzheimer's dementia, or Lewy body dementia, etc. Choices A, C, and D are incorrect. Decreased bone density (osteoporosis), atelectasis, and hypercalcemia are all expected due to prolonged immobility. Risk factors related to mobility can affect every organ system. The musculoskeletal system can experience contractures, joint ankylosis, and depletion of necessary minerals/loss of bone density. Hypercalcemia (Choice D) may occur with prolonged immobility. Prolonged immobilization deranges bone remodeling because of the lack of mechanical stress. This causes an imbalance between bone formation and bone resorption where resorption exceeds formation. Consequently, there is a net efflux of calcium from the bone. Respiratory complications such as atelectasis (Choice C) and pneumonia may occur. Gastrointestinal manifestations (constipation) may occur due to decreased peristalsis. Immobile individuals are also more prone to orthostatic hypotension, decreased metabolism, and skin breakdown/decubitus ulceration. Last Updated - 06, Nov 2021

The nurse is caring for a client admitted to the acute care facility. The nurse takes a phone call from the client's neighbor who wants to know where the client is located. The nurse should A. inform the individual that this information cannot be released. B. provide the caller with the client's current location. C. not acknowledge the presence of this individual. D. inquire with the caller as to the reasoning for the information. Submit Answer

Explanation Choice B is correct. HIPAA allows directory information (client name, location in the facility, health condition expressed in general terms that do not communicate specific medical information about the individual, and religious affiliation) to be communicated. However, the client may also decide against sharing this information in the directory. If that is the case, the nurse should not acknowledge that an individual by this name is currently in the facility. The item provided does not state that the client has decided against being in the directory. No additional consent is required to share this directory information. Directory information can be released to any caller unless the client requests not to. For more information regarding this HIPAA provision, refer to the HHS website. Choices A, C, and D are incorrect. Directory information may be released, and stating that it cannot be divulged would be inappropriate. Unless the client has asked to be removed from the directory, the nurse is permitted to a state where the client is located, the health condition in general terms, and their religious affiliation. Not acknowledging the presence of this client would only be appropriate if the client wanted to be removed from the hospital directory. The nurse would simply state, "I do not have a client by that name." The nurse does not need to inquire about the reasoning for the caller's inquiry - that would be inappropriate. Additional Info HIPAA allows directory information (client name, location in the facility, health condition expressed in general terms that do not communicate specific medical information about the individual, and religious affiliation) to be communicated. The client must be informed about the information to be included in the directory and to whom the information may be released, and must have the opportunity to restrict the information or to whom it is disclosed, or opt-out of being included in the directory. The client may be informed and make their preferences known, orally or in writing. Reference: HHS Last Updated - 27, Apr 2022

A client is prescribed bed rest by the physician after surgery. The nurse that takes care of the patient always avoids putting pressure on the back of the client's knees. This is done in order to prevent which complication? A. Cerebral embolism B. Pulmonary embolism C. Limb gangrene D. Coronary vessel occlusion

Explanation Choice B is correct. Once a thrombus is dislodged and travels through the circulatory system, the pulmonary capillary beds are the first small vessels that the embolus will encounter, resulting in pulmonary embolism. Choice A is incorrect. Once a thrombus is dislodged and travels through the circulatory system, the pulmonary capillary beds are the first small vessels that the embolus will encounter, not the cerebral blood vessels. Choice C is incorrect. Gangrene occurs when the blood supply to the affected limb is compromised. Putting pressure on the back of the client's knees, like a pillow, does not impair circulation. Choice D is incorrect. Once a thrombus is dislodged and travels through the circulatory system, the pulmonary capillary beds are the first small vessels that the embolus will encounter, not the coronary blood vessels. Last Updated - 01, Feb 2022

The nurse is caring for a patient in the emergency department who has just received a head injury following a car accident. After a hyphema has been noted, which position should the nurse encourage this patient to be in? A. Supine B. Semi-Fowler's C. Lateral on the affected side D. Lateral on the unaffected side Submit Answer

Explanation Choice B is correct. Semi Fowler's position is the most appropriate position after a hyphema, or blood in the anterior chamber has been diagnosed. This position works with gravity to keep blood accumulation away from the optical center of the cornea. Choice A is incorrect. Supine, or lying facing upwards, is not the best position to place a patient who is experiencing hyphema after a car accident. This position could cause blood to accumulate near the optical center of the cornea. Choice C is incorrect. Lateral-lying, whether on the affected or unaffected side, does not keep blood from collecting near the optical center of the cornea. Choice D is incorrect. Lateral-lying, whether on the affected or unaffected side, does not keep blood from collecting near the optical center of the cornea. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential Last Updated - 15, Nov 2022

You are administering scheduled amoxicillin to your 12-year-old patient in the PICU. The order reads 750 mg/day in 3 divided doses. The tablets are each 125 mg. How many tablets do you give to your patient for their morning dose? A. 1 B. 2 C. 3 D. 4

Explanation Choice B is correct. The first thing you need to do in this calculation is to find how many milligrams to administer with each dose. So, 750 mg divided by three daily doses is 250 mg per dose. Next, you need to calculate how many tablets will deliver the correct dose of 250 mg. The formula for calculating the correct medication dose is: the desired medication divided by the medication you have timed the vehicle the medication comes in. (D/H) x V. In this case, your desired dose is 250 mg, so D = 250. The dose that you have is 125 mg, so H = 125. The vehicle that the medication comes in is one tablet, V = 1. Therefore: (250 mg/125 mg) x 1 mL = 2 tablets. You will administer two tablets of amoxicillin to your patient for a total of 250 mg. Choice A is incorrect. You need to administer 250 mg of amoxicillin to your patient. One tablet is 125 mg. This is not the correct dose. Choice C is incorrect. You need to administer 250 mg of amoxicillin to your patient. Three tablets is 375 mg. This is not the correct dose. Choice D is incorrect. You need to administer 250 mg of amoxicillin to your patient. Four tablets is 500 mg. This is not the correct dose. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological Therapies, Medication Administration Last Updated - 15, Jan 2022

