Archer Review 1b

Why should a patient's family not be present during an interview about violence? Select all that apply. A. The patient may not answer questions related to the family member which may be perceived as insensitive or inappropriate. [21%] B. The family member may be the perpetrator of abusive behavior, which may cause the patient to be hesitant to provide honest answers. [31%] C. The patient may feel uncomfortable speaking openly with a relative present. especially if that person has contributed to the patient's stress. [31%] D. The family member may be embarrassed or ashamed by the patient's actions or statements and try to withhold or change the facts. [17%]

Explanation Choices A, B, C, and D are all correct. Individuals who have been in violent situations often decline to answer questions related to a family member, which could be perceived as insensitive or inappropriate for fear of retaliation. This is especially true if the family member is the perpetrator of violence. Patient interviews are done in private, including without significant others or anyone else who may or could be a perpetrator. Healthcare providers should never make assumptions about who may or may not be a perpetrator of violence. Some family members try to withhold or suggest that the patient's recall of events is incorrect to prevent being personally embarrassed by the patient's answers. NCSBN Client Need Topic: Psychosocial Integrity; Subtopic: Violence Victimization and Perpetration

A 6-year-old child is diagnosed with conjunctivitis. Which of the following discharge instructions should the nurse go over with the family? Select all that apply. A. Use warm compresses to lessen the irritation. [16%] B. It is okay to go back to school after 48 hours of antibiotic administration. [12%] C. Avoid sharing towels with family members. [35%] D. Avoid rubbing the eyes to prevent injury. [36%]

Explanation Choices C and D are correct. Sharing towels should be discouraged to prevent the spread of infection to other family members. Rubbing the eyes can cause both injuries to the eye itself and the spreading of the infection. For the 6-year-old patient, it will be essential to help keep them calm and comfortable to prevent this as well as explain this to the parents. Choice A is incorrect. Cold compresses should be used to lessen irritation, not warm. Choice B is incorrect. It is okay to send the child back to school or daycare after just 24 hours of administration of the antibiotic, not 48 hours. NCSBN Client Need: Topic: Physiological Adaptation Subtopic: Alterations in Body Systems

An experienced nurse is caring for a 24-hour old newborn in the nursery. She suspects asphyxia in utero. All of the following assessment findings would indicate asphyxia in utero, except: A. There is a present palmar-grasp reflex. [71%] B. The nurse strokes the sole of the newborn's feet but there is no response. [9%] C. The neonate is unresponsive when the nurse claps her hands above him. [9%] D. The neonate has weak and ineffective sucking. [11%]

Explanation Choice A is correct. A present palmar-grasp reflex indicates that there is an intact neurologic response from the neonate. Choice B is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes of the newborn. This absence in Babinski reflex indicates asphyxia in utero. Choice C is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes of the newborn. This absence in the Startle reflex indicates asphyxia in utero. Choice D is incorrect. Asphyxia in utero manifests as neurological damage in the neonate. Neurological damage is seen as absent or depressed reflexes of the newborn. This absence or depression in the sucking reflex indicates asphyxia in utero.

The emergency department (ED) nurse is caring for a client with acetaminophen toxicity. The nurse anticipates a prescription for which medication? A. Acetylcysteine [85%] B. Deferoxamine mesylate [5%] C. Succimer [2%] D. Flumazenil [7%]

Explanation Choice A is correct. Acetylcysteine is given to convert toxic metabolites to nontoxic ones. Acetaminophen is one of the most commonly used oral analgesics and antipyretics. The maximum dose for an adult is four grams in a 24-hour period. Toxicity starts after the consumption of seven grams. Choices B, C, and D are incorrect. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is the antidote for lead poisoning. Flumazenil is the antidote for the sedative effect of benzodiazepines. Additional Info Acute hepatic necrosis may result from large ingestion of acetaminophen. Acute hepatotoxicity can usually be reversed with acetylcysteine, whereas long-term toxicity is more likely to be permanent. The issue with acetaminophen toxicity is that most cases come from accidental ingestion because clients are unaware the cold remedies contain acetaminophen. Thus, appropriate education must be provided to avoid this type of toxicity.

