Archer Review 12b

When performing a transcultural assessment, the nurse must: A. Determine which questions to ask the client. [37%] B. Wait until the nurse-patient relationship is established before asking questions. [32%] C. Ask all questions for completeness of the assessment. [13%] D. Include all questions as part of an admitting assessment. [18%]

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

The nurse is triaging phone calls for the primary healthcare provider (PHCP). Which client situation requires immediate notification to the PHCP? A. A client with heart failure that reports an overnight weight gain of three pounds. [79%] B. A client with peritoneal dialysis who has not had a bowel movement in two days. [7%] C. A client with irritable bowel syndrome (IBS) that reports frequent diarrhea. [2%] D. A client with nephrolithiasis that reports bloody urine and flank pain. [12%]

Explanation Choice A is correct. The PHCP should be immediately notified about the client who gained three pounds overnight. Two pounds convert to one kilogram, and that converts to one liter of fluid. Thus, this client is retaining a significant amount of fluid and requires immediate follow-up to ensure they do not develop complications such as pulmonary edema. Choices B, C, and D are incorrect. A client with peritoneal dialysis should be evaluated for their complaints of constipation because it is a major cause of poor outflow. A client with IBS reporting frequent diarrhea is an expected finding as this condition is manifested by constipation, diarrhea, and abdominal spasms. Nephrolithiasis characteristically presents with hematuria and flank pain. Each client calls about symptoms expected with the corresponding disease process; thus, they do not need to be reported immediately to the PHCP. Additional information: It is essential for a client with heart failure to weigh themselves daily. This weight should be completed first thing in the morning and after the morning void. The weight should be obtained with the same amount of clothing each day. The client should report a weight gain of 1-2 pounds overnight or 3 pounds in a week. NCSBN Client need: Topic: Management of Care; Subtopic: Establishing Priorities

The nurse is performing a verbal hand-off report for a patient. Which essential information should the nurse include in the report? A. Current medication list [47%] B. Involuntary admission status [39%] C. Food and mealtime preferences [8%] D. The presence of family at the bedside [6%]

Explanation Choice B is correct. Admission status is essential information to provide in the hand-off report because involuntary admission status requires the patient to stay in the healthcare facility. This status typically is required when a patient may pose a threat to themselves or others. This type of involuntary admission status also may raise the risk for the patient eloping. This should be communicated because if a patient is involuntarily admitted, they may not have a rational thought process which may raise the risk of self-injury if they do successfully elope. Choices A, C, and D are incorrect. The current medication list is generally not communicated during the hand-off report. Hand-off reports should include new prescriptions or prescriptions pertinent to the patient's care. The oncoming nurse may easily obtain this list by accessing the medication administration record. Food and mealtime preferences are important to delivering patient-centered care but do not prioritize the patient's admission status. Finally, the presence of family at the bedside may be irrelevant unless pertinent family dynamics impact care. Additional information: When a patient is admitted involuntarily, the nurse should still respect the patient's autonomy for treatment decisions (this includes the right to refuse medication). The exception to this rule is if the patient is experiencing a behavioral crisis and requires emergent medications for stabilization. This requires the prescriber to note their reasoning. Additionally, a patient's right to refuse medications may be overridden by a court order (for example, a court order stating that the patient must take risperidone for stabilization).

Hemophilia is an X-linked recessive disorder. If an unaffected man has a baby with a woman who is a carrier then what percent of their male offspring would be expected to have hemophilia? A. 25% [51%] B. 50% [40%] C. 75% [5%] D. 100% [5%]

Explanation Choice B is correct. If an unaffected man has a baby with a woman who is a carrier for hemophilia then their male offspring have a 50% chance of having hemophilia. To solve this problem, you should use a Punnett square. The nurse knows that the allele for hemophilia is x-linked; H is the normal allele and h is the abnormal allele. When we complete the Punnett square, we see as follows: The question asks for what percent of the male offspring have hemophilia. The male family will receive a Y chromosome from their father, and either an XH normal allele or an Xh abnormal allele from their mother. This means their possible genotypes are XHY or XY. There is a 50% chance they will be unaffected (XHY) and a 50% chance they will have hemophilia (XhY). Choice A is correct. In this scenario, there is a 50% chance of male offspring having hemophilia, not 25%. Choice C is correct. In this scenario, there is a 50% chance of male offspring having hemophilia, not 75%. Choice D is correct. In this scenario, there is a 50% chance of male offspring having hemophilia, not 100%. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Risk of the potential reduction; Pediatrics - Hematology

You are working in a long-term psychiatric rehabilitation center and are assigned to a patient with debilitating agoraphobia. He is going through desensitization therapy. Which of the following interventions is an appropriate part of this treatment? Select all that apply. A. Speak frequently of what causes the fear to start for him. [22%] B. Take a short walk in the hallway outside of his room. [35%] C. Build rapport with the client [21%] D. Encourage him to face his fear outside where he is least comfortable. [22%]

Explanation Choice B is correct. Since your client has agoraphobia, they will be reluctant to leave any place they feel comfortable. Leaving the place where they feel comfortable is either unfamiliar or hard to escape from, which is why people with agoraphobia have difficulty leaving the house. The client needs to be desensitized to this fear slowly, and a short walk in the hallway outside of his room (where they feel safe) is an appropriate choice. Choice C is correct. Building rapport with the client is a fundamental part of building a trusting relationship, and building a trusting relationship with a patient going through desensitization therapy is essential. You need the client to trust you so that when you ask them to do little things outside of their comfort zone, they will be able to do them. This is the key to slow, gradual progress in desensitization. Choice A is incorrect. When treating clients with a phobia, it is not advisable to talk about what frequently causes the phobia. Although you will need to address the phobia over time, focusing on this does not help the patient desensitize. Instead, it keeps them focused on the phobia. Just speaking about their phobia can send them into a panic attack for some patients. Choice D is incorrect. The key to desensitization therapy with phobias is a gradual change over time, not a dramatic leap to facing the phobia directly. This advice would likely cause your client to have a panic attack, which would set them back considerably. Instead of suggesting that they face their phobia and jump to where he is least comfortable, start with little steps and gradually work towards those bigger goals.

Which of the following iso-enzymes is most specific to myocardial infarction? A. CPK-MB [13%] B. Troponin [82%] C. Creatinine kinase [3%] D. Myoglobin

Explanation Choice B is correct. Troponin is the most specific iso-enzyme when evaluating if a patient has had a myocardial infarction (MI). Levels of troponin will elevate within 3-4 hours of myocardial infarction and remain elevated for three weeks. This means that not only is troponin the most specific cardiac biomarker for an MI; it is also the most reliable test to run if the patient does not seek care for some time after their symptoms begin. Choice A is incorrect. CPK-MB is not the most specific iso-enzyme to myocardial infarction. CPK-MB is a cardiac iso-enzyme and levels of this iso-enzyme do become elevated with damage to the cardiac cells of the myocardium, it is just not the most specific. Levels of CPK-MB increase about 3 to 6 hours after there is damage to the heart muscle and their levels peak in 24 hours. Choice C is incorrect. Creatine kinase is not the most specific iso-enzyme to myocardial infarction. It is an enzyme found in the heart, but it is also found in the brain, skeletal muscle, and other tissues. Any time there is muscle damage, there are increased amounts of creatinine kinase released into the blood. This means, however, that it is not a sensitive indicator for myocardial infarction because muscle damage of any kind will cause elevated levels. When running this lab after a myocardial infarction is suspected, negative results are a good thing to aid in ruling out an MI. Still, positive results are not specific and further testing will need to be done. Choice D is incorrect. Myoglobin is not an iso-enzyme, but a red protein containing heme, which carries and stores oxygen in muscle cells. Myoglobin levels do increase after myocardial infarction because any muscle breakdown will release myoglobin into the bloodstream. This means, however, that it is not a sensitive indicator for myocardial infarction because muscle damage of any kind will cause elevated levels. When running this lab after a myocardial infarction is suspected, negative results are a good thing to aid in ruling out an MI. Still, positive results are not specific, and further testing will need to be done. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Laboratory Values

Which stage of psychosocial development does the nurse know a 2-month-old infant will be in? A. Initiative vs. Guilt [2%] B. Autonomy vs. Shame and Self Doubt [5%] C. Trust vs. Mistrust [91%] D. Industry vs. Inferiority [2%]

Explanation Choice C is correct. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. This is the stage the nurse would expect for her 2-month-old patient. In this stage, children develop a sense of trust when caregivers provide reliability, care, and affection. When infants do not have that, they will build mistrust. Choice A is incorrect. Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds, so this is incorrect for your 2-month-old patient. In Initiative vs. Guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty. Choice B is incorrect. Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years, so this is not what the nurse would expect for her 2-month-old patient. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, and it leads to a sense of autonomy. When they are not successful, they think they are a failure and it results in shame and self-doubt. Choice D is incorrect. Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds, so this is not correct for your 2-month-old patient. In this stage, children need to cope with new social and academic demands. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, and it results in inferiority. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatrics - Development

A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness for the will. Which of the following is the most appropriate response? A. "Don't worry, I will sign as a witness to your signature." [3%] B. "Because it is a legal document, you will need to find a witness on your own." [21%] C. "Whoever is present at the time will sign as a witness for you." [12%] D. "I will contact the nursing supervisor for assistance regarding your request."

Explanation Choice D is correct. Living wills are written legal instructions, signed by the client, and must be witnessed by specified individuals or those who are able to notarize. Laws and guidelines regarding a living will vary from state to state, and it is the responsibility of the nurse to be knowledgeable of the rules. Many rules prohibit an employee, in this case, a nurse of a facility where the client is receiving care from being a witness. Choices A, B, and C are incorrect. These are inappropriate and unhelpful responses. The nurse should seek the assistance of the nursing supervisor.

Your client has been diagnosed with chronic pancreatitis secondary to alcohol abuse. Which of the following is the most appropriate tertiary prevention expected outcome for this client? A. Altered digestion is secondary to pancreatitis. [9%] B. Altered coping secondary to alcoholism. [11%] C. The client will be free of insomnia during hospitalization. [4%] D. The client will participate in a 12 step recovery program. [76%]

Explanation Choice D is correct. The client participating in a 12 step recovery program is the most appropriate tertiary prevention expected outcome since they have been diagnosed with chronic pancreatitis secondary to alcohol abuse. Tertiary prevention includes rehabilitation, so a 12 step recovery program is a form of this. Choice A is incorrect. Altered digestion secondary to pancreatitis is a physiological nursing diagnosis and not an expected outcome or client goal. Choice B is incorrect. Altered coping secondary to alcoholism is a psychological nursing diagnosis and not an expected outcome or client goal. Choice C is incorrect. The client being free of insomnia during hospitalization is a possible outcome. However, insomnia during hospitalization is a secondary, rather than a tertiary, prevention expected outcome or client goal.

A 30-year old patient presents to the Emergency Department with alcohol withdrawal seizures. The psychiatry nurse understands that the patient will soon be admitted to the non-medical psychiatric care unit. To keep this patient safe, the nurse must perform which priority nursing action? A. Ask the physician for a clonazepam prescription, an anxiolytic that may help with the withdrawal symptoms. [12%] B. Ensure that a working IV pump is set up at the patient's bedside. [3%] C. Order a STAT arterial blood gas (ABG). [2%] D. Pad the side rails of the patient's assigned bed.