While working in the PICU, you are checking the drip rates of your vasoactive infusions. Your patient is ordered to have epinephrine running at 0.03 mcg/kg/min. Their weight is 10 kg. The concentration of the epinephrine bag is 20 mcg to 1 mL. What rate should the pump be set to? A. 0.99 mL/hr B. 0.9 mL/hr C. 0.09 mL/hr D. 9 mL/hr Submit Answer

Explanation Choice B is correct. The formula for calculating the rate of vasoactive infusion is dose x weight x minutes, then divided by the concentration of the drug. In this case, the epinephrine is ordered at 0.03 mcg/kg/min. So the calculation is 0.03 mcg x 10 kg x 60 minutes = 18 mcg/hr. Then divide by the concentration to get the final rate: (18mcg/hr)/20mcg/1mL = 0.9mL/hr. This is the rate the pump should be set to. Choice A is incorrect. This rate is too fast and will deliver too much epinephrine to your patient. Choice C is incorrect. This rate is too slow and will not deliver enough epinephrine to your patient. Choice D is incorrect. This rate is too fast and will deliver too much epinephrine to your patient. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological Therapies, Medication Administration Last Updated - 02, Feb 2022

The nurse is taking care of a client with a chest tube due to a flail chest. After 3 days, the water seal compartment is no longer tidaling. What is the most appropriate action of the nurse? A. Assess the tubing for any dependent loops B. Auscultate the client's back for breath sounds C. Prepare to remove the chest tube D. Notify the physician that the lungs have re-expanded Submit Answer

Explanation Choice B is correct. The nurse should check the client's lungs for re-expansion once the water-seal drainage has stopped tidaling. Tidaling refers to fluctuations in the water-seal chamber with respiration. With the chest tube in pleural space, the water level in the chamber fluctuates - water level rises during spontaneous inspiration and falls during expiration. Absence of tidaling indicates: A potential kink or occlusion in the tubing Re-expansion of the client's lung. If the lung has re-expanded, auscultation can help detect it. The nurse should begin with assessing the client's lung. Choice A is incorrect. The nurse should expect that the lungs have re-expanded after a chest tube has been inserted. Dependent loops do not cause the water-seal compartment to stop tidaling. However, an occlusion in the tubing or air leak may cause the tidaling to stop. Choice C is incorrect. Once it is confirmed that the lungs have re-expanded, the nurse may go ahead and prepare to remove the chest tube. However, in this case, it is still not confirmed if the lungs have re-expanded or not. Choice D is incorrect. The nurse should inform the physician once she determines that the lungs have re-expanded. A chest x-ray is then taken to confirm re-expansion. Learning Objective Understand that "tidaling" is an expected phenomenon noted in the water seal chamber and recognize the factors that cause absence of tidaling. Additional Info Last Updated - 12, Feb 2022

Which phase of the nursing process is most foundational for delivery of care? A. Evaluation B. Assessment C. Planning D. Diagnosis Submit Answer

Explanation Choice B is correct. This assessment determines which diagnoses will be the focus of care, the interventions that will be initiated, and those that will be reevaluated. In this way, the assessments drive care, whereas the reassessments loop back into the further assessments and revision of care planning. Choices A, C, and D are incorrect. All aspects of the nursing process are essential. However, without proper assessment, the other steps in the process are ineffective. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; The Nursing Process Last Updated - 13, Jan 2022

Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, "I do not want to become a druggie." How would you respond to this client's comment? A. "That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse." B. "The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse." C. "A lot of people prefer to be brave and stick it out so you are not alone." D. "You have a right to refuse any and all treatments, so just do without it."

Explanation Choice B is correct. You would respond to the client's statement of "I do not want to become a druggie" with "The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse" when your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. Responding in this manner allows you to educate the client about a misconception related to pain management in terms of fears of addiction because only a small number, approximately 5% of people, without a prior history of substance abuse that take narcotic analgesics for pain become addicted to them. This response also educates the client about some of the possible complications of unrelieved pain, such as immobility, atelectasis, and infections. Choice A is incorrect. This is an inappropriate response because it is NOT therapeutic, and it is also false. Approximately 5% of people without a prior history of substance abuse that take narcotic analgesics for pain become addicted to them. Choice C is incorrect. This is an inappropriate response because you have failed to educate the client about their fears of addiction by telling them that only approximately 5% of people without a prior history of substance abuse that take narcotic analgesics for pain become addicted to them. Choice D is incorrect. This is an inappropriate response because you have failed to educate the client about their fears of addiction by telling them that only approximately 5% of people without a prior history of substance abuse that take narcotic analgesics for pain become addicted to them. Last Updated - 12, Nov 2021

A nurse is caring for a client who sustained a level T4 spinal cord injury. As the nurse enters the client's room, the physical therapist exits after completing the client's daily session. Which of the following statements, if spoken by the client, would indicate a need for an additional review of basic transfer techniques? A. "I should maintain an ideal body weight." B. "I should lead with the same arm and go the same direction when transferring if possible." C. "Transferring downhill is easier and safer than when transferring uphill." D. "To protect my shoulders, I will keep my arms close to my body when I lift myself."