The nurse in charge of the labor and delivery department is making the patient assignments for the day. Which patient should the most experienced nurse receive? A. A 40-week pregnant patient attached to the fetal monitor having late decelerations. [83%] B. A 39-week pregnant patient in labor with contractions 3 minutes apart. [7%] C. A 33-week pregnant patient with triplets who is on bed rest. [6%] D. A 26-week pregnant patient who is having Braxton Hicks contractions. [4%]

Explanation Choice A is correct. Late decelerations are a sign of fetal distress, indicating that the life of the fetus is threatened. The most experienced nurse should be assigned to this patient. Choice B is incorrect. Labor contractions 3 minutes apart are a sign of normal progression of labor. This does not necessitate the most experienced nurse. Choice C is incorrect. The patient with triplets is not in any kind of imminent danger. This client would not need the most experienced nurse to take care of her. Choice D is incorrect. Braxton Hicks contractions are not real contractions of labor. They are irregular and occur throughout the pregnancy. The most experienced nurse is not needed for this patient.

The nurse is caring for a client with angle-closure glaucoma. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)? A. Timolol [66%] B. Hydroxyzine [12%] C. Phenylephrine [10%] D. Imipramine [11%]

Explanation Choice A is correct. Timolol is an intraocular beta-blocker and is effective in treating angle-closure glaucoma. This medication is indicated for this ocular emergency as it lowers the intraocular pressure. Choices B, C, and D are incorrect. Angle-closure glaucoma is an ocular emergency that requires prompt treatment. Anticholinergics, decongestants, and antihistamines should be avoided by raising intraocular pressure. NCLEX Category: Physiological Adaptation Activity Statement: Medical Emergencies Question type: Knowledge/comprehension Additional Info Angle-closure glaucoma is an ocular emergency that occurs when the intraocular pressure exceeds 30 mm Hg (normal is 10-21 mm Hg). The client may experience manifestations such as ipsilateral headache, brow pain, nausea, and blurred vision. Emergent prescriptions such as timolol eye drops are used to lower intraocular pressure. Other useful agents include oral/intravenous acetazolamide. The client should be placed supine, which will assist in the lens falling away from the iris, decreasing the pupillary block.

The nurse gives discharge instructions to a client who sustained a brain injury from a motor vehicle accident. His wife is concerned regarding her husband having seizures at home. Which statement from the wife indicates that she understood the nurse's teaching? A. "I will make sure that my husband does not wet himself." [1%] B. "I will clear all furniture that might injure him when he has a seizure." [87%] C. "I will call 911 once he has a seizure lasting about 3 minutes." [11%] D. "I will ensure he sleeps well after a seizure." [1%]

Explanation Choice B is correct. One of the major goals during a seizure is injury prevention. Caregivers should be taught about injury prevention precautions. The wife should ensure that the furniture is moved out of the way when her husband seizes, improving his safety. Choice A is incorrect. There is a chance for the client to urinate while having a seizure. However, the wife does not have any control over his urinary incontinence unless the client wears incontinence aids. The priority should be placed on injury prevention, not urinary incontinence. Choice C is incorrect. Self-limiting seizures are not life-threatening. The wife need not call 911 unless the seizure lasts longer than 5 minutes. Status Epilepticus is defined as a single seizure lasting more than five minutes or two or more seizures occurring within a five-minute period without the person returning to normal between them. The wife should be educated that status epilepticus is a medical emergency and she should seek help if such an event occurs. Choice D is incorrect. It is essential that the client rests after his seizure. However, the caregiver's priority concern among the given options is injury prevention.

The pediatric office nurse uses an otoscope to assess the ear canal of a 14-year-old patient. Of the following, the nurse would recognize which finding is consistent with exostosis?

Explanation Choice B is correct. This image shows exostosis, a condition in which small, bony, hard, rounded nodules of hypertrophic bone that typically do not occlude visualization of the eardrum. These nodules are more common in cold-water swimmers. They do not require treatment but may result in the accumulation of cerumen which can block the ear canal. Choice A is incorrect. This image shows an osteoma; a single, stony, hard, non-tender, rounded nodule that occludes the eardrum. While usually benign, this finding should be referred for removal. Choice C is incorrect. This image shows excessive cerumen in the ear canal. This occurs due to excessive production or impaction due to a narrow ear canal or poor cleaning and may either partially or completely occlude the eardrum, resulting in ear fullness and/or hearing loss. Choice D is incorrect. This image shows a polyp arising from granulomatous or mucosal tissue. The polyp will be redder than the surrounding tissue and bleeds easily. It is often surrounded by foul, purulent discharge and is a sign of chronic ear disease. While usually benign, this finding should be referred for removal.