Explanation Choice D is correct. The patient presented with alcohol withdrawal seizures. The priority nursing action is to pad the patient's bed's side rails to prevent injury since the patient is at high risk of a recurrent seizure. In an acute care setting, side rails are often used as a medical assistive device and not a restraint. Side rails are considered a restraint only if the intent is to prevent the patient's free access and keep them in bed. In the setting of seizure precautions, side rails are raised, and the bumper pads are used as a medical assistive device. Choice A is incorrect. While clonazepam may help with the anxiety associated with alcohol withdrawal, it is not the drug of choice in managing alcohol withdrawal. Instead, diazepam, lorazepam, and chlordiazepoxide are used most frequently to treat or prevent alcohol withdrawal. Furthermore, providing the patient with this medication is not the priority action in patient safety. Choice B is incorrect. Since the patient will be admitted to a non-medical psychiatry floor, continuous intravenous infusion is not permitted while on that unit. However, necessary injections, oral medications, or other non-invasive procedures are performed while on the non-medical unit. Choice C is incorrect. Ordering a STAT arterial blood gas is not necessary when the patient arrives at the psychiatry unit. Before the patients are sent to the non-medical psychiatry floor, they are already deemed clinically stable and medically cleared. NCSBN client need Topic: Safety and Infection Control, Injury Prevention

The nurse is caring for a patient with post-gastrectomy dumping syndrome. What teaching should the nurse provide for this patient? A. Take small sips of water during meals to soften the food for easier digestion. [10%] B. Symptoms will resolve in about 4-6 weeks as the stomach adjusts post-surgery. [11%] C. Plan rest periods of 10-15 minutes after every meal. [33%] D. Meals should consist of dry foods with low carbohydrates, moderate fat, and protein content. [46%]

Explanation Choice D is correct. The patient should be instructed to eat small portions of dry foods to aid digestion. A low carbohydrate, moderate fat, and moderate protein content will promote tissue healing and help to meet the body's increased energy demands. Choice A is incorrect. Patients experiencing dumping syndrome should be instructed to avoid drinking during meals to prevent fullness and distention. Patients should drink in between meals at least 30-45 minutes before or after eating. Choice B is incorrect. Symptoms of dumping syndrome generally resolve in several months to a year after gastrectomy surgery. Choice C is incorrect. Post-meal rest periods should be at least 30 minutes to allow enough time for the digestion process to begin. NCSBN Client Need Topic: Adult health, Subtopic: Gastrointestinal/nutrition

The nurse is caring for a client with the below tracing on the electrocardiogram (ECG). It would be correct for the nurse to document this tracing as See the image below. A. sinus bradycardia. [5%] B. normal sinus rhythm with first degree block. [18%] C. atrial flutter. [17%] D. atrial fibrillation. [60%]

Explanation Choice D is correct. This tracing reflects atrial fibrillation. Atrial fibrillation characteristically has no definitive P-waves because fibrillatory waves replace them before each QRS. Choices A, B, and C are incorrect. This tracing does not reflect these options because of the absence of P-waves, irregularity, and fibrillatory waves before the QRS making it atrial fibrillation. Additional Info Atrial fibrillation is associated with atrial fibrosis and loss of muscle mass. These structural changes are common in heart diseases such as hypertension, heart failure, and coronary artery disease. Characteristically, atrial fibrillation is irregularly, irregular with no P-waves identified. The biggest complication associated with atrial fibrillation is stroke because of blood pooling in the atrium. Treatment options for atrial fibrillation include digoxin (not as commonly used), amiodarone, diltiazem, verapamil, or atenolol. The client may be prescribed an oral anticoagulant such as apixaban to prevent thrombosis. If medication is not desired, synchronized cardioversion may be prescribe

The nurse knows that benefits of delayed cord clamping in the newborn include: Select all that apply. A. Increased blood volume [34%] B. Decreased brain hemorrhages [20%] C. Decreased risk of polycythemia [27%] D. Decreased jaundice [19%]

Explanation Choices A and B are correct. Potential benefits of delayed cord clamping in the newborn include increased blood volume, decreased risk of brain hemorrhages, increased blood pressure, lower risk of necrotizing enterocolitis, decreased anemia, and improved neurodevelopmental outcomes. Potential adverse effects of delayed cord clamping include an increased risk of polycythemia and jaundice and possible delay in resuscitation efforts for at-risk newborns. Current research indicates that cord clamping can be delayed for 30-60 seconds in vigorous newborns as long as the team manages the newborn's temperature to keep the infant warm. Choices C and D are incorrect. Delayed cord clamping does not decrease the risk of polycythemia or jaundice. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Complications of Diagnostic Tests/Treatments/Procedures, Newborn

Which of the following symptoms should the nurse monitor for in her patient suspected of intussusception? Select all that apply. A. Red, currant jelly stool [40%] B. Hematemesis [10%] C. Palpable, sausage-shaped mass in the RUQ [38%] D. Steatorrhea [12%]

Explanation Choices A and C are correct. Red, currant jelly stool is a classic finding of intussusception. When the bowel telescopes into another portion of the intestine, it causes intestinal obstruction and subsequently red, currant jelly stools (Choice A). A palpable, sausage-shaped mass in RUQ is a classic finding of intussusception. This is due to the physical telescoping of the intestine and the weight can sometimes be felt on palpation (Choice C). Choice B is incorrect. Hematemesis, or bloody vomiting, is not an expected finding in intussusception. We would expect vomiting of gastric contents and possibly green bile if there is an obstruction. Choice D is incorrect. Steatorrhea is the passage of oily, pale, foul-smelling stool. It indicates fat malabsorption and can be a sign of Celiac disease, but would not be present in a patient with intussusception. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatrics - Gastrointestinal

The nurse assists a mother in labor to the bathroom and notes that the fetal heart rate increases from 130 to 190. She sits the mother back down in bed, and the fetal heart rate remains 190. Which of the following nursing actions would be appropriate? Select all that apply. A. Lie the mother down on her left side [41%] B. Decrease the rate of her IV fluids [8%] C. Administer oxygen [36%] D. Continue to just observe the mother

Explanation Choices A and C are correct. The nurse has noted fetal tachycardia. Any increase in fetal heart rate above 160 is considered tachycardia. When it persists for longer than 10 minutes, it is problematic and requires intervention. Any non-reassuring fetal heart rate will require intervention. One could remember these interventions with the mnemonic: LION: lie the mother on her left side, increase IV fluids, oxygen, and notify the healthcare provider. In this case, the non-reassuring sign of fetal tachycardia necessitates intervention, therefore lying the mother on her left side is an appropriate intervention. Administering oxygen is an appropriate nursing intervention for the noted fetal tachycardia. The idea is to improve fetal oxygenation. This will go along with repositioning the mother onto her left side, increasing the rate of IV fluid administration, and notifying the healthcare provider. Choice B is incorrect. Decreasing the rate of the mother's IV fluids is not appropriate. Instead, the nurse should increase the IV fluid rate to help better facilitate blood perfusion to the placenta and fetus. Choice D is incorrect. It is inappropriate to continue to observe the mother. The nurse has noted fetal tachycardia, a non-reassuring sign that requires intervention. The nurse should lay the mother on her left side, increase her IV fluids, administer oxygen, and notify the healthcare provider. NCSBN Client Need Topic: Effective, safe care environment; Subtopic: Coordinated care

Which of the following are signs of decreased cardiac output in a pediatric patient with a history of CHF? Select all that apply. A. Feeding difficulties [36%] B. Polyuria [4%] C. Bradycardia [24%] D. Irritability [35%]

Explanation Choices A and D are correct. Feeding difficulties are often an early symptom of decreased cardiac output in a pediatric patient, especially in infants. It becomes harder for them to coordinate the suck, swallow, breathe sequence needed to breast or bottle-feed, and they begin having trouble feeding (Choice A). Irritability is a classic sign of decreased cardiac output in pediatric and infant patients. Because they cannot explain to you how they are feeling, irritability, restlessness, and fussiness are often their way of showing that something is going on (Choice D). Choice B is incorrect. Polyuria is not a sign of decreased cardiac output. Instead, oliguria is. With decreased cardiac output, there is less perfusion to the kidneys and with less renal blood flow, the body makes less urine leading to oliguria. Choice C is incorrect. Bradycardia is a very ominous sign in children and would not occur until the child is in heart failure. Tachycardia is a more appropriate symptom of decreased cardiac output, as the body starts to recognize the reduced amount of blood being pumped to its organs, it will try to compensate by increasing the heart rate. This will correct decreased cardiac output for a little while but is not sustainable and, if left untreated, will progress to more severe symptoms. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Cardiovascular

You are treating an 18-month-old who has tested positive for Respiratory Syncytial Virus (RSV). Which of the following signs and symptoms do you expect to see? Select all that apply. A. Thin nasal secretions [23%] B. Productive cough [29%] C. Bradypnea [12%] D. Nasal flaring [36%]

Explanation Choices A and D are correct. Thin nasal secretions are an expected symptom of Respiratory Syncytial Virus, otherwise known as RSV. This is an acute viral infection that affects the bronchioles. Children experience a lot of upper respiratory congestion when dealing with RSV; they need frequent suctioning to keep their airway clear and lessen their work of breathing (Choice A). Nasal flaring is an expected sign of RSV. This is a typical signal of respiratory distress in an infant or young child. As they take a breath, their nares flare outward with inspiration. This is because they are using a lot of effort to breathe. They are working so hard and using all of their accessory muscles that the sides of their nose flare outward with each inspiration. Nasal flaring is a symptom of RSV (Choice D). Choice B is incorrect. The cough found with RSV is typically nonproductive. Upon auscultation, you will note wheezing in the lungs and other signs of increased work of breathing. Their cough will sound dry and be spontaneous, but it does not typically produce any sputum. Choice C is incorrect. Bradypnea is not an expected finding of RSV. Instead, one would expect to see tachypnea. In children, we typically hope to see their vital sign numbers go up before they go down. This is because they are compensating. The child is working harder to breathe with RSV as they fight to keep their body oxygenated. They have increased work of breathing and start to breathe faster and faster to try to keep up. This is why tachypnea is an expected finding of RSV, not bradypnea. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatrics - Respiratory

Which of the following are causes of dystocia? Select all that apply. A. Hypertonic contractions [17%] B. Macrosomia [31%] C. Hypotonic contractions [19%] D. Breech presentation [32%]

Explanation Choices A, B, C, and D are all correct. A is correct. Hypertonic contractions are contractions that are too strong and too frequent. This is a cause of dystocia. The contractions are not effective in causing dilation and effacement and do not help labor progress. They are extremely painful. Treatment for mothers experiencing hypertonic contractions would include tocolytics and pain medication. B is correct. Macrosomia is defined as a fetus that is much larger than average, more significant than 4,000 grams. Because of the size of these infants, it is difficult for them to fit through the maternal pelvis. This often causes a specific type of dystocia, shoulder dystocia, where the shoulder of the infant essentially becomes stuck behind the pubic bone and causes prolonged and painful labor. C is correct. Hypotonic contractions are contractions that are very weak and uncoordinated. They are a cause of dystocia. When contractions are weak and uncoordinated, they are ineffective in causing dilation and effacement, and labor does not progress as expected. Treatment would include oxytocin or helping the mother walk to get her contractions into a pattern. D is correct. Breech presentation is one type of malpresentation that can cause dystocia. When the fetus is not lined up in a cephalic presentation, fitting through the maternal pelvis becomes very difficult and causes dystocia. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Labor and Delivery

The nurse manager is completing an annual performance apprasial/evaluation on a staff nurse. Which elements should the nurse manager include when completing the evaluation? Select all that apply. A. The nurses' bar-code medication administration scan rate [15%] B. The number of times the nurse has been absent or tardy [29%] C. The nurse achieving a national certification [18%] D. The nurses' performance compared to other staff nurses [15%] E. The number of medication errors the nurse has self-reported. [23%]

Explanation Choices A, B, and C are correct. The performance appraisal/evaluation goal is to provide a broad review of the employee's performance with minimal evaluator bias. The more objective the evaluation, the less the bias. Objective metrics such as bar-code medication administration rate, attendance, and national certifications are logical elements to include in the appraisal. Choices D and E are incorrect. The nurses' performance should not be compared/contrasted with other nurses. The annual performance review should be focused solely on the nurses' performance. Self-reporting is valued by the nursing profession and promotes a culture of safety. Using self-reports of a medication error against the nurses' performance would likely discourage future reporting. If the nurse manager observes unsafe practices by the nurse, they should be corrected. However, self-reporting should be encouraged and not weaponized against the nurse. Additional Info Performance appraisals/evaluations serve a variety of functions, including: Appraisals help the nurse manager in updating personnel records and making decisions on staffing, including hiring, scheduling, promotions, or termination Sets expectations for what the employer will provide, such as fair treatment, acceptable working conditions, and feedback on their job performance. Develops the nurse-manager relationship leading to increased employee retention and morale. Ensures legal compliance if consequential decisions such as termination should occur.