Explanation Choice B is incorrect. If spoken by the client, this statement indicates the need for additional review of basic transfer techniques, as the statement expressed by the client is incorrect. Following this statement by the client, the client should be instructed to alternate leading arms and the direction of the transfers, as this will keep the muscles in the bilaterally upper extremities balanced while reducing the likelihood of muscle strains on each individual side. Choice A is correct. The client is correct in stating that they should maintain an ideal body weight. The more the client weighs, the more weight the client will need to transfer, resulting in increased stress placed on the client's shoulders and arms. Choice C is correct. Based on physics, transferring downhill is easier and (when performed at a modest height) safer than transferring uphill. Choice D is correct. In order to protect their shoulders, the client should be instructed to keep their arms as close to their body as possible (i.e., approximately 30-45 degrees away from their body) while lifting their body weight. Learning Objective Identify the statement regarding leading with the same arm and in the same direction when transferring as the paraplegic client's incorrect statement which demonstrates a need for additional education. Additional Info Often regarded as the best long-term treatment option, rehabilitation is typically provided through a team approach, combining physical therapies, skill-building activities, and counseling to meet social and emotional needs. Physical therapy focuses on exercises for muscle strengthening, passive stretch exercises to prevent contractures, and appropriate use of assistive devices such as braces, a walker, or a wheelchair which may be needed to improve mobility. Last Updated - 15, Nov 2022

Which question would you ask to assess the family as the basic unit of society when applying the systems theory of family? A. Tell me about the traditions that your family has and practices. B. What form of discipline is used in the home? C. Tell me about your involvement in school activities with your children. D. Are you able to share home responsibilities with your spouse?

Explanation Choice C is correct. Asking the family about their involvement in school activities with their children is an example of applying the systems theory to the family and its interactions with and exchanges with others outside of the boundaries of the family. Choice A is incorrect. "Tell me about the traditions that your family has and practices" assesses intrafamily dynamics and functioning, not its interactions with the environment outside of the boundaries of the family. This is an assessment question that applies a structural-functional theory of family, not a systems approach. Choice B is incorrect. "What form of discipline is used in the home?" assesses intrafamily dynamics and functioning, not its interactions with the environment outside of the boundaries of the family. This is an assessment question that applies a structural-functional theory of family, not a systems approach. Choice D is incorrect. Asking "Are you able to share home responsibilities with your spouse?" assesses intrafamily dynamics and functioning, not its interactions with the environment outside of the boundaries of the family. This is an assessment question that applies a structural-functional theory of family, not a systems approach. Last Updated - 31, Oct 2021

The nurse cares for a client and is notified by the laboratory department of a critical sodium level of 122 mEq/L. The nurse should take which initial action? A. Notify the primary healthcare provider B. Implement seizure precautions C. Read back the result for verification D. Recollect the laboratory specimen Submit Answer

Explanation Choice C is correct. Before the nurse should execute any action, the nurse should read back the result to ensure effective and safe communication. It is essential that this process is not skipped to avoid client identification errors. Choices A, B, and D are incorrect. All of these actions are plausible for a client with severe hyponatremia as this may induce seizure activity. Recollecting the specimen may be necessary if the results are not clinically congruent or if contamination is suspected. Additional Info When critical results are obtained, the nurse should clarify the results by reading back the result. This protects client safety by ensuring that the result is linked with accurate client identification. Last Updated - 08, Nov 2022

The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client A. exercises both extremities simultaneously. B. knows their heart rate should be monitored while exercising. C. practices forced resistance against stable objects. D. swings their limbs through the full range of motion. Submit Answer

Explanation Choice C is correct. Isometric exercises involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall. Choices A, B, and D are incorrect. Isometric exercises do not include simultaneous exercising of both extremities. Since isometric exercises are not classified as aerobic exercises, the client's heart rate is typically not monitored while performing isometric exercises. Each isometric exercise is performed in one position without movement to maintain strength in a specific group of the client's muscles. Therefore, a client performing isometric exercises would not be swinging their limbs in their full range of motion. Learning Objective Identify a client practicing forced resistance against stable objects as a sign the client fully understands the proper technique of isometric exercise techniques. Additional Info ✓ Isometric exercise increases muscle tension or work but does not shorten or actively move a muscle(s). ✓ This type of exercise is ideal for clients who do not tolerate increased activity, such as immobilization in bed. ✓ Examples of resistive isometric exercises are push-ups and hip lifting. ✓ The benefits of isometric exercise include increased muscle mass, tone, and strength, thus decreasing the potential for muscle wasting, increasing circulation to the involved body part(s), and increasing osteoblastic activity. Last Updated - 02, Jan 2023

The nurse supervises a student nurse prepare a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student A. asks the client if they have claustrophobia. B. instructs the client to apply earplugs before the exam. C. moves the nitroglycerin patch from the torso to the back. D. tells the client that they will not have any exposure to radiation.

Explanation Choice C is correct. Nitroglycerin transdermal patches should be temporarily removed during the procedure because they may burn the client. The transdermal patch may contain aluminum which is contraindicated for an MRI. Moving the patch would not be helpful as it should be totally removed during the procedure. Choices A, B, and D are incorrect. An MRI questionnaire is always completed before this exam to ensure client safety. MRI units can produce sounds up to 120 decibels, resulting in hearing damage. MRIs do not use radiation; this imaging exam uses magnets to create 3D cross-sectional images of the body. Additional Info An MRI is a unique imaging exam that uses magnets (not radiation) to assist clinicians in diagnostic imaging. MRI is most suited to image soft tissue structures in the body with a high water content to utilize the protons in water molecules. The brain and spinal cord are often evaluated using MRI. MRI can differentiate between gray and white matter and blood vessels. Nursing care for a client scheduled for an MRI includes - Completing a comprehensive MRI screening form that is submitted before the exam. MRIs are safe during pregnancy because it does not use radiation. MRIs may be ordered with contrast. The contrast agent of choice is gadolinium-based. The MRI may become unsafe for a pregnant client if this contrast is necessary. MRI safety includes having the client wear ear protective device(s) as this test is extremely loud. A good resource is http://www.mrisafety.com/TMDL_list.php, as this is a searchable database for objects that may (or may not) be safe. Last Updated - 27, Nov 2022