You are caring for a 55-year-old male patient in the emergency department. He has a history of chronic obstructive pulmonary disease (COPD). He came to the ED with a complaint of shortness of breath. His respiratory rate is 28 per minute, and his breaths are shallow and somewhat difficult. You put him on supplemental oxygen at 2 L/minute. You draw ABGs. You receive results of the arterial blood gas that show: pH = 7.30 PaCO2 = 49 Bicarbonate = 25 You determine that this ABG shows: A. Metabolic alkalosis [1%] B. Respiratory acidosis [89%] C. Respiratory alkalosis [5%] D. Metabolic acidosis [5%]

Explanation Choice B is correct.This ABG shows a respiratory acidosis. The first clue in this patient is the diagnosis of COPD. In COPD, the patient suffers from severe hypoventilation. This hypoventilation results in the retention of carbon dioxide. The registered nurse must know the basics of ABG interpretation, including the normal ranges for each of the values. First, the nurse should look at the pH. The normal range is 7.35-7.45. A value below 7.35 indicates an acidosis; a value above 7.45 indicates an alkalosis. The normal partial pressure of carbon dioxide (PaCO2) is 35-45 mmHg. Standard bicarbonate for a man this age is 22-29 mmol/L. The pH in this patient shows that the condition is acidosis. The high PaCO2 indicates that it is a respiratory problem. These values would support the assumption based on the diagnosis of COPD. The pH and PaCO2 define respiratory disorders. Respiratory acidosis is defined as a pH below 7.35 and a PaCO2 above 45 mmHg. Respiratory alkalosis is defined as a pH above 7.45 and a PaCO2 below 35 mmHg. Metabolic disorders are defined by the pH and the bicarbonate (HCO3). Metabolic acidosis is defined as a pH below 7.35 and an HCO3 below 22 mmol/L. Metabolic alkalosis is defined as a pH above 7.45 and an HCO3 above 29 mmol/L. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Physiological Adaptation, Sub-Topic: Fluid and Electrolyte Imbalances, Respiratory

Which type of social support would be the most beneficial for a young new father with the nursing diagnosis of "at risk for the lack of parental bonding related to the lack of parenting skills"? A. A competent local maternal child health nurse [33%] B. A competent doula who has cared for the family [19%] C. A competent contemporary who has had children [35%] D. A competent clergy member who counsels families [13%]

Explanation Choice C is correct. A competent contemporary who has had children and can offer the new father ways to facilitate and provide helpful tips on cuddling, cooing, feeding, and bathing the child to promote paternal bonding is an excellent option for social support. Choice A is incorrect. Although a competent local maternal child health nurse is responsible for promoting paternal bonding, a maternal-child health nurse is not considered social support. Instead, this is a member of the healthcare team. Social support includes individuals or networks of individuals who are not part of the multidisciplinary team that provides care to the client but, instead, family, friends, or community networks. Choice B is incorrect. Although a competent doula that has cared for the family and coached the mother during the labor and delivery process may be able to promote paternal bonding, doulas are not considered social support. Instead, this is a member of the healthcare team. Social support includes individuals or networks of individuals who are not part of the multidisciplinary team that provides care to the client but, instead, family, friends, or community networks. Choice D is incorrect. Although a competent clergy member who counsels families may be able to promote paternal bonding and a loving relationship with the new infant, this is not considered their primary role in terms of social support.

What should the nurse do during assessment when a patient reports swelling in his ankles? A. Measure his ankles at their widest point. [10%] B. Ask the patient to elevate his feet to better visualize his ankles. [5%] C. Press fingers in the edematous area to evaluate for a remaining indentation after the nurse removes his/her fingers. [75%] D. Evaluate further for brown hyperpigmentation that is associated with venous insufficiency. [10%]

Explanation Choice C is correct. Reports of swelling require evaluation for pitting edema. This can be done by pressing fingers in the edematous area to evaluate for a remaining indentation after removing one's fingers. Choice A is incorrect. The nurse would not measure his ankles at their widest point. Choice B is incorrect. The patient's ankles should be evaluated for pitting edema. Elevating his feet is an intervention to prevent the pooling of fluid. However, it is not part of the assessment for edema. Choice D is incorrect. Hyperpigmentation is an indication of late-stage chronic venous insufficiency. Assessing for hyperpigmentation is not an immediate assessment necessary for the report of swelling of the ankles. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Assessing the Neurologic, Musculoskeletal, and Peripheral Vascular Systems