At your 6 AM assessment in the PICU, your 4-year-old patient has a temperature of 38.4 degrees Celsius. You notify your provider, and she writes the following orders. Which of these orders should you question? Select all that apply. A. Administer 150 mg ibuprofen. [19%] B. Re-check temperature every 30 minutes until afebrile. [9%] C. Provide a tepid sponge bath. [8%] D. Administer 325 mg acetylsalicylic acid (ASA). [38%] E. Initiate IV rehydration with D51/2 NS at 80ml/hr. [25%]

Explanation Choices D and E are correct. Fevers are very common in children and have varying causes. Fevers over 38.0 degrees Celsius require intervention in the ICU setting. Administering antipyretics such as ibuprofen or acetaminophen is appropriate. Rechecking the temperature until the patient is afebrile is also necessary to ensure adequate treatment and follow-up. Providing a tepid sponge bath is an appropriate nursing intervention to lower your patient's temperature. No alcohol should be used in the febrile patient as it can cause peripheral vasoconstriction. Choices D and E are correct answers to the question because they are inappropriate actions for the child with a fever and the nurse should question these orders. Acetylsalicylic acid (aspirin), should never be administered to a child unless specifically prescribed due to the high risk of Reye's syndrome. Initiating IV fluids is not indicated at this time as we have no information that this patient is dehydrated or not tolerating PO intake. Only when this occurs should the provider order IV fluids. Choices A, B, and C are incorrect. These are all appropriate orders to receive and should be carried out. NCSBN client needs: Topic: Pharmacological and Parenteral Therapies Subtopic: Medication Administration

The nurse is working with a client who suffered a blunt injury to the chest wall. Which of the following assessment findings would indicate the presence of a pneumothorax? A. Diminished breath sounds [62%] B. A barrel chest [10%] C. Lower than normal respiratory rate [2%] D. A sucking noise at the site of the injury [26%]

Explanation Choice A is correct. Since this is a closed chest injury, the most common sign of pneumothorax (PTX) will be diminished breath sounds. Choice B is incorrect. A barrel chest occurs over time and indicates chronic obstructive pulmonary disease (COPD). Choice C is incorrect. With most cases of pneumothorax, the patient will become tachypneic rather than have a lower than usual respiratory rate. Choice D is incorrect. A sucking noise is noted in an open chest injury. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

A 35-year-old patient presents to the emergency department complaining of fever, chills, and headaches for the past two days. There is a pink, macular rash on the palms, wrists, and soles of the feet. Which statement by the patient would indicate to the nurse a potential medical emergency? A. "I am allergic to amoxicillin." [21%] B. "There have been cases of hand-foot-mouth in the child's daycare recently." [30%] C. "I went hiking 2 weeks ago." [47%] D. "I switched my laundry detergent last week because of my sensitive skin." [2%]

Explanation Choice C is correct. The patient is experiencing symptoms of Rocky Mountain Spotted Fever (RMSF): fever, chills, headache, and a macular rash that appears on the palms of hands, wrists, soles of feet, and ankles within ten days of exposure. RMSF occurs due to Rickettsia rickettsii bacteria that can be transmitted to humans via the Ixodes tick (deer tick). The patient has been hiking, which puts them at risk for coming into contact with ticks. RMSF is hard to diagnose in the early stages and without treatment can be fatal. Choice A is incorrect. An amoxicillin allergy is vital for the nurse to be aware of, but does not indicate an emergency. The nurse should ask about the patient's reaction to amoxicillin and document it in the patient's chart. The patient has been experiencing symptoms for several days and there is no information provided that suggests the patient received any antibiotics recently. Choice B is incorrect. Hand-foot-mouth disease is a common childhood virus that may be transmitted to adults but typically results in a blistering rash, not macular. It is not a medical emergency and usually resolves on its own with only supportive treatment. Choice D is incorrect. Allergic contact dermatitis is a hypersensitivity reaction of the skin that can result from changing laundry detergents. The area of rash is usually limited to the skin that is exposed to allergens, so the patient would have a more widespread outbreak if this were the cause. It is not often accompanied by the patient's other symptoms of fever, chills, or headache, and would not be a medical emergency. NCSBN Client Need Topic: Infectious disease, Subtopic: High-risk behaviors, pathophysiology, medical emergencies

The nurse is caring for a client receiving a continuous infusion of diltiazem who has the below tracing on the electrocardiogram (ECG). On assessment, the client has irregular peripheral pulses, an S3 heart sound, and 2+ pedal edema. The nurse should plan to take which priority action? See the image below. A. Assess the client for chest pain [19%] B. Perform a 12-lead electrocardiogram [9%] C. Stop the infusion [64%] D. Obtain an immediate troponin level

Explanation Choice C is correct. This tracing reflects atrial fibrillation and diltiazem may be used as a treatment. Diltiazem is a calcium channel blocker and may cause the client to develop heart failure because of its negative inotropic and chronotropic effects. An S3 heart sound is one of the earliest manifestations of heart failure. This, combined with pedal edema, supports the nurses' decision to stop this infusion to prevent further clinical deterioration. Choices A, B, and D are incorrect. These manifestations are not suggestive of myocardial infarction (MI), and assessing the client for chest pain and obtaining a troponin level would be irrelevant based on symptoms. The nurse should not delay acting when the client exhibits early signs of an adverse effect such as heart failure. If the nurse fails to act, the client may develop flash pulmonary edema. Additional Info Key assessments for a client receiving diltiazem include - • Monitor HR and BP; bradycardia and hypotension are common side effects. • Teach clients to report dyspnea, orthopnea, distended neck veins, or swelling of the extremities; HF can occur, necessitating a decrease in dosage or discontinuation of the drug.

While at the park, the nurse witnesses an elderly woman fall. Upon evaluation, the woman complains of severe pain and an inability to move her left leg. The nurse also notes that the woman's left leg appears shorter than the right, but there are no visible wounds. A femoral fracture is suspected. Which of the following is the greatest immediate risk for the client? A. Infection [2%] B. Fat emboli [72%] C. Neurogenic shock [11%] D. Hypovolemia [15%]

Explanation Choice D is correct. A femoral fracture puts the client at risk for hypovolemia due to hemorrhage, which may be covert and is fatal when undetected. Following a closed femoral fracture, patients can bleed into the thigh's closed space without any external bleeding signs. The nurse should be aware of this immediate risk to the client. Approximate blood loss expected with a closed femur fracture is about 1000-1500 mL, enough to predispose the client to hemorrhagic shock/hypovolemia. Choices A, B, and C are incorrect. Although infection and fat emboli are potential complications following femoral fractures, they are less frequent than a hemorrhage. Also, these do not occur immediately after the fracture. A fat embolism (Choice B) occurs at about 12 to 36 hours after a traumatic injury. Fat embolism syndrome incidence can be reduced by effective early fracture immobilization as well as prompt hypovolemia and hypoxia correction. Infection (Choice A) following a fracture is not an immediate concern; it takes time to develop. Infections are more common with open fractures of the femur than with closed fractures. Femoral fractures are less likely to bring about neurogenic shock (Choice C).

The primary healthcare provider (PHCP) prescribes 30 mg of phenobarbital by mouth, once daily. The medication label reads phenobarbital 10 mg. The nurse prepares to administer how many tablet(s) per dose? Fill in the blank. tablet(s)

Explanation The formula of dose ordered / dose on hand x volume will be utilized to solve this problem. Divide the prescribed amount of medication by what is on hand 30 mg / 10 mg = 3 tablets Additional Info Phenobarbital is a barbiturate and indicated in the treatment of epilepsy. This medication suppresses seizure activity and is a central nervous system depressant.

The nurse is teaching a group of students about renal disorders. Which statement, if made by the student, requires follow-up? Select all that apply. A. "Pyelonephritis causes a client to have massive amounts of proteinuria." [21%] B. "Acute kidney injury may be caused by nephrotoxic medications." [13%] C. "Bacterial cystitis is diagnosed using a 24-hour urine collection." [23%] D. "Polycystic kidney disease may cause hematuria after a cyst rupture." [15%] E. "Diabetic nephropathy is prevented by increasing the hemoglobin A1C." [28%]

Explanation Choices A, C, and E are correct. These statements are not accurate and do require further teaching from the nurse. Acute pyelonephritis is a consequence of untreated cystitis. This produces symptoms similar to cystitis in addition to manifestations of flank pain, fever, and dehydration. Massive amounts of proteinuria are a classic manifestation associated with nephrotic syndrome. A 24-hour urine collection is not necessary to diagnose bacterial cystitis. A simple single specimen, urine analysis (UA), would be evaluated to determine if the client has cystitis. Diabetic nephropathy can be prevented by tight glycemic control reflected in the hemoglobin A1C. The higher the A1C equates to more complications such as diabetic nephropathy. Choices B and D are incorrect. These statements are correct and do not require further teaching from the nurse. The cause of AKI may be multifactorial, including the exposure to nephrotoxic medications (NSAIDs, aminoglycosides). PKD is a genetic disorder causing cysts to develop on the affected kidney and may rupture, producing pain and hematuria. This would be an expected finding with PKD. Additional Info Pyelonephritis Pyelonephritis can be divided into either acute or chronic. In acute pyelonephritis, a pathogen ascends the urinary tract causing the client to experience manifestations similar to cystitis as well as fever, tachycardia, and flank pain. Treatment is aggressive antibiotics, hydration, and sometimes hospitalization, depending on its severity. Acute Kidney Injury Acute kidney injury (AKI) is a condition caused by hypotension, nephrotoxic medications, or trauma. Treatment is the underlying cause and prevents complications such as chronic kidney disease progression. Nursing care involves administering prescribed intravenous fluid challenges, daily weights, and dietary measures to reduce sodium and potassium. Bacterial Cystitis Bacterial cystitis is also known as a bladder infection. E. coli is the offending pathogen in this condition. Treatment is antibiotics, hydration, and avoiding bladder irritants (caffeine, alcohol). Polycystic Kidney Disease Polycystic Kidney Disease is a genetic disorder manifested by fluid-filled cysts that grow on the kidneys. Findings in PKD include abdominal or flank pain, hypertension, and hematuria during cyst rupture. The only effective cure for PKD is a kidney transplant. The disease may be treated with ACE inhibitors and dietary modifications (increased sodium intake and the beginning and then decreased as the disease progresses). Diabetic Nephropathy Diabetic nephropathy is a vascular complication associated with diabetes mellitus. Its cause is triggered by poor diabetes management which is evidenced by an increased hemoglobin A1C (goal is to be less than 7% for those with diabetes). Treatment is thorough education on diabetes management through lifestyle modifications. ACE inhibitors are quite effective in treating this disorder.