Medications bound to protein have the following effect: A. Enhancement of drug availability. B. Rapid distribution of the drug to receptor sites. C. The more the drug is bound to protein, the less it is available for the desired effect. D. Increased metabolism of the drug by the liver. Submit Answer

Explanation Choice C is correct. Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect. Plasma protein binding refers to the degree to which medications attach to proteins within the blood. A drug's efficiency may be affected by the degree to which it binds. The less bound a drug is, the more efficiently it can traverse cell membranes or diffuse. A drug in blood exists in two forms: bound and unbound. Depending on a specific drug's affinity for plasma protein, a proportion of the drug may become attached to plasma proteins, with the remainder being unbound. Only the unbound fraction of the drug undergoes metabolism in the liver and other tissues. As the drug dissociates from the protein, more and more drug undergoes metabolism. Changes in the levels of the free drug change the volume of distribution because the free drug may distribute into the tissues leading to a decrease in plasma concentration profile. For the medicines which rapidly undergo metabolism, clearance is dependent on hepatic blood flow. For drugs that slowly undergo metabolism, changes in the unbound fraction of the drug directly change the approval of the drug. Choice A is incorrect. Less of the drug is available if it is bound to protein. Choice B is incorrect. Distribution to receptor sites is irrelevant since the drug bound to protein cannot unite with a receptor site. Choice D is incorrect. Metabolism would not be increased. The liver will first have to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Pharmacological Therapies, What Happens After a Drug Has Been Administered, Drug Metabolism Last Updated - 30, Sep 2021

The nurse is teaching a client about newly prescribed tamsulosin. Which of the following statements should the nurse include? A. "This medication may turn your urine reddish/orange." B. "You will urinate more often with this medication." C. "Change positions slowly while you take this medication." D. "Avoid calcium-containing foods while on this medication." Submit Answer

Explanation Choice C is correct. Tamsulosin is an alpha-1 antagonist medication indicated in the treatment of benign prostatic hypertrophy. This medication causes vasodilation, and the biggest side effect is orthostatic hypotension. The nurse should educate the client to change positions slowly while taking this medication to reduce the risk of orthostasis. Choices A, B, and D are incorrect. Tamsulosin does not cause urine to change colors. This effect is more consistent with rifampin or phenazopyridine. The client will not urinate more often with this medication as it is not a diuretic. Rather, the client should urinate less often because of the ability for him to empty his bladder. Calcium-containing foods do not need to be avoided while a client takes this medication. Additional Info Tamsulosin is an alpha-1 antagonist which induces vasodilation. This allows smooth muscle to relax, therefore improving urine flow and decreasing the symptoms of BPH. Orthostatic hypotension is the most common effect associated with this medication.

The nurse detects an elevated temperature in a patient who is scheduled for surgery. The patient has been afebrile and has no other symptoms of fever. What should be the first nursing action? A. Inform the charge nurse B. Inform the surgeon C. Validate the finding D. Document the finding

Explanation Choice C is correct. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Choices A and B are incorrect. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. Choice D is incorrect. The nurse should be sure that all data recorded is accurate. Thus the data should be validated before documentation if there are any doubts about the accuracy. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Validating Findings Last Updated - 23, Dec 2021

The nurse is caring for a patient who is recovering from open-heart surgery. For the first 24 hours following the surgery, there is a noticeable pinkish fluid oozing from the incision site. Which phase of the inflammatory response does this represent? A. Vascular response B. Cellular response C. Exudate formation D. Healing Submit Answer

Explanation Choice C is correct. The fluid and white blood cells that leak from blood vessels in response to an injury/inflammation are exudates. Exudates are present in the wounds as they heal. The nature and quantity of exudates depend on the severity of the damage and the tissues involved. For example, a surgical incision may ooze clear or pinkish (serous or serosanguinous) exudate for a day or two. If an exudate becomes purulent (thick, tan, green, or yellow), it is not normal and may suggest infection. In such cases, the nurse should immediately notify the health care provider. Choice A is incorrect. The vascular response of the inflammatory process involves constriction of blood vessels at the injury site immediately after the injury to control bleeding, followed by dilation, increased blood flow to the area (hyperemia), and swelling (edema). Choice B is incorrect. The cellular response of the inflammatory process involves specialized white blood cells (phagocytes) migrating to the site of injury and engulfing bacteria, other foreign material, damaged cells, to ultimately destroy them. The cellular response must occur before the formation of exudate. Choice D is incorrect. Healing is the replacement of tissue by regeneration or repair. Recovery is the replacement of the damaged cells with identical or similar cells. Most injuries heal by repair, wherein scar tissue replaces the original tissue. This is the last phase of the inflammatory response. Learning objective: The inflammatory response is a local reaction to cell injury. Regardless of the stressor, the mechanisms are the same. The inflammatory process includes a vascular response, cellular response, formation of exudate, and healing. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological Adaptation Last Updated - 21, Sep 2021

A 30-year old female on a cardiac unit states to the nurse, "I'm just not sure my incision is ever going to look right. I don't want to look like a freak." What should the nurse say to comfort her? A. "It will heal fine." B. "Why are you worrying?" C. "What do you think you will look like?" D. "Tell me more."