The nurse is assessing a client that has been on bed rest for 48 hours. The nurse asks the client to point his toes upward and the client tells the nurse that he feels pain in his right calf. What should be the next action of the nurse? A. Massage the calf and heel of the client. [4%] B. Instruct the client not to ambulate. [23%] C. Arrange for a Venous Doppler study of the right leg. [57%] D. Attach a pneumatic compression device. [15%]

Explanation Choice C is correct. The client exhibited a positive Homan's sign (pain in the calf upon dorsiflexion of the ankle) which is suggestive of Deep Vein Thrombosis (DVT). However, a positive Homan's sign does not confirm the presence of a DVT. It is neither extremely sensitive nor specific for DVT. The nurse should arrange for a venous Doppler study to confirm the presence of DVT and initiate appropriate treatment. Choice A is incorrect. The nurse should suspect right lower extremity deep vein thrombosis. The nurse should not massage the client's calf during an acute DVT since it may lead to the dislodgement of the clot leading to pulmonary embolism. Choice B is incorrect. The client is positive for Homan's sign, leading the nurse to suspect a DVT. There has been a long-held belief that ambulation would dislodge the clot and cause a pulmonary embolism. This belief is not supported by scientific evidence. Early ambulation can be encouraged, and recent data does not suggest an increased risk of pulmonary embolism in patients with DVT. Choice D is incorrect. A pneumatic compression device is a device that is used to increase venous return to the heart. It is used to prevent DVT in high-risk clients especially when prophylactic anticoagulation is contraindicated. Attaching this device would not be beneficial in a client with suspicion of existing DVT.

A client scheduled for abdominal surgery has just signed the informed consent form. Five minutes later, he tells the nurse "I can't wait to go to the Bahamas. Tell the captain to wait for me!" What is the most appropriate action of the nurse? A. Wheel the client to the OR [2%] B. Administer the pre-operative diazepam intramuscularly [2%] C. Assess the client's level of consciousness [90%] D. Ask the wife to co-sign the consent [6%]

Explanation Choice C is correct. The nurse needs to establish the client's competence in signing the informed consent. An assessment of the client's level of consciousness and neurological assessment would determine if the client is mentally competent to give consent for surgery. Choice A is incorrect. The nurse should not yet bring the client to the operating room as his statement may indicate confusion. Consent for surgery must be made by a mentally competent individual. The nurse needs to assess the client first to check if he is competent to sign an operative consent. Choice B is incorrect. Administering pre-operative diazepam may worsen the client's level of consciousness as diazepam is a sedative-hypnotic. The nurse should assess the client first to determine his level of consciousness. Choice D is incorrect. If the client is deemed incompetent to sign the consent, the next-of-kin is the one that signs the consent for the client. The nurse however, should determine the client's level of consciousness first.

Which of the following members of the intradisciplinary team should be consulted for an infant suspected of having Celiac disease? A. Pharmacist [0%] B. Pulmonologist [5%] C. Occupational therapist [1%] D. Dietician [94%]

Explanation Choice D is correct. Consulting with a dietician is of the utmost importance for the patient who is suspected of having Celiac disease. The dietician is the expert in this area and will provide support, education, and a dietary plan for this patient. Learning to avoid gluten can be difficult for the family, so the dietician is the best resource to help them navigate this. Choice A is incorrect. A pharmacist may be involved in the intradisciplinary team, but there is another specialist of particular importance in the answer choices (a dietician) for the patient with Celiac disease. Choice B is incorrect. It is not necessary to consult with a pulmonologist for a patient with Celiac disease. They should not be experiencing respiratory issues, as Celiac disease is a gastrointestinal disorder. Choice C is incorrect. It is not necessary to consult with an occupational therapist for a patient with Celiac disease. Celiac disease is a gastrointestinal disorder that should not affect the normal functioning and ADLs of this patient. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care; Pediatrics - Gastrointestinal

A nurse is caring for a client on total parenteral nutrition (TPN). Strict surgical asepsis is required when changing TPN dressings and tubing because: A. TPN requires refrigeration and without it, would potentially cause infection if strict surgical asepsis is not utilized. [8%] B. The presence of manganese and zinc in TPN increases the risk of infection, therefore requiring strict surgical asepsis. [2%] C. Strict surgical asepsis is necessary due to the magnesium and cobalt often present in TPN which increases the risk of infection. [2%] D. Due to the high concentration of dextrose in TPN, there is an increased risk of infection, requiring strict surgical asepsis. [87%]