Seizure precautions have been ordered for a patient admitted to the psychiatric unit. Which of the following nursing interventions is not appropriate when initiating seizure precautions? Select all that apply. A. Pad the side rails of the bed [4%] B. Lower side rails while the patient sleeps [40%] C. Remove hard or sharp objects from the bed [4%] D. Use four point restraints to prevent injury [44%] E. Adhere a fall risk bracelet to the seizure prone patient [8%]

Explanation Choices B and D are correct. Lowering the side rails and using four point restraints are not appropriate actions while deploying seizure precautions. Padded bed rails should remain up while the patient sleeps. Patients should be provided with a call light so that they may call for help if needed. Four-point restraints are not appropriate for the seizing patient and could result in injury. Choice A, C, and E are incorrect. These are appropriate seizure precautions. When initiating seizure precautions, the nurse should ensure that the side rails are padded ( Choice A). All sharp objects should be removed from a patient's bed when instituting seizure precautions ( Choice C). Patients prone to seizures should wear a fall risk bracelet to alert members of the health care team to the patient's need for increased supervision (Choice E). NCSBN client need Topic: Physiologic integrity, reduction of risk potential

The nurse is positioning a client following a liver biopsy. Which position is best suited for this client? A. On the left side with a pillow under the ribs. [26%] B. Supine with a pillow under the client's knees. [7%] C. Face down with a pillow under the hips. [1%] D. On the right side with a pillow under the biopsy site. [65%]

xplanation Choice D is correct. The client should lay on the right side with a pillow against the site of the biopsy at the costal margin to prevent illness. Choice A is incorrect. Clients who have just had a liver biopsy should have pressure on the site of the biopsy. Laying laterally with a pillow underneath the ribs does not provide enough support. Choice B is incorrect. Supine with a pillow under the client's hips is not the best position. This position does not provide any support to the site of the liver biopsy. Choice C is incorrect. Facedown, or prone, is not an appropriate way to lay after a liver biopsy. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential Additional Info

The nurse is instructing a nursing student on the correct application of personal protective equipment (PPE). The nurse should tell the student to apply the PPE in what order? Place each action in the correct order. Apply the gown Secure the mask Apply the goggles/face shield Don gloves

Apply the gown Secure the mask Apply the goggles/face shield Don gloves Explanation For donning personal protective equipment, the nurse should instruct the student to Apply the gown that should be securely fastened behind the neck and waist. Secure the mask that should extend below and under the chin. Fit the goggles/face shield. Don gloves that are a snug fit. Additional Info For donning personal protective equipment, the nurse should instruct the student to Apply the gown that should be securely fastened behind the neck and waist. Secure the mask that should extend below and under the chin. Fit the goggles/face shield. Don gloves that are a snug fit. For doffing personal protective equipment, the nurse should instruct the student to Gloves Goggles/face shield Gown Mask

While working in the resuscitation area of the emergency department, EMS notifies you that a 7-year-old male with an avulsion fracture to the left tibia is 20 minutes out. You know to expect which of the following? A. A fracture that pulls a part of the bone from the tendon or ligament. [63%] B. A fracture with which the whole cross-section of the bone is fractured. [16%] C. A fracture that results from an underlying disease or disorder, not physical trauma or stressors. [12%] D. A fracture that affects only one side of the bone. [9%]

Explanation Choice A is correct. An avulsion fracture pulls a part of the bone from the tendon or ligament. Fractures are a common occurrence and patients often present to the emergency department for treatment. A nurse should be able to recognize different types of bone fractures and plan for appropriate nursing interventions. Choice B is incorrect. A fracture with which the whole cross-section of the bone is fractured is referred to as a complete fracture. Choice C is incorrect. A fracture that results from an underlying disease or disorder, not physical trauma or stressors, is referred to as a pathological fracture. Such fractures are common with metastatic cancer, multiple myeloma, and osteoporosis. Choice D is incorrect. A fracture that affects only one side of the bone is referred to as a greenstick fracture. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Physiological Adaptation

The nurse is teaching a hospital orientation class reviewing standard precaution guidelines. Which situation would require hand hygiene using soap and water only? A. Before eating lunch. [31%] B. Before, after, and between direct patient contact. [46%] C. Before putting on sterile gloves. [17%] D. After contact with objects in the patient's room. [6%]

Explanation Choice A is correct. Hand hygiene is a crucial component of standard precautions. It is the most important measure to prevent the spread of infections among patients. Usually, hand hygiene may be performed either by washing hands with soap and water or by using an alcohol-based waterless antiseptic agent. However, in certain situations, it is mandatory that hand hygiene is performed only by washing hands with soap and water. CDC guidelines call for washing hands with soap and water when hands are visibly dirty, soiled with blood or other body fluids, before eating, and after using the toilet. Choices B, C, and D are incorrect - An alcohol-based waterless antiseptic agent can be used before, after, and between direct patient contact (Choice B), unless hands are visibly soiled. An alcohol-based waterless antiseptic agent may also be used before wearing sterile gloves (Choice C) and after contact with inanimate objects in the patient's room (Choice D).

The nurse is preparing to administer a scheduled intramuscular injection to an apprehensive child. Which therapeutic action should the nurse take? A. Draw a "magic circle" on the area before the injection. [71%] B. Have another nurse hold down the child. [11%] C. Apply EMLA cream to the area immediately before the injection. [14%] D. Administer the medication right after the child's nap.

Explanation Choice A is correct. Techniques to make an intramuscular injection less traumatizing include drawing a magic circle around the area, and after the injection, the nurse may fill in a smiley face. Choices B, C, and D are incorrect. These measures are not therapeutic. Having another nurse restrain the child is not therapeutic and would make the child agitated. EMLA cream may be utilized to attenuate the pain from the injection. However, this cream must be applied 30-60 minutes before the IM injection. Applying it and then immediately proceeding with the injection would not allow the medication to reach its effect. Delaying the injection until the child wakes up from a nap would not be an effective strategy because this would disrupt the dosing schedule of the medication. Additional Info The nurse can strategize ways to make medication administration less upsetting for a child. For IM injections, the nurse may Let child handle syringe, vial, and alcohol swab and give an injection to a doll or stuffed animal. Have the child count to 10 or 15 during the injection. Draw a "magic circle" on the area before injection; draw a smiling face in the circle after injection but avoid drawing on the puncture site.

The patient has a history of chronic venous insufficiency, atrial fibrillation, and varicose veins. Upon assessment, the RN finds the patient to be afebrile with left calf edema, pain, and erythema that is warm to the touch. What is the RN's most urgent concern? A. Deep vein thrombosis (DVT) [90%] B. Cellulitis [8%] C. Osteomyelitis [1%] D. Lymphedema [2%]

Explanation Choice A is correct. The patient has a history of chronic venous insufficiency, atrial fibrillation, and varicose veins, which are all risk factors for developing blood clots. The patient is also presenting with hallmark signs of deep vein thrombosis (unilateral lower leg pain, swelling, and redness). DVT is an emergency because a clot may dislodge and travel, causing a stroke or myocardial infarction. Of the choices, DVT is the most emergent situation. Choice B is incorrect. Cellulitis is an infection in the soft tissue. Although it is typically unilateral, it would not be as urgent as a blood clot. The patient's history of venous problems would not be a relevant risk factor for developing cellulitis. Choice C is incorrect. Osteomyelitis is an infection of the bone, caused by an external pathogen that usually enters the blood or tissue via an open wound. The patient's history of venous problems would not be a relevant risk factor for developing osteomyelitis. Choice D is incorrect. Lymphedema would cause bilateral swelling that is not warm to the touch. NCSBN Client Need Topic: Prioritization, Subtopic: Potential for complications from health alterations, pathophysiology, illness management, medical emergencies

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 [5%] B. 30-40 degrees [79%] C. 10-20 degrees [11%] D. 5-10 degrees [5%]

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

The nurse is caring for a client in the emergency department (ED) experiencing delirium tremens. The nurse should take which initial action? A. Assess the client's pain level. [5%] B. Implement seizure precautions. [79%] C. Obtain a prescription for chlordiazepoxide. [6%] D. Administer the Glasgow Coma Scale (GCS).

Explanation Choice B is correct. Delirium Tremens (DTs) is a medical emergency that may result in seizure activity. The nurse should always put the client's safety at the forefront and provide seizure precautions. This includes padding the side rails, ensuring that intravenous access has been established, oxygen is at the bedside, and suction is available. Choices A, C, and D are incorrect. While assessing a client's pain is an essential task, this is not a pertinent assessment for DTs. The nurse should assure client safety by implementing seizure precautions. Obtaining a prescription for chlordiazepoxide (benzodiazepine) is a reasonable task but does not prioritize over assuring client safety. Benzodiazepines are the hallmark in preventing seizure activity in DTs and increasing the client's comfort during DTs (they experience tachycardia, hypertension, flushing, and diaphoresis). A GCS is not a relevant assessment for DTs, as The Clinical Institute, Withdrawal Assessment Alcohol Scale-Revised (CIWA-Ar) is utilized to determine the severity of the withdrawal. Additional Info Delirium Tremens (DTs) is a medical emergency and may cause autonomic hyperactivity, resulting in tachycardia, diaphoresis, fever, anxiety, insomnia, and hypertension. Delusions and visual and tactile hallucinations are common in alcohol withdrawal delirium. This may occur during 72 hours following the last alcoholic beverage consumed. Withdrawal seizures may occur within 12 to 24 hours after alcohol cessation. These seizures are generalized and tonic-clonic. Additional seizures may occur within hours of the first seizure. Diazepam is given intravenously as a common treatment for withdrawal seizures. Nursing care for DTs include - Rapid assessment of the client's vital signs Initiate seizure precautions and establish patent intravenous access Obtain a prescription for benzodiazepines, such as lorazepam or diazepam Administer intravenous fluids and electrolytes to replete the lost fluids Assess the client using the CiWa-Ar scale to trend the severity of the symptoms

The nurse is giving discharge instructions to the patient who has been prescribed niacin for hyperlipidemia. Discharge instructions should reflect the fact that: A. Monitoring liver status is not needed [5%] B. Facial flushing is often a side effect of the medication [50%] C. Low doses will usually increase the LDL level [10%] D. Hypotension is a common side effect with the medication [35%]

Explanation Choice B is correct. Facial flushing is often a side effect of niacin, mainly when prescribed in high doses. Choice A is incorrect. High doses of niacin can cause liver problems, so the provider will want to monitor liver function tests. Choice C is incorrect. Niacin will usually increase the HDL levels. Choice D is incorrect. Niacin can cause a worsening of high blood pressure, so the nurse should warn the patient with hypertension about this common risk. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-topic: Adverse Effects/Contraindications/Side Effects/Interactions, Endocrine

After reporting to her usual adult medical-surgical floor, the LPN is told she must float to the mother-baby unit. The LPN has never cared for this patient population before. Which of the following actions is most appropriate? A. Refuse the assignment. [1%] B. Float to the mother-baby unit and identify tasks within her training that she can safely perform. [93%] C. Call the nurse manager. [6%] D. Float to the mother-baby unit and ensure no one knows about her inexperience.