Explanation Choice C is correct. This encourages the patient to explain what they think they will look like, which in turn leads to open conversation. Choice A is incorrect. This statement is inappropriate for a nurse regarding any situation because it may not heal properly in the end. This also doesn't allow the patient to express any feelings. It shuts down open conversation. Choice B is incorrect. This statement is demeaning towards the patient because it is asking the patient why she feels a certain way instead of talking about her feelings. Choice D is incorrect. Even though this may be an excellent therapeutic communication technique in some situations, it isn't the best answer. It does not acknowledge the patient's feelings of disfigurement but only tells the patient to keep talking. NCSBN Client Need Topic: Psychosocial integrity, Sub-topic: Therapeutic Communication Last Updated - 17, Jan 2022

The nurse notices a physician's order for ibuprofen 600 mg. However, the patient's chart states that he is allergic to NSAIDs. What is the appropriate nursing action? A. Administer the medication per the physician's order because they are trained to know best. B. Find out how serious the patient's reaction to NSAIDs was in the past. C. Contact the physician to verify the order and discuss concerns. D. Ask the patient if he or she feels comfortable taking the medication. Submit Answer

Explanation Choice C is correct. Verifying orders that seem inappropriate for a patient is a safety procedure and a way of advocating for the patient's safe healthcare delivery. Choice A is incorrect. No one is above making a mistake. Following the physician's order without verifying is not appropriate. Choice B is incorrect. Any history of allergic reactions on a patient's chart (or from patient history) should be taken seriously. Even if the first exposure only caused a minor response, subsequent exposure to an allergen could result in worse effects. Choice D is incorrect. Patients may feel pressured to take a medication if the nurse asks if he/she feels comfortable. If an allergy has been reported, the patient should not be given the option to take the medication. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Verifying Medication Orders Last Updated - 06, Feb 2022

The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client A. advances the walker 10 inches with each step. B. has their elbow flexed 15-30 degrees. C. ascends the stairs by advancing the walker first. D. advances the walker and then the affected leg. Submit Answer

Explanation Choice C is correct. Walkers should not be used on stairs or escalators. This places the client at a significant risk for falling. Choices A, B, and D are incorrect. These observations reflect the effective use of a walker. The walker's height should be measured to the client's wrist crease, and the client should have elbow flexion of 15-30 degrees. As the client ambulates, they should lift the walker 10 inches and then advance the affected leg first. Additional Info The client with upper extremity weakness faces a challenge with walkers because they require the client to lift the device up and forward. Alternatively, walkers with wheels may be used; however, the walker can roll forward when weight is applied, causing the client to lose their balance. Walkers should never be used on stairs or on an escalator. Last Updated - 10, Sep 2022

The nurse is providing patient teaching regarding phenazopyridine, a medication used to treat pain resulting from a urinary tract infection. Which priority teaching should the nurse provide to this patient? A. Discontinue this medication if urinary discoloration occurs B. Take this medication on an empty stomach C. Only take the medication before bed D. Urine may have a reddish or orange coloration after taking this medication

Explanation Choice D is correct. After taking this medication, the urine may become discolored. The nurse should provide teaching that this is an expected finding, and the patient should be advised to refrain from becoming alarmed. Choice A is incorrect. A reddish-orange discoloration of the urine is an expected finding when taking phenazopyridine. Patients should not discontinue this medication when this change in the urine occurs. Choice B is incorrect. This medication should be taken with food to prevent stomach discomfort. Choice C is incorrect. This medication can be taken anytime during the day, not only before bedtime. Last Updated - 02, Dec 2022

The nurse is caring for a client that was newly prescribed clozapine. It would be essential to teach the client to do which of the following? A. Maintain a healthy diet because of weight gain B. Exercise regularly and maintain hydration C. Expect excessive secretions in the mouth D. Obtain follow-up laboratory work Submit Answer

Explanation Choice D is correct. Follow-up laboratory work is essential for a client taking clozapine. The medication may adversely cause neutropenia. The client will be instructed to obtain this necessary laboratory work to ensure they are not experiencing agranulocytosis, which may make the client susceptible to infection. Choices A, B, and C are incorrect. Clozapine may cause significant weight gain and hypersalivation. The client should be instructed to watch their calorie intake and exercise with appropriate hydration. Additional Info Clozapine is an atypical antipsychotic reserved for those who have not responded to other agents. This medication is used to treat schizophrenia as well as mood disorders that may cause significant aggression or violence. This medication carries serious effects, including agranulocytosis, myocarditis, sialorrhea, and weight gain. The client will require frequent laboratory work to monitor their neutrophil count. Source : Archer Review Last Updated - 06, Feb 2022

Which of the following is helpful in reducing a patient's post-surgical pain and anxiety? A. Preoperative anxiety medications B. Psychological counseling C. Prepare a preoperative checklist D. Preoperative teaching Submit Answer

Explanation Choice D is correct. Patient teaching before surgery not only helps to reduce a patient's anxiety and postsurgical pain, but it also decreases the amount of anesthesia needed, and a lack of concern additionally speeds up wound healing. Choice A is incorrect. Preoperative medication can decrease the amount of anesthetic needed and respiratory tract secretions, but it does not help with postoperative pain. Choice B is incorrect. Psychological counseling is typically unnecessary except under highly unusual circumstances. Choice C is incorrect. Preoperative checklists are a form of nursing documentation that is used to guide and document the care of the patient before surgery. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation Last Updated - 30, Jan 2022

Which of the following terms, according to the North American Nursing Diagnosis Association, is defined as the lack of ability by the client to integrate the purpose and meaning of life into connectedness as well as interrelationships with the higher power, self, and others at the end of life? A. Guilt B. Isolation C. Religious distress D. Spiritual distress Submit Answer