Explanation Choice D is correct. Strict surgical asepsis must be maintained at all times to prevent infection. Due to the nutritional needs of clients requiring total parenteral nutrition (TPN), the formulation contains a high dextrose concentration, leading to an increased predisposition to catheter-related bloodstream infections. Additionally, it is essential to monitor the client's blood glucose frequently and avoid hyperglycemia to prevent infections. Choice A is incorrect. Although TPN does not require refrigeration, TPN does always require strict surgical asepsis. Additionally, it is important to remember that single container of parental nutrition (PN) should never hang for more than 24 hours. Choices B is incorrect. Specific formulations of TPN may contain manganese and zinc. These minerals do not predispose the client to an increased risk of infection from receiving specific formulations containing manganese and zinc. Regardless of the specific formulation or brand of TPN the client is receiving, strict surgical asepsis adherence is essential. Choice C is incorrect. Specific formulations of TPN may contain magnesium and cobalt. These minerals do not predispose the client to an increased risk of infection from receiving specific formulations containing magnesium and cobalt. Regardless of the specific formulation or brand of TPN the client is receiving, strict surgical asepsis adherence is essential. Learning Objective Understand why strict surgical asepsis is necessary when performing dressing or tubing changes for clients receiving total parenteral nutrition (TPN). Additional Info Strict surgical asepsis must be utilized during insertion and maintenance of any TPN line. TPN lines should not be used for any other purpose than TPN administration. A single container of parenteral nutrition (PN) should never hang for more than 24 hours. Lipids should never hang for more than 12 hours. To prevent infection, the TPN administration set infusion tubing should be replaced every 24 hours or with each new PN container (whichever occurs sooner). Dressings should be kept sterile and every 48 hours (or per facility policy) using strict sterile techniques. Poor adherence to aseptic technique during insertion, care, or maintenance of a central line may lead to localized infection at the entry or exit sites. Administration of parenteral nutrition may occur in a variety of settings (hospitals, nursing homes, LTACs, etc.), including client's homes. If TPN is given outside of a clinical setting, patients must be taught to recognize symptoms of infection, and qualified home nursing must be arranged.

You are caring for a patient with Raynaud's disease who has intractable pain. The patient is scheduled to undergo surgical interruption of pain conduction pathways to improve vascular blood supply as well as eliminate vasospasm and pain. Which type of surgery is the patient most likely to undergo? A. Cordotomy [13%] B. Rhizotomy [15%] C. Neurectomy [41%] D. Sympathectomy [31%]

Explanation Choice D is correct. Sympathectomy severs the paths to the sympathetic division of the autonomic nervous system. The outcomes of this procedure include improvement in vascular blood supply and the elimination of vasospasm. It is used to treat the pain from vascular disorders, such as Raynaud's disease. Raynaud's phenomenon is a problem that causes decreased blood flow to the fingers. In some cases, it also causes less blood flow to the ears, toes, nipples, knees, or nose. This happens due to spasms of blood vessels in those areas. The seizures occur in response to cold, stress, or emotional upset. Raynaud's can occur on its own, known as the primary form or it may happen along with other diseases, known as the secondary form. The conditions most often linked with Raynaud's are autoimmune or connective tissue diseases. Choice A is incorrect. Cordotomy interrupts pain and temperature sensation below the tract that is severed. This is most frequently done for leg and trunk pain. Choice B is incorrect. Rhizotomy interrupts the anterior or posterior nerve route that is located between the ganglion and the cord. Anterior interruption is generally used to stop spastic movements that accompany paraplegia, whereas posterior interruption eliminates pain in the area innervated. This procedure may be safely performed at any level along the spine but is most often used for head and neck pain produced by cancer. Choice C is incorrect. Neurectomy is used to eliminate intractable localized pain. The pathways of peripheral or cranial nerves are interrupted to block pain transmission. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care & Comfort

The nurse overhears another nurse state to a client "If you do not behave, I will restrain you." This statement demonstrates an example A. battery. [15%] B. libel. [2%] C. slander. [5%] D. assault. [78%]

Explanation Choice D is correct. Verbal assault means any willful spoken threat to inflict physical injury on another person. The nurse should not threaten a client with punitive actions in an attempt to gain their adherence. Choices A, B, and C are incorrect. Battery is a physical act that results in harmful or offensive contact with another person without that person's consent. Libel is committed when written documentation causes damage to an individual's reputation that is malicious in nature. Slander is false verbal statements that are made to erode an individual's character. Additional Info The nurse should conduct themselves legally and ethically. Threatening a client with restraints, tubes, or devices is assault. The nurse should maintain a professional relationship with the client that fosters the client to have autonomy. If a conflict arises in the nurse-client relationship, the nurse should be professional and establish concordance with the client versus engaging in a power struggle.