Explanation Choice B is correct. Floating to the mother-baby unit and identifying tasks within her training that she can safely perform is the correct action. This promotes patient safety and benefits both the nurse and the unit. Choice A is incorrect. It is not appropriate to refuse the assignment. Nurses may be asked to float to another unit, depending on the hospital census, and it is not beneficial to refuse to take an assignment if asked to float. Choice C is incorrect. It is not appropriate to call the nursing manager. Floating is an acceptable legal practice used by the hospital to solve understaffing. Choice D is incorrect. Floating to the mother-baby unit and ensuring not to let anyone there know she does not have experience in this area is not appropriate and does not promote patient safety. The nurse should identify tasks that she can safely perform. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Fundamentals of care; Ethical & Legal Issues

The client in the delivery room has just delivered her third child. The physician ordered methylergonovine (Methergine) for the client and it was promptly administered. Which manifestation would indicate to the nurse that the medication is having its intended effect? A. The client reports a decrease in pain. [7%] B. The nurse palpates a firm uterus on the client. [71%] C. The client states that she wants to empty her bladder. [7%] D. The client's blood pressure increases.

Explanation Choice B is correct. Methylergonovine promotes vasoconstriction and uterine contraction. A firm and contracted uterus is a sign that the medication is having its desired effect. Choice A is incorrect. Methylergonovine does not control pain. It is an ergot alkaloid that promotes vasoconstriction and uterine muscle constriction. Choice C is incorrect. Methylergonovine does not promote urine production nor stimulate urination. Choice D is incorrect. An increase in blood pressure is a side effect of methylergonovine. Its primary indication/effect is uterine contraction and vasoconstriction, which leads to a rise in blood pressure.

The nurse is about to lift a 350-pound patient using an electric lift attached to the bed and transfer him to a stretcher. What should be the priority nursing action? A. Call for assistance from two staff members. [33%] B. Make sure the client is correctly positioned in the lift prior to operating the lift. [40%] C. Slowly lift the client off the bed. [0%] D. Make sure the stretcher is locked. [26%]

Explanation Choice B is correct. The safety of the client should take priority. The nurse must ensure that the client is safely secured and adequately attached to the lift. Incorrect positioning of the client in the lift's sleeves might put the client at risk for falls. Choice A is incorrect. The lift can be handled by two people, the nurse plus one other staff; there is no need to call for two additional staff members. Moreover, the priority action is to ensure safety by securing the patient on the lift and ensuring proper positioning. Choices C and D are incorrect. The nurse should ensure that the stretcher is locked and then slowly lift the client. However, the priority action is to make sure the client is correctly positioned.

A patient is being discharged from the hospital after being diagnosed with lupus erythematosus. The patient is advised to follow up with what to monitor his condition? A. HbA1C [5%] B. Daily blood pressure checks [8%] C. Monthly urine specimens [17%] D. Monthly CBC

Explanation Choice C is correct. A patient with SLE needs monthly urine specimens to check for proteinuria and any kidney functioning damage. Choices A, B, and D are incorrect. If the client has a history of diabetes, the A1C may be checked at specified intervals, but it is not indicated because of a Lupus diagnosis. Daily blood pressure checks are reported for a client with a diagnosis of hypertension or on new medication for blood pressure/heart disease. Monthly CBC is not meant for a Lupus patient. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

The ICU nurse is caring for a sedated patient on a pressure-cycled ventilator. The ventilator alarm is beeping persistently despite the patient's civil status and stable vitals. What is the most appropriate action for the RN to take first? A. Suction secretions [6%] B. Check tubing for holes or kinks [90%] C. Call respiratory therapy STAT [2%] D. Continue to monitor [2%]

Explanation Choice B is the correct answer. If the patient's presentation and vitals are stable, the nurse should check for any apparent equipment malfunction. If no air leaks or kinks are immediately identifiable, the nurse should call respiratory therapy or the rapid response team (RRT). Persistent alarms despite stable vitals may indicate the patient is trying to talk, or is developing a pneumothorax from increased intrathoracic pressure, or is biting/gagging on the endotracheal tube, or is experiencing bronchospasms. These alarms should never be ignored or turned off, as they may indicate early signs of a change in the patient's condition. Choice A is incorrect. The nurse should assess the patient and breath sounds before performing suction. Choice C is incorrect. The nurse should assess the patient, suction if needed, check the ventilator and tubing, remove excess water from the pipe, and check the endotracheal cuff pressure. If no clear cause for alarm, the nurse should then remove the patient from the ventilator and manually ventilate with an Ambu bag, then call respiratory therapy (STAT). After that, the nurse can continue to assess until mechanical ventilation is resumed. Choice D is incorrect. Alarms should not be ignored or silenced. If unable to determine the cause of fear, the nurse should call for assistance. NCSBN Client Need Topic: Critical care concepts (ventilator), Subtopic: Potential for complications of diagnostic treatments/procedures, the potential for complications from surgical procedures and health alterations, therapeutic procedures

The nurse is preparing to administer prednisone 5 mg to a client with hyperparathyroidism. The nurse understands that prednisone is given to the client because: A. Prednisone increases the client's immune function [16%] B. Prednisone increases the client's Vitamin D levels [5%] C. Prednisone decreases GI absorption of calcium [30%] D. Prednisone decreases the release of calcium by the bones [48%]

Explanation Choice C is correct. Prednisone decreases the absorption of calcium in the gastrointestinal system thereby reducing serum calcium levels in the patient with hyperparathyroidism. Choice A is incorrect. Prednisone is an immunosuppressant. It does not promote immune function. Choice B is incorrect. Prednisone does not have any effect on Vitamin D levels. Choice D is incorrect. Etidronate (Didronel) and calcitonin are drugs that prevent the release of calcium from the bones, not prednisone.

The movement of a client from a lower to a higher level of care and intensity of care is an example of: A. A decreasing level of acuity [12%] B. Retrospective reimbursement [10%] C. Movement along the continuum of care [66%] D. Prospective reimbursement

Explanation Choice C is correct. The movement of a client from a lower to a higher level of care and intensity of care is an example of change along the continuum of care. The continuum of care moves from primary prevention to secondary prevention and then to tertiary prevention. It also moves from a lower to a higher level of acuity when the client's condition worsens and from a higher to a lower level of acuity when the client's health improves because the client has needs that can perhaps be met with fewer and less intense services/care. Choice A is incorrect. The movement of a client from a lower to a higher level/intensity of care is an indication that the client has a more elevated and not decreasing level of acuity. Choice B is incorrect. Retrospective reimbursement is no longer used in healthcare. Choice D is incorrect. Although prospective reimbursement requires the movement of a client based on medical necessity, potential compensation is not, in itself, progression in the continuum of care.

A patient presents with a body mass index (BMI) of 14. The nurse expects which of the following nursing interventions to be implemented? A. Make sure the patient eats complete meals twice daily. [7%] B. Reduce total fat and calorie intake for the client. [3%] C. Provide additional high protein and calorie shakes. [88%] D. Increase the intake of green leafy vegetables.

Explanation Choice C is correct. The patient is underweight. Body mass index (BMI) is calculated as weight in kilograms divided by height in meters squared. A BMI of 18.5-24.9 is considered healthy. A BMI of less than 18.5 is underweight. A BMI of 25-29 is overweight and a BMI of 30 or higher is obese. To increase BMI, adding healthy food choices is essential. Foods that are rich in nutrients and high in calories include brown rice, granola, raisin bran cereals, bananas, dried apricots, avocados, sweet potatoes, peas, yogurt, milk, and fatty fish such as salmon and tuna, tofu, beans, lean red meat, nuts, and seeds. Choice A is incorrect. An underweight patient should not be limited to two meals daily. Choice B is incorrect. Calorie intake should be increased, not decreased. Choice D is incorrect. An increase in green leafy vegetables is not indicated to increase BMI. Instead, the patient needs an increase in protein and calories. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential

The nurse is assigned a client with Bell's palsy. This client's affected eye does not blink. The nurse's plan of care should include which of the following? A. Providing the client an eye patch to be taped to the affected eyelid at all times [34%] B. Instruct the client to keep both eyes closed [1%] C. Evaluate the pupil's reaction to light and accommodation [16%] D. Obtain a physician's order for application of eye lubricant [48%]

Explanation Choice D is correct. Bell's palsy is a lower motor neuron facial nerve palsy that can result in the weakness of facial muscles and the muscles responsible for eye-closure ( orbicularis oculi) . A client with Bell's palsy who is unable to blink, would not be able to close the affected eye. As a result, the cornea becomes overly dry, there is a risk of corneal ulceration and scarring. Artificial tears must be applied as often as every hour during the day to keep the eye moist and prevent corneal drying. A moisturizing eye ointment may be used at night. The nurse should, therefore, ensure that a doctor's order is obtained for eye lubrication or artificial tears to prevent corneal drying. Choice A is incorrect. Applying an eye patch with a tape on the eyelid may cause the patch to slip into the open eye and cause corneal abrasion. During the day, the client should protect the open eye with glasses or goggles. During the night, the client may use soft eye patch to cover the open eye but it should not be taped to the eyelid. Instead, the pad should be secured with one end of the tape on client's forehead and the other end to the cheek diagonally. Choice B is incorrect. It is not necessary to keep the unaffected eye closed. Choice C is incorrect. The pupil's reaction to light and accommodation is not affected by Bell's palsy.

The nurse assesses a client's central venous catheter dressing, and it appears loose and wet. The nurse should take which action? A. Reinforce the dressing with paper tape [2%] B. Remove the dressing and the central vascular device [4%] C. Apply a clean occlusive dressing to the site [7%] D. Clean the site and apply a new sterile dressing [87%]

Explanation Choice D is correct. When moisture comes into contact with a sterile dressing, this causes contamination. The nurse should prepare to change the dressing using medical asepsis to remove the old dressing and surgical asepsis to apply the new dressing. Choices A, B, and C are incorrect. Reinforcing the dressing with paper tape would be inappropriate. Moisture causes contamination, and the nurse should intervene and change the dressing. Removing the central line would be inappropriate as the issue is with the dressing - not the catheter. An occlusive dressing does not need to be applied as the old dressing needs to be removed, the site cleaned with chlorhexidine, and a new central line dressing applied. Additional Info The central line should be anchored with a securement device and covers the site with a sterile bio-occlusive dressing. Central line dressings should be changed at least every 7 days or immediately if dressing integrity is disrupted (e.g., lifted/detached on any border edge or within transparent portion of dressing, visibly soiled, presence of moisture, drainage, or blood).