Explanation Choice D is correct. Spiritual distress, as defined by the North American Nursing Diagnosis Association, is the lack of ability by the client to integrate the purpose and meaning of life into connectedness as well as interrelationships with the higher power, self, and others. Choice A is incorrect. Guilt is defined as a feeling of inner discomfort that occurs when a person believes that they have done something wrong and not the lack of ability by the client to integrate the purpose and meaning of life into connectedness and interrelationships with the higher power, self, and others. Choice B is incorrect. Isolation may occur as a result of spiritual distress. However, separation is quite different from the lack of connectedness with self, others, and a power greater than oneself and not the lack of ability by the client to integrate the purpose and meaning of life into connectedness and interrelationships with the higher power, self, and others. Choice C is incorrect. Religious distress is the feeling that some who are not able to feel that they have followed the mandates of their religion and its traditions and not the lack of ability by the client to integrate the purpose and meaning of life into connectedness and interrelationships with the higher power, self, and others. Last Updated - 11, Feb 2022

You are called to assist in caring for the client depicted below. Which of the following diagnoses would you suspect when you see the client? A. Chronic obstructive pulmonary disease (COPD) B. An airway obstruction from the accumulation of respiratory secretions C. Hypoxia related to a cardiovascular or pulmonary disorder D. Central sleep apnea related to muscular dystrophy Submit Answer

Explanation Choice D is correct. The device shown in the exhibit is a continuous positive airway pressure (CPAP) device. You would suspect central sleep apnea when you see a client as in the exhibit provided. Central sleep apnea is treated with a CPAP device and often results from muscular dystrophy with a compromised brain stem. The brain stem houses the respiratory control mechanisms for the body. By providing continuous pressure (CPAP) keeps airways open and promotes better ventilation. Sleep apnea is classified into two types: central and obstructive. CPAP is also used for the treatment of obstructive sleep apnea. Choice A is incorrect. The CPAP device is not used to treat chronic obstructive pulmonary disease (COPD), and it does not deliver oxygen. A BiPAP (Bi-level positive airway pressure) machine is often used in providing ventilation to clients with chronic obstructive pulmonary disease (COPD) exacerbations. Both CPAP and BiPAP are considered methods to deliver non-invasive positive pressure ventilation (NPPV). Choice B is incorrect. The CPAP device is not used to treat airway obstruction from the accumulation of respiratory secretion. It does not deliver oxygen or suctioning. Choice C is incorrect. The CPAP device is not used to treat hypoxia related to a cardiovascular or pulmonary disorder. In some cases of respiratory distress due to congestive heart failure (CHF) exacerbations, a BiPAP may be used. By increasing intrathoracic pressure, a BiPAP results in decreased preload and decreased afterload. It may prevent intubation by decreasing respiratory effort and improving gas exchange. Last Updated - 15, Feb 2022

Which of the following alternative therapies are not considered a low-risk treatment? Select all that apply. A. St. John's Wort B. Meditation C. Acupuncture D. Relaxation techniques E. Guided imagery Submit Answer

Explanation Choices A and C are correct. St. John's Wort, an herbal remedy for depression that may interfere with specific medical treatments and should not be taken without medical supervision. Acupuncture, while generally safe, is not always well-tolerated and should also be approved and supervised by a health care provider. Choices B, D, and E are incorrect. These are all appropriate forms of alternative therapy that do not require supervision. NCSBN client need Topic: Psychosocial Integrity: Cultural awareness Additional Info Last Updated - 24, Nov 2021

You have been asked by a new graduate nurse why peaks and trough levels of medications are measured. How should you respond to this new graduate nurse's question? A. "Monitoring medication peaks and troughs are important to ensure that the medication is not causing a sensitivity reaction." B. "Measuring medication peaks and troughs are necessary to ensure that the medication is not causing an adverse effect." C. "We can ensure that the medication is administered at the most effective intervals by measuring peaks and troughs." D. "Medication peaks and troughs are essential to monitor and ensure that the medication creates the concentration in the bloodstream required to achieve the desired effect."

Explanation Choice D is correct. You should state that medication peaks and troughs are essential to ensure that the medication creates the concentration in the bloodstream required to achieve the desired effect. Peak and trough levels are most often performed for the clients receiving antimicrobial medication(s). Choice A is incorrect. Peaks and troughs of medications are not indicated to monitor a sensitive reaction to the medication. Choice B is incorrect. Peaks and troughs of medications are not indicated to monitor if an adverse reaction to the medication is occurring. Choice C is incorrect. The main reason for measuring peaks and troughs of medications is to ensure therapeutic drug levels. Although this may affect the dosing schedule, the primary reason for measuring these labs is not to determine the dosing schedule. Learning Objective Verbalize the rationale behind the need for peak and trough lab monitoring. Additional Info Peak and trough are used to describe drug concentrations. Both peak and trough levels are typically measured from blood samples. The peak level is when the drug has reached the highest level in the blood. This must be monitored, as drug toxicity may occur if the peak blood level elevates above a therapeutic level. The trough level is the lowest blood level of a drug. The time the peak level is taken depends on the medication's route of administration, while the trough level is taken just prior to administration of the next dose. If the trough level is too low, the drug may not be at a therapeutic level capable of generating a response. Therapeutic drug monitoring is utilized to verify therapeutic effects and minimize drug toxicity. A clinical pharmacist often carries out this monitoring. Last Updated - 30, Jul 2022

You are caring for a client in the step-down unit who tells you that they are an active member of the Seventh-Day Adventist church. When their breakfast tray comes up, you see the following items. Knowing the religious dietary preferences of these clients, which items should the nurse remove from the breakfast tray? Select all that apply A. Coffee B. Bacon C. Scrambled eggs D. Pancakes Submit Answer