Which of the following statements are true regarding neural tube defects? Select all that apply. A. Types of neural tube defects include spina bifida occulta, spina bifida cystica, meningocele, and myelomeningocele. [40%] B. The nurse should protect the exposed sac by covering with a sterile, moist, non-adherent dressing. [37%] C. Left-lateral is the optimal position to minimize tension on the sac. [12%] D. Neurological deficits are always present in patients with neural tube defects. [11%]

Explanation Choices A and B are correct. Spina bifida occulta, spina bifida cystica, meningocele, and myelomeningocele are the types of neural tube defects (Choice A). If there is exposed spinal cord or meninges in a sac, it is essential to cover them with a sterile, moist, non-adherent dressing. This prevents infection and maintains the moisture of the pouch containing the spinal cord and meninges (Choice B). Choice C is incorrect. Prone is the best position to place the infant so that tension is minimized and the risk of trauma is reduced. Choice D is incorrect. Neurological deficits are not present with all neural tube defects. With spina bifida occulta and meningocele, neurological deficits are not usually present. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Neurology

Which of the following rhythm changes will have an impact on cardiac output? Select all that apply. A. Supraventricular tachycardia [28%] B. Sinus bradycardia [18%] C. Ventricular tachycardia [30%] D. Mobitz type II heart block [23%]

Explanation Choices A, B, C, and D are all correct. All rhythm changes will affect cardiac output. This is especially important to remember when you are administering antiarrhythmics to your patient, as these medications and their effect will also change the cardiac output. There are two reasons that rhythm changes affect cardiac output. 1 - they break your heart rate. 2 - they change your stroke volume. Remember, CO = HR x SV, so any change to either heart rate or stroke volume subsequently affects your cardiac output. A - Supraventricular tachycardia (SVT) - There is an increase in heart rate, but a decrease in stroke volume. This is because the heart is beating so fast that there is not enough time for diastole and, therefore, not enough time for the atriums to fill with blood. This decreases preload, which decreases contractility due to starling's law, which reduces stroke volume. Patients in SVT have decreased cardiac output. B - Sinus bradycardia - The heart rate is lower, due to bradycardia, so the cardiac output is lowered. Remember, CO = HR x SV. Decreased HR = decreased CO. C - Ventricular tachycardia - There is an increase in heart rate and a decrease in stroke volume. This is because the heart is beating fast and irregularly. There is not enough time for diastole and therefore not enough time for the atriums to fill with blood. This decreases preload, which decreases contractility due to Starling's law, which reduces stroke volume. Patients in VT have decreased cardiac output. This is a lethal rhythm. D - Mobitz type II heart block - This type of heart block causes a decreased heart rate, which once again decreases cardiac output. CO = HR x SV. Decreased HR = decreased CO. Patients in Mobitz type II heart block have decreased cardiac output. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Cardiac

A cast is applied to a thirteen-month-old girl for the treatment of talipes equinovarus (clubfoot). Which of the following instructions should the nurse give the child's mother regarding the child's care while in the cast? Select all that apply. A. "It is important to do frequent skin checks around the edges of the cast." [23%] B. "Pay attention if your child expresses discomfort that may suggest numbness or tingling in her toes." [23%] C. "Reassure your child that this type of cast will be removed in a week for good." [0%] D. "Check the temperature and color of the skin on your child's feet." [24%] E. "Ask the child once per day if she feels that the cast is too tight." [7%] F. "Call the doctor if the child has pain unrelieved by medication." [22%]

Explanation Choices A, B, D, and F are correct. Caregiver education is essential for the proper care of a young child. A thirteen-month-old child may cry if they are uncomfortable or in pain but will not be able to articulate what the pain feels like or where it is coming from. The parent should be educated on warning signs of impaired circulation and comfort measures. Choices A and D: Skin checks around the edges of the cast are an excellent way to check for impaired circulation. Assessing the color and temperature of the skin will help determine any circulatory compromise. Choice B: Although the thirteen-month-old may not use the words numbness or tingling, they can likely express discomfort, which should be assessed. Choice F: Any time pain is persistent and unrelieved by medication, the physician should be notified. Choice C is incorrect. The casts for talipes equinovarus are reapplied weekly, so this is likely not the child's last cast. Choice E is incorrect. The child will likely say that the cast is too tight because it is an unfamiliar feeling. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Basic Care and Comfort

While working in the PICU, you are assigned to a 12-year-old male who is 1-hour post-op from transsphenoidal hypophysectomy. He has 2 PIV's, is on room air, has an NG tube, and a foley catheter. You complete your assessment and note the following: HR: 141 RR: 24 Temp: 37.1 O2: 99% PIV's: Patent and saline locked NG: No drainage, clamped Foley: 400 mL of clear urine Which of the following actions are appropriate given your assessment? Select all that apply. A. Notify the health care provider of the urine output. [34%] B. Request an order for IV fluids. [24%] C. Document your findings. [38%] D. Initiate NC 2L O2 at 100%. [3%]

Explanation Choices A, B, and C are correct. A is correct. This is an excessive amount of urine output for 1 hour and is concerning for diabetes insipidus given the procedure the patient recently underwent. Any urine output greater than 300 mL is alarming and the healthcare provider should be notified immediately. Diabetes insipidus is a severe complication from neurosurgery that occurs around the pituitary. This amount of urinary output can lead to shock if not treated promptly. B is correct. Requesting an order for IV fluids is an appropriate nursing action given your assessment. You are concerned about the possibility of DI considering the excessive urine output and there is no fluid replacement currently ordered for this patient. This is concerning for shock, and IVF should be initiated to rehydrate and adequately replace losses from the urinary output. C is correct. These findings should be accurately documented to ensure proper follow-up and orders for this patient. Choice D is incorrect. No oxygen therapy is indicated for this patient at this time. His O2 saturation is adequate on room air, he is not tachypneic, and the question stem gave you no other information to indicate that there was an increased work of breathing or oxygen requirement. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Fluid & Electrolytes

The nurse is caring for a patient who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions? Select all that apply. A. Major Depressive Disorder [33%] B. Attention Deficit Hyperactivity Disorder [5%] C. Obsessive-Compulsive Disorder [17%] D. Generalized Anxiety Disorder [28%] E. Bipolar Disorder [16%]

Explanation Choices A, C, and D are correct. Sertraline is a Selective Serotonin Reuptake Inhibitor (SSRI). This medication is efficacious in depression, anxiety, and obsessive-compulsive disorders. Choices B and E are incorrect. Sertraline is not indicated for bipolar disorder because it may exacerbate the condition. Attention Deficit Hyperactivity Disorder (ADHD) is a condition that is treated with psychostimulants such as amphetamines or methylphenidates. Additional information: Sertraline being serotonergic, requires time to become efficacious. Two to four weeks is usually required for the patient to achieve a response. The nurse should counsel the patient to report worsening of their mood and any suicidal ideations. Gastrointestinal side effects are common with SSRIs and may decrease by taking the medication with food.

Which of the following are not part of the upper respiratory tract? Select all that apply. A. Adenoids [24%] B. Trachea [18%] C. Sinuses [11%] D. Pharynx [10%] E. Epiglottis [10%] F. Bronchus [27%]

Explanation Choices B and F are correct. The trachea and bronchi belong to the lower respiratory tract, not the upper. The respiratory tract is divided into two sections: the upper respiratory tract and the lower respiratory tract. The upper respiratory tract and the mouth function as the entry point of air and food into the body. The nose, mouth, and throat serve as a common channel for air to reach the lungs and food to enter the esophagus and stomach. The upper respiratory tract warms, filters, humidifies, and transports air into the lower respiratory tract. The upper respiratory tract includes the nostrils, nasal cavities, pharynx, epiglottis, and larynx. Pharynx is often referred to as Throat. Larynx ( voice box) is the portion of the airway between the pharynx and the trachea. Larynx is the transition point between upper and lower respiratory tracts. The larynx contains two important parts: the epiglottis and the vocal cords. The lower respiratory tract includes the trachea, bronchi, bronchioles, and lungs. Choices A, C, D, and E are incorrect. All of these answer choices constitute parts of the upper respiratory tract. Adenoids (Choice A) are lymphatic glands located behind the nasal cavity, usually at the nasopharynx (a part of the upper respiratory tract). Adenoids and the tonsils belong to the lymphatic system. They help fight infections. Sinuses (Choice C), throat/pharynx (Choice D), and epiglottis (Choice E) are parts of the upper respiratory tract as well. Knowing the parts of the respiratory system helps the nurse to identify the source/site of the symptoms. Certain serious conditions like epiglottitis in children should be identified right away. The epiglottis is a component of the larynx. It is a small, movable leaf-like structure just above the larynx that serves as a lid, preventing food and drink from entering the airway. If the epiglottis becomes swollen (epiglottitis), it may obstruct the airway. Epiglottitis refers to infection/inflammation of the epiglottis, which may cause stridor, and is characterized by the "four D's" - dysphagia (difficulty swallowing), dysphonia (muffled voice), drooling, and distress. Stridor is a high-pitched sound during breathing. An inspiratory stridor (stridor during breathing in) suggests airway obstruction above the glottis, such as in the case of acute epiglottitis. NCSBN Client Need I Topic: Health Promotion and Maintenance, Subtopic: Nose, Sinuses, Mouth, and Throat; Structure and Function

A client was admitted for acute exacerbation of asthma. Auscultation findings reveal almost absent breath sounds. Albuterol nebulization was administered. Thirty minutes later, the nurse auscultates and hears diffuse inspiratory and expiratory wheezes throughout the lung fields. This finding means: A. There is increased airflow [69%] B. There is no improvement in the airflow [9%] C. There is worsening of the condition [18%] D. The airflow issue was not addressed

Explanation Choice A is correct. Changes in breath sounds indicate that the client has responded to treatment. When the client came in, there were nearly absent breath sounds, indicating that there was severe airflow obstruction. A noisy chest is a sign that airflow has improved even though they are still partially obstructed. Choices B, C, and D are incorrect.

The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PHCP)? A. WBC 19,000 mm3 [69%] B. Hemoglobin 9 mg/dL [17%] C. Calcium 8.6 mg/dL [5%] D. Serum pH 7.33

Explanation Choice A is correct. The biggest complication associated with peritoneal dialysis is peritonitis. Manifestations associated with peritonitis include fever, abdominal rigidity, purulent effluent, and nausea/vomiting. Choices B, C, and D are incorrect. A client with chronic kidney disease will have anemia, hypocalcemia, and metabolic acidosis. These are all expected findings and do not need to be reported to the PHCP. The anemia is related to the kidney's inability to secrete erythropoietin (EPO). Hypocalcemia is linked to the inability of the kidneys to recycle vitamin D. Finally, acidosis is consistent because of the kidney's inability to regulate sodium bicarbonate. Additional information: When caring for a client performing peritoneal dialysis, it is essential to reinforce measures to reduce the risk of infection. These measures should include meticulous hand hygiene, sterile dressing to the catheter insertion site, and appropriate cleaning of the insertion site with antibacterial soap and water. NCSBN Client need: Topic: Physiological Adaptation; Subtopic: Illness Management

When a patient refuses to stay in the hospital, the nurse stops him from leaving due to her concern for his health. Which legal charge could this nurse face? A. False imprisonment: the nurse is not allowing the patient to leave as he has decided to. [80%] B. Malpractice: the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty [6%] C. Negligence: the nurse ignored the patient's right to choose with regard to his healthcare. [5%] D. Invasion of privacy: as the nurse is getting involved in the patient's private decisions regarding healthcare. [9%]

Explanation Choice A is correct. Refusing to let a patient leave against medical advice (AMA) is a form of false imprisonment and is a legal issue for nurses. Nursing liability is usually involved with tort law. The nurse needs to know the differences between professional negligence (an unintentional tort) and intentional tort. Nurses must also recognize those nursing situations in which negligent actions are most likely to occur and take measures to prevent them. Choice B is incorrect. Malpractice is professional negligence; negligence that occurred while the person was performing as a professional. Malpractice applies to primary care providers, dentists, lawyers, and generally includes nurses. Choice C is incorrect. Negligence and professional negligence are examples of unintentional torts that may occur in the health care setting. Negligence is misconduct or practice that is below the standard expected of an ordinary, reasonable, and prudent person. Such conduct places another person at risk for harm. Both nonmedical and professional individuals can be liable for the negligent act. Choice D is incorrect. Invasion of privacy injures the feelings of the person and does not take into account the effect of revealed information on the reputation of the person in the community. The right to privacy is the right of individuals to withhold themselves and their lives from public scrutiny. It can also be described as the right to be left alone. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care, Potential Areas of Liability

A 7-year-old child is brought to the emergency department because of a fall. A fractured arm was confirmed and a plaster cast was applied. The nurse is providing instructions to the child's mother regarding the cast. Which statement by the mother necessitates further instructions from the nurse? A. "As the cast dries, it can feel a bit warm." [5%] B. "I'll just put some powder or lotion on the edges of the cast in case my child complains of an itch." [52%] C. "I can use shoe polish to clean the cast." [35%] D. "I can use a blow dryer on the cool setting to dry the cast in case it gets wet." [8%]

Explanation Choice B is correct. This is an incorrect statement and indicates a need for nurse reinforcement of teaching (therefore, this is the correct answer to the question). The patient is not allowed to put lotion or powder into the cast as it may be sticky and cause skin irritation. Choice A is incorrect. This is a correct statement. As the cast dries, it feels a bit warm due to the water evaporating and the patient's body heat. Choice C is incorrect. This is a correct statement. The cast can be cleaned by using shoe polish. Choice D is incorrect. This is a correct statement. The cast may be dried using a blow dryer on a lower setting.

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. [4%] 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. [82%] 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. [10%] D. Heparin was refused during the shift. Risks reviewed. [4%]

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

An emergency response nurse has just arrived on the scene of a 911 call. The patient is unconscious and without a pulse. The nurse's priority action is to: A. Administer two rescue breaths. [1%] B. Begin chest compressions. [70%] C. Check the patient for a patent airway. [29%] D. Ask another health care professional to check the carotid artery. [1%]

Explanation Choice B is correct. If the nurse has found an unconscious and pulseless patient, they should begin chest compressions. Immediate chest compressions are the most effective way to maintain total body oxygenation. Choice A is incorrect. Rescue breaths, while important, should not be initiated at this point. Instead, rescue breaths should be started if the patient is apneic and after chest compressions have been undertaken. Choice C is incorrect. While checking a pulseless patient for a patent airway is a reasonable step, it is not the best action at this point. Choice D is incorrect. Asking another health care professional to check for pulselessness delays necessary treatment. NCSBN client need Topic: Safety and Infection Control: Emergency Response Plan

The nurse is caring for a client receiving nifedipine. Which of the following findings would indicate a therapeutic response? A. Sinus rhythm on the electrocardiogram [17%] B. Blood pressure 128/77 mm Hg [79%] C. Total cholesterol 180 mg/dl [2%] D. Weight loss of 2 kilograms [1%]

Explanation Choice B is correct. Nifedipine is a calcium channel blocker and is indicated for hypertension. A therapeutic effect of this medication would be normal blood pressure. This medication does not lower heart rate compared to other calcium channel blockers (verapamil and diltiazem). Choices A, C, and D are incorrect. Nifedipine is not indicated for arrhythmias, and thus, normal sinus rhythm would not be an accurate outcome related to this medication. This medication does not lower cholesterol levels or have a diuretic effect. Additional Info Calcium channel blockers are medications such as verapamil, nifedipine, and diltiazem. Verapamil and diltiazem are rate-lowering calcium channel blockers. These medications are indicated for arrhythmias such as atrial fibrillation. The nurse should assess the patient's blood pressure and heart rate before administering these two medications. Nifedipine does not lower the heart rate when compared to verapamil or diltiazem. Calcium channel blockers are contraindicated in heart failure, and they should not be taken concurrently with grapefruit products.

The nurse is administering Pitocin intravenously to a client having an induction of labor. The nurse notes that the client's fundus has been contracting non-stop for the past 5 minutes. Assessment of fetal heart reveals 95 beats per minute. What should be the nurse's initial action? A. Place the client in Trendelenburg position [4%] B. Stop the infusion [85%] C. Administer oxygen via facemask [8%] D. Administer IV fluids at a high rate [3%]

Explanation Choice B is correct. The nurse should immediately stop the infusion of Pitocin, as there is already evidence of fetal distress. Turning off the Pitocin infusion relieves hypoxia. Choice A is incorrect. The nurse should place the client in a side-lying position to aid in improving fetal circulation. The Trendelenburg position is used in situations of cord prolapse. Choice C is incorrect. The nurse should start oxygen to aid fetal circulation; however, this should not be the priority intervention. Choice D is incorrect. IV fluids at a high rate would help the client when she needs hydration; however, in this case, hydration is not necessary as the cause of the problem is the infusion of Pitocin.

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. [13%] B. Inflates the tracheostomy's cuff with 5 mL of air prior to suctioning. [74%] C. Preoxygenates the client with 100% oxygen prior to suctioning. [3%] D. Provides mouth care after suctioning the tracheostomy. [9%]

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 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 reviews a client's understanding of newly prescribed nitroglycerin sublingual tablets. Which of the statements, if made by the client, would require follow-up? A. "I will get a refill of my prescription every six months." [6%] B. "I will take one tablet every 2 minutes if chest pain occurs." [13%] C. "I will place my medication in a dark amber bottle." [77%] D. "I must not chew on the tablet when taking it." [4%]

Explanation Choice B is correct. This statement is incorrect and requires follow-up. When chest pain occurs, the client should take one tablet of nitroglycerin sublingually every five minutes for three doses. Taking the medication too frequently may result in severe hypotension. Choices A, C, and D are incorrect. These statements are factual and do not require follow-up. Nitroglycerin expires after six months and should be replaced. The client should seek emergency care if the chest pain does not improve after the first dose. Nitroglycerin tablets are not to be swallowed or chewed but kept under the tongue. Finally, nitroglycerin is photosensitive and should be kept in the dark amber bottle. Additional Info Nitroglycerin is a potent vasodilator (it decreases preload and afterload). It is indicated in angina. It is given in a variety of preparations, including sublingual, translingual, and topical. Dosing for sublingual nitroglycerin is one tablet under the tongue every five minutes (as long as the chest pain is persisting). The maximum tablet (or sprays) is three. The client should be instructed that emergency care should be sought if the pain is not relieved after the first dose. Nitroglycerin expires after six months, and the client should be instructed to keep their supply current. Nitrates are contraindicated if the client is taking medications such as vardenafil, tadalafil, or sildenafil. The client should take the nitroglycerin in a sitting or laying down position because sudden movement changes may cause orthostatic hypotension. Headache is an expected side effect of this medication and may be treated with acetaminophen. Nitroglycerin cannot be applied to a client for 24 hours as the client will develop a tolerance. Blood pressure should be monitored closely.

Your 75-year-old female client complains of pain due to post-herpetic neuralgia. She is taking Naproxen. Which of the following analgesics should additionally be added to her pain management regimen? A. Oxycodone [30%] B. Acetaminophen [26%] C. Ibuprofen [15%] D. Topical lidocaine [29%]

Explanation Choice D is correct. Topical lidocaine is a co-analgesic. Co-analgesics are also referred to as adjuvant analgesics. It is crucial to use adjuvant analgesics for adequate pain control before moving to initiate opioid analgesics ( according to the World Health Organization's pain ladder). Topical lidocaine is very useful in local control of post-herpetic neuralgia pain. The lidocaine patch provides analgesia by reducing the abnormal firing of sodium channels on injured pain nerve fibers directly under the patch. Topical patches are considered relatively safe because only less than 5% of the topically applied lidocaine is absorbed. Choice A is incorrect. Oxycodone is not a co-analgesic. It is an opioid analgesic. Choice B is incorrect. Acetaminophen is not a co-analgesic. It is classified under non-opioid analgesics. Choice C is incorrect. Ibuprofen is not a co-analgesic. It's a non-opioid analgesic and an NSAID (non-steroidal anti-inflammatory agent), like Naproxen.

The nurse is giving discharge instructions to a client recently diagnosed with vaginitis. Which of the following instructions should the nurse include? A. Use oral contraceptives during sexual intercourse. [2%] B. Practice regular douching. [6%] C. Abstain from eating yogurt. [2%] D. Wear loose-fitting clothing and cotton underwear. [90%]

Explanation Choice D is correct. Clients are encouraged to wear loose-fitting clothing, cotton underwear, avoid tight pants and thongs, as well as avoid using tampons to facilitate ventilation and improve circulation. Choice A is incorrect. The client should use a condom during sexual intercourse to prevent her partner from acquiring the infection. Oral contraceptives do not provide a barrier that prevents disease. Choice B is incorrect. Clients are advised not to practice regular douching unless prescribed by the healthcare provider. Choice C is incorrect. Clients are advised to include yogurt or supplements containing Lactobacillus acidophilus in their diet to maintain vaginal flora.

Crisis helplines are highly important due to which of the following? A. Facilitates the ability of the nurse to visit the home. [1%] B. Allows the caller and the call center to plan follow-up care. [7%] C. Serves as a cost free way to develop new coping strategies. [9%] D. Often saves lives when a person is in a severe crisis. [83%]

Explanation Choice D is correct. Crisis helplines are highly relevant because these helplines often save lives when a person is in a severe crisis. These helplines are staffed with people who use somewhat scripted verbal communication that addresses the here and now of the crisis. The caller can remain anonymous if they choose to do so. They are also allowed to solve their immediate problem and be able to cope with their stressors in the crisis. Choice A is incorrect. Call centers for crises do not facilitate a visit to the person's home, but they do provide other needed help. When necessary, they may call for help to the person's house when the client's life is in danger. Choice B is incorrect. Although these call centers allow the caller and the call center to remain on the line, follow-up care is encouraged, but it is not planned. Choice C is incorrect. Crisis call lines are free of cost, but these lines are not intended to help the client to develop new coping strategies; this is done during the follow-up to the immediate crisis.