Explanation Choices A and B are correct. Members of the Seventh-Day Adventist church are not permitted to consume alcohol or caffeinated beverages. Due to this dietary preference, the nurse should remove the coffee from the client's breakfast tray. Furthermore, Seventh-Day Adventists are usually lacto-ovo vegetarians, and pork is avoided for those who consume meat. Therefore, the nurse should remove the bacon from the breakfast tray. Choice C is incorrect. Scrambled eggs would be allowed for lacto-ovo vegetarians. Choice D is incorrect. Pancakes would not violate any of these dietary restrictions. NCSBN client need: Topic: Psychosocial Integrity Subtopic: Religious and Spiritual Influences on Health Additional Info Note: It is important to remember that every individual is unique and may choose to follow different dietary restrictions than what their religion suggests. These dietary restrictions represent the stated diet from the Seventh-Day Adventist church and are the standard the nurse should be familiar with when preparing for the NCLEX. As the bedside nurse, always remember to ask the client their specific preferences and restrictions to respect their needs. Last Updated - 03, Sep 2021

This nurse is caring for a client who is receiving prescribed ketorolac. Which of the following findings would indicate a therapeutic response? Select all that apply. A. Decreased pain B. Increased urinary output C. Decreased blood pressure D. Decreased temperature E. Increased muscle coordination Submit Answer

Explanation Choices A and D are correct. Ketorolac is a medication used to treat pain and pyrexia. A client exhibiting a decrease in pain and having a decrease in temperature would be a therapeutic response. Choices B, C, and E are incorrect. Ketorolac does not therapeutically lower blood pressure, increase urinary output, or increase muscle coordination. Medications that could be used to lower blood pressure would be agents such as lisinopril, atenolol, etc. Agents used to increase urinary output would be diuretics such as furosemide. The improvement in muscle coordination may be achieved by medications such as levodopa-carbidopa. NCLEX Category: Pharmacological and Parenteral Therapies Related Content: Expected Actions/Outcomes Question Type: Application Additional Info Ketorolac is an anti-inflammatory drug that may be administered parenterally (IM/IV). This medication is efficacious for pain or pyrexia. This medication is nephrotoxic; therefore, monitoring renal function (BUN and creatinine) is essential while this medication is being taken. Last Updated - 15, Feb 2022

The nurse is teaching a group of clients strategies to promote effective sleep. The nurse should recommend that the clients Select all that apply. A. empty their bladder before bed. B. take more naps throughout the day. C. eat a high amount of calories before bed. D. plan to vigorous exercise earlier in the day. E. use multiple nightlights in the bedroom.

Explanation Choices A and D are correct. Strategic ways for a client to get a restful night's sleep include emptying their bladder before bed and engaging in vigorous exercise in the early morning and afternoon. Vigorous exercise within two hours of bed may increase the client's arousal level and decrease sleep induction. Choices B, C, and E are incorrect. These measures would be detrimental to promoting sleep. The client should be instructed to eliminate naps. If naps cannot be eliminated, they should be done in the earlier part of the day and limited to thirty minutes. To prevent reflux, the client should be instructed to avoid heavy meals within three hours of bedtime. A light snack may be permitted, but it should be low in calories (a glass of skim milk or peanut butter with crackers). The light should be minimized (or eliminated) in the room. Having a dark room promotes the release of melatonin. Thus, the client should have dark shades and limited nightlights. Additional Info When educating a client about ways to promote sleep, the nurse should encourage the following - ➢ If unable to sleep for 15 to 30 minutes, do a relaxing activity such as reading ➢ Eliminate naps unless they are a routine part of the schedule ➢ If naps are taken, limit them to 30 minutes and time them early in the day ➢ Establish a nightly bedtime routine ➢ Do not eat a heavy meal within three hours of planned sleep ➢ Empty your bladder immediately before bed ➢ Limit caffeine and nicotine in the late afternoon and evening ➢ Discontinue use of electronic devices about 30 minutes before going to bed ➢ Avoid vigorous exercise in the evening within 2 hours of bedtime

The nursing instructor is supervising a nursing student feeding a client at risk for aspiration. Which action by the nursing student requires follow-up by the nursing instructor? Select all that apply. A. Instructs the client to tilt the head backward when drinking. B. Reminds the client to assume a chin-down position. C. Provides rest periods as needed during the meal. D. Positions the client upright for 30-60 minutes after a meal. E. Positions the head of the bed at a 45-degree angle during the meal. Submit Answer

Explanation Choices A and E are correct. These observations require follow-up because this is inappropriate. Instructing the client to tilt their head back when eating or drinking would facilitate aspiration. The correct instruction would be to advise the client to have the client assume a chin-down position after they have chewed their food thoroughly. The client should be placed upright with their head of bed at 90 degrees to prevent aspiration. Choices B, C, and D are incorrect. This is a correct position for clients to assume once they have thoroughly chewed their food. Rest periods are essential to ensure that the client is not fatigued during the feeding. If a client becomes fatigued, they are more likely to aspirate because of the exhaustion of the muscles involved with chewing and swallowing. Once the feeding is completed, the client should be positioned upright 30-60 minutes after the meal to prevent aspiration. Oral hygiene should be performed on the client after the meal to reduce plaque secretions, therefore decreasing pneumonia. Additional Info If a client is at risk for aspiration and requires to be fed, here are a few guidelines to remember - ➢ Position the client upright (90 degrees) in a chair or elevate the head of the client's bed to a 90-degree angle. ➢ Minimize distractions, do not talk, and do not rush the client. ➢ Allow time for adequate chewing and swallowing. ➢ Provide rest periods as needed during meals. ➢ Observe for throat clearing, coughing, choking, gagging, and drooling of food; suction airway as needed. ➢ Avoid mixing foods of different textures in the same mouthful. ➢ Alternate liquids and bites of food. Last Updated - 19, Nov 2022