A client who has sustained a sports injury just underwent a diagnostic arthroscopy of the left knee. Which of the following should the nurse prioritize assessing after the procedure? A. Wound and skin integrity [4%] B. Mobility assessment [11%] C. Skin and vascular assessment [16%] D. Circulatory and neurologic assessments

Explanation Choice D is correct. Knee arthroscopy is a common orthopedic procedure. Among the potential complications of knee arthroscopy, the most devastating complication is the development of "acute compartment syndrome." Following an arthroscopy, swelling may occur in the affected limb due to the extravasation of fluid in the leg. Such fluid accumulation increases the compartment pressures and carries a risk of compartment syndrome. Acute compartment syndrome can be limb-threatening and is an emergency because it can cause impairment of the neurological and circulatory functions of the limb. Symptoms include increasing pain and paresthesia. Early signs of compartment syndrome include swelling, pallor, cool extremity, numbness, and weak pulses. Late signs include pulselessness and paralysis. It is, therefore, a priority to assess the neurological and circulatory status of the extremity and ensure that it is intact. Once the neurologic and circulatory integrity is established, the nurse may proceed to address the concerns of the skin integrity, mobility, and the wound. Choices A, B, and C are incorrect. The priority action is to assess and monitor for any presenting signs and symptoms of acute compartment syndrome. The neurologic and circulatory functions must be assessed first. If compartment syndrome is detected early, irreversible damage can be prevented. Assessment of the skin integrity, mobility, and wound status is also important but should follow the priority action of assessing neurological and circulatory status. Inability to move the limb (paralysis) and complete absence of pulses are often late signs of compartment syndrome, not the early signs. The nurse should not wait until the late signs develop since the presence of late signs indicate the damage may be irreversible.

A depressed pregnant patient is being seen in the clinic. Her physician has suggested that she try an anti-depressant to treat the condition. But the patient is nervous. The nurse should explain that all of the following are possible outcomes of untreated depression, except: A. Teratogenicity [42%] B. Non-adherence to prenatal care [8%] C. Tobacco use [22%] D. Respiratory distress post-birth [27%]

Explanation Choice D is correct. Respiratory distress is not caused by untreated depression during pregnancy. Choices A, B, and C are all incorrect. Teratogenicity, non-adherence to prenatal care, and tobacco use are associated issues with untreated depression in pregnancy. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care

While working in the emergency department, the nurse assesses a 3-day old infant brought in by the mother. The mother states, "My baby is always so sweaty and hot, and just doesn't want to eat! I think something is wrong." The nurse is unable to palpate a femoral pulse but notes +3 brachial pulses. Based on this assessment, which congenital heart defect does the nurse suspect? A. Hypoplastic left heart syndrome (HLHS) [10%] B. Patent ductus arteriosus (PDA) [26%] C. Transposition of the great arteries (d-TGA) [18%] D. Coarctation of the aorta (COA) [46%]

Explanation Choice D is correct. The nurse suspects that this infant has coarctation of the aorta. In this defect, there is a stricture in the aorta preventing blood flow out of the left ventricle. It usually occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. So blood flow to the upper body is abundant, but hardly any of it can make it to the lower part of the body. Therefore, there are decreased lower extremity pulses and increased upper extremity pulses. Choice A is incorrect. The nurse does not suspect that this infant has hypoplastic left heart syndrome (HLHS). HLHS is characterized by a very small, underdeveloped left atrium, ventricle, and aorta. Essentially, the entire left side of their heart is not developed. This infant will appear cyanotic and quickly show signs of heart failure, but will not present with absent femoral pulses and +3 brachial pulses. The nurse suspects a different congenital heart defect. Choice B is incorrect. The nurse does not suspect that this infant has a patent ductus arteriosus. The ductus arteriosus is a normal duct in fetal circulation which allows oxygenated blood to shunt from the pulmonary artery to the aorta and bypass pulmonary circulation. It should close shortly after birth, but if it does not, it is known as a patent ductus arteriosus (PDA). These infants present with a machine-like murmur but do not have absent femoral pulses and +3 brachial pulses. The nurse suspects a different congenital heart defect. Choice C is incorrect. The nurse does not suspect that this infant has transposition of the great arteries. In this defect, the pulmonary artery and aorta are switched. This creates two separate loops for blood circulation: deoxygenated blood entering the right atrium from the body and then being sent directly back out to the body via the transposed aorta, and oxygenated blood entering the left atrium from the lungs and being sent back to the lungs via the transposed pulmonary artery. These two closed loops can only be connected via a hole in the septum; either an ASD, VSD, PDA, or PFO. The child will be dependent on one of these holes for any systemic oxygenation. They will be very cyanotic at birth but do not have absent femoral pulses and +3 brachial pulses. The nurse suspects a different congenital heart defect. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Physiological adaptation, Pediatrics - Cardiac

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?" [7%] B. "Hello, my name is Susan Jones and I am your nurse for today." [14%] C. "How are you today? Remember, you're in the hospital." [1%] D. "Good morning. You're in the hospital. I am your nurse, Susan Jones." [78%]

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

Your client had an appendectomy 4 to 5 days ago. He is tolerating an oral diet. Which of the following assessment findings would be a priority? Select all that apply. A. WBC count [32%] B. Hydration status [22%] C. Temperature [33%] D. Pulses [13%] Incorrect Correct Answer(s): A,C

Explanation Choices A and C are correct. Monitoring the patient's WBCs is an essential consideration after an appendectomy. The patient is at risk of infection, so monitoring for a rising WBC count will assist in identifying any disease early. The most common complication after appendectomy is wound infection and it occurs about 4-5 days following the surgery (Choice A). Monitoring the patient's temperature is an important consideration after an appendectomy. The patient is at risk of infection, so monitoring for fever will assist in identifying any disease early (Choice C). Choice B is incorrect. While monitoring hydration status is vital in all patients, it is not the priority for a 4-day status-post appendectomy patient who is tolerating an oral diet. The primary risk after this surgery is an infection, so monitoring for signs and symptoms of the disease is the priority. Choice D is incorrect. While monitoring pulses is vital in all patients, it is not the priority for a postoperative appendectomy patient. The primary risk after this surgery is an infection, so monitoring for signs and symptoms of the disease is the priority. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Infection control and safety; Pediatrics - Gastrointestinal

You are assessing a 9-month-old infant in the clinic. Which of the following findings requires follow up? Select all that apply. A. Infant sits up with the help of mom [39%] B. Infant is rolling over from front to back [7%] C. Infant holds a cube in the palm of his hand and closes his fingers around it [4%] D. Infant cannot bring toys to their mouth [50%]

Explanation Choices A and D are correct. A is correct. This finding requires follow-up. At 7 months old, the infant should be able to sit up without any support. This milestone is a gross motor skill that should be achieved around 6 to 8 months. So at 9 months old, if the infant still requires help from mom to sit up, this needs to be further evaluated. D is correct. This finding requires follow-up. At 4 months of age, the infants should have developed the fine motor skill of bringing objects to their mouths. This is an important way that infants explore the world around them, and it is not normal for a 9-month-old infant to not be able to bring toys up to their mouth. The nurse should follow up on this finding, as it is abnormal. Choice B is incorrect. This does not require any follow-up. Rolling over completely from front to back is a gross motor skill that should be achieved by 6 months of age. At 9 months of age, it is appropriate that the infant is able to do this. Choice C is incorrect. This does not require any follow-up. Holding a cube in the palm of their hand and closing fingers around it describe the palmar grasp, which is a fine motor skill that should be developed by 6 months of age. This is an appropriate developmental milestone for the 9-month-old infant, so no further follow up is needed. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics - Development

The charge nurse is planning patient care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following patients would be most appropriate to assign to the LPN? Select all that apply. A. A patient receiving antibiotics for lower extremity cellulitis. [29%] B. A patient newly admitted with an exacerbation of myasthenia gravis. [1%] C. A patient with a chest tube and receiving mechanical ventilation. [7%] D. A patient requiring a referral for an outpatient support group. [7%] E. A patient needing to receive intramuscular RhoGAM. [23%] F. A patient needing scheduled tube feedings and colostomy irrigations. [33%]

Explanation Choices A and F are correct. When making patient assignments, the LPN should be assigned to the stable patient with a predictable outcome. A patient receiving antibiotics for lower extremity cellulitis is a low acuity illness and may be cared for by the LPN. Scheduled tube feedings and colostomy irrigations are within the scope of an LPN, and this can be delegated. Choices B, C, D, and E are incorrect. The RN should assume care for patients who are unstable and may have unpredictable outcomes. The patient having an exacerbation of myasthenia gravis may be unstable and required frequent assessment. A patient receiving mechanical ventilation with a chest tube has an unpredictable outcome and should be assigned to the RN. An RN can only initiate referrals, and thus, this patient is appropriate for the RN. RhoGAM is a blood product and can only be given by an RN. Additional information: When making patient assignments, the nurse should always assign the most unstable patient to the RN. This also involves patients requiring initial assessments or discharge teaching. The LPN may reinforce teaching, data collection, and care for patients with low acuity illnesses. Additional Info

The nurse is caring for a patient with dementia who exhibits increased confusion during the evenings and frequently attempts to get out of bed. Which interventions would be appropriate for the nurse to implement before resorting to physical restraints? Select all that apply. A. Initiate toileting schedule [25%] B. Place patient near the nurses' station [35%] C. Keep one bedrail fully up and the other side half up [5%] D. Implement electronic bed alarm [34%]

Explanation Choices A, B, and D are correct. A: Patients with dementia often experience increased confusion during evenings (sundowning effect) and may not be able to effectively communicate their needs. Cognitively impaired patients who frequently try to get out of bed at night may be attempting to get to the bathroom. This nurse and other members of the patient's care team should implement a toileting schedule for this patient to reduce unsafe attempts and prevent incontinence. B: Placing this patient near the nurses' station would be appropriate since it would allow for faster assistance/alarm response and more frequent assessments. D: Electronic bed and chair alarms would be an appropriate, non-restraint intervention for this patient that would help to reduce the risk of falls by signaling to staff that the patient may be attempting to get out of bed. Choice C is incorrect. Full-length bedrails are a form of physical restraint when used to prevent the patient from getting out of bed. Confused patients may not recognize the bedrail as a reminder to stay in bed, and studies have shown that routine use of these barriers can increase the risk of falls and injury.

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 [33%] B. Decreased total cholesterol [21%] C. Increased visual acuity [16%] D. Improved focus and attention [30%]

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.

A nurse is caring for a woman that just had a normal delivery an hour ago. The nurse understands that the patient is still at risk for uterine atony at this stage. All of the following interventions should be included in the care plan of the patient for detection of uterine atony, except: A. Checking for saturated perineal pads every shift [52%] B. Palpating the fundus at frequent intervals [18%] C. Weighing perineal pads once they are changed, noting the time it was changed and the saturation [21%] D. Checking vital signs frequently for signs of shock [10%]

Explanation Choice A is correct. Checking perineal pads every shift is an incorrect practice and therefore the correct answer to this question. The nurse should assess the perineal pad of the immediate post-partum woman every 30-minutes, not every turn. Perineal pads getting soaked with blood within 30 minutes should be a cause of concern for the nurse for this is a sign of continuous bleeding through the uterus due to uterine atony. Choice B is incorrect. Palpating the fundus frequently is correct practice. The nurse should palpate the patient's fundus frequently to make sure that it is firm and contracted. A firm and contracted uterus prevents blood loss. Choice C is incorrect. Weighing used perineal pads once they are changed is correct practice. The nurse should weigh the perineal pads after they are soaked to accurately assess the amount of blood lost by the patient through the perineum. One gram in weight is equivalent to 1 mL in plasma. Taking note of the time that the pads were changed would signify the frequency of pad changes, which is also essential in the assessment. Choice D is incorrect. Checking vital signs for signs of shock is correct nursing practice. The nurse should assess the patient frequently for signs of trauma. These include low blood pressure, weak, thready pulses, increased heart rate, and increased respiratory rate.