The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply. A. Legumes B. Almond butter C. Grilled chicken D. Apricots E. Baked fish F. Seafood salad Submit Answer

Explanation Choices A, B, and D are correct. The crux of a vegetarian diet is that it excludes foods such as meat, fish, and poultry. Foods such as vegetables, nuts, legumes, plant-based oils, and seeds are encouraged. Dairy products are generally permitted on a vegetarian diet. However, subvariants of this diet exist. Choices C, E, and F are incorrect. The vegetarian diet excludes meat, poultry, and seafood. Additional Info ✓ The vegetarian diet focuses on no meat, poultry, or seafood. ✓ Foods such as dairy, legumes, tofu, grapefruit, melon, and soy are permitted. ✓ Vegan and vegetarian diets are generally safe during pregnancy but require appropriate meal planning. ✓ The primary difference between a vegan and a vegetarian diet is that a vegetarian diet includes eggs and dairy. Last Updated - 11, Jan 2023

The nurse is caring for a client with the following clinical data. Based on the vital signs, which medications would the nurse clarify with the primary healthcare provider (PHCP) prior to administration? See the exhibit. Select all that apply. A. Atenolol 50 mg PO Daily B. Spironolactone 50 mg PO Daily C. Albuterol 2.5 mg via nebulizer Daily D. Fentanyl 50 mcg IV Push q 6 hours PRN Pain E. Modafinil 100 mg PO Daily

Explanation Choices A, B, and D are correct. The vital signs show hypotension (90/60 mm Hg). The nurse should clarify the prescriptions of atenolol, spironolactone, and fentanyl. All these medications decrease blood pressure, and considering how low the client's blood pressure is, it would be highly detrimental. Choices C and E are incorrect. Albuterol is a beta-adrenergic agonist; thus, this medication would cause an increase in blood pressure and heart rate. Modafinil is a stimulant medication used in the management of narcolepsy. Therefore, this medication tends to raise blood pressure, not lower it. Additional Info Atenolol is a beta-blocker and would lower blood pressure and heart rate. The nurse should assess both prior to administration. Spironolactone is a potassium-sparing diuretic. This medication decreases fluid volume, therefore, reducing blood pressure. Fentanyl is an opioid and causes vasodilation, therefore, lowering blood pressure. Last Updated - 10, Nov 2022

The nurse is teaching progressive relaxation techniques to a client. Which of the following statements by the client indicates that the teaching has been effective? Select all that apply. A. "I will breathe in and out in rhythm." B. "I expect my pulse to be faster afterwards." C. "I expect to require less pain medication." D. "I expect my muscles to feel less tense." E. "I will report any increased sensitivity."

Explanation Choices A, C, D, and E are correct. Progressive relaxation involves rhythmic breathing and progressive tension and relaxation of one muscle group at a time. When implemented, clients typically experience decreased muscle tension and a reduction in the need for pharmacologic measures to relieve pain and anxiety. Although sensitivity may be normal for clients who are new to progressive relaxation exercises, any sensitivity or exhaustion should be reported and monitored so the nurse can decide whether the client would be better suited for passive relaxation techniques. Choice B is incorrect. When relaxation techniques are properly implemented, the client should experience a decreased pulse rate. Additional Info Clients who are unable to perform progressive relaxation due to advanced disease, immobility, or decreased energy can still benefit from passive relaxation or guided imagery. Passive relaxation involves slow, mindful breathing without tensing and relaxing the muscles. Imagery, or visualization, involves consciously using the mind to call forth mental images such as ocean waves along with the rhythm of the breath. These techniques can stimulate a similar relaxation response without expending additional physical energy. Last Updated - 29, Mar 2022

The nurse is planning a staff development conference about medications utilized in an emergency. Which of the following information should the nurse include? Select all that apply. A. Sodium bicarbonate is prescribed for severe cases of metabolic acidosis. B. Diphenhydramine should be administered before epinephrine for anaphylaxis. C. Glucagon may be prescribed to treat calcium channel blocker toxicity. D. Calcium gluconate is prescribed to treat dysrhythmias associated with hypokalemia. E. Magnesium sulfate is the prescribed treatment for torsades de pointes.

Explanation Choices A, C, and E are correct. Sodium bicarbonate may be used to treat severe metabolic and respiratory acidosis. Glucagon is an approved treatment for calcium channel and beta-blocker toxicity. Magnesium sulfate is the treatment for torsades de pointes, a fatal ventricular dysrhythmia. This should be combined with defibrillation if the client is hemodynamically unstable with torsades de pointes. Choices B and D are incorrect. Epinephrine is the priority treatment over diphenhydramine in anaphylaxis because of its ability to relieve upper airway obstruction or hypotension. Calcium gluconate is utilized to protect the myocardium from the irritability caused by hyperkalemia - not hypokalemia. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Expected Actions/Outcomes Question type: Knowledge/comprehension Additional Info Sodium bicarbonate is an alkaline agent used to correct severe acidosis. This medication is given in ampules via intravenous push or a continuous infusion. Epinephrine is the drug of choice for anaphylaxis as it relieves upper airway obstruction and treats hypotension. The intramuscular (IM) route is preferred over IV. Glucagon is an effective treatment for hypoglycemia as well as beta-blockers and calcium channel blocker toxicity. This medication is given intravenously (IV) or intramuscular (IM) along with other treatments such as epinephrine and calcium gluconate. Magnesium sulfate is indicated in the treatment of severe asthma attacks, eclamptic seizures, and torsades de pointes which is a ventricular dysrhythmia that may be fatal if not treated. Last Updated - 28, Apr 2022