The nurse is caring for a client with newly prescribed zolpidem. The nurse understands that this medication is indicated for which condition? A. Attention Deficit Hyperactivity Disorder [10%] B. Generalized Anxiety Disorder [26%] C. Narcolepsy [15%] D. Insomnia [49%]

Explanation Choice D is correct. Zolpidem is a non-benzodiazepine indicated in the treatment of insomnia. Choices A, B, and C are incorrect. ADHD is characterized by the inability to sustain attention, impulsivity, and hyperactivity. It is treated with stimulants or non-stimulants. Generalized anxiety disorder is characterized by excessive worry and is treated with antidepressants such as SSRIs. Narcolepsy is a disorder characterized by sleep attacks. The client should be prescribed psychostimulants such as modafinil. Additional Info Zolpidem is a short-acting nonbenzodiazepine hypnotic. A special concern with this medication is the possibility of somnambulation (sleepwalking). This medication will increase the fall risk, and appropriate precautions should be implemented.

The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The client has an oral temperature of 101 o F (38.3o C). The nurse should be prepared to obtain which prescription from the primary healthcare provider (PHCP)? Select all that apply. See the image below. A. 0.9% saline bolus [34%] B. Clonidine [19%] C. Levothyroxine [5%] D. Metoclopramide [9%] E. Acetaminophen [34%]

Explanation Choices A and E are correct. This tracing reflects sinus tachycardia (ST). ST can be caused by an array of conditions such as a febrile illness which is likely to induce dehydration. The appropriate action for the nurse is to obtain prescriptions for fluids to rehydrate the client and acetaminophen to mitigate the fever. Choices B, C, and D are incorrect. Clonidine is an antihypertensive medication that would make the heart rate increase further because it causes reflex tachycardia. Levothyroxine would worsen the tachycardia because levothyroxine increases thyroid hormone, thereby increasing metabolic and sympathetic processes. Additional Info Sinus tachycardia is regular, with a p-Wave present. The rate of sinus tachycardia is over 100 beats per minute. Treatment of ST is the underlying cause; if the client is hypovolemic, fluids need to be replaced. ST may be worrisome as it is one of the earliest manifestations of shock.

The emergency department (ED) charge nurse is preparing for a surge of clients diagnosed with Ebola virus disease (EVD). The nurse should plan to take which action? Select all that apply. A. Implement visitor restrictions for affected clients [27%] B. Log entry and exit of all healthcare workers who provide care [25%] C. Ensure that bleach disinfectant wipes are available in each room [25%] D. Provide reusable personal protective equipment [5%] E. Have an observer for donning and doffing of personal protective equipment [18%]

Explanation Choices A, B, C, and E are correct. EVD is highly contagious, and despite a vaccine being available, it has a high mortality rate. For any infectious outbreak, visitation should be restricted. This also includes non-essential healthcare workers. When caring for a client with a pathogen like Ebola, logging the entry and exit of healthcare providers would be helpful to contact trace for any potential exposures. Bleach is the cleaning agent of choice, and bleach sprays and wipes should be readily available. Having a trained observer while staff don and doff PPE has effectively prevented accidental exposures. Choice D is incorrect. Single-use PPE should be utilized - not reusable. Reusable PPE would substantially raise the risk of exposing individuals to the virus. Additional Info Ebola virus disease (EVD) Standard, contact, and droplet precautions should be utilized. If aerosolized procedures should be performed (nebulizer, bronchoscopy), airborne precautions should be implemented. Do not cohort a client with ebola with others Required PPE Single-use (disposable) fluid-resistant gown that extends to at least mid-calf or single-use (disposable) fluid-resistant coverall without integrated hood. Single-use (disposable) full-face shield. Single-use (disposable) surgical mask. Single-use (disposable) gloves with extended cuffs. Two pairs of gloves should be worn. At a minimum, outer gloves should have extended cuffs. Single-use (disposable) ankle-high shoe covers. Shoe covers should allow for ease of movement and not present a slip hazard to the wearer Single-use (disposable) powered air-purifying respirators (PAPR) or N95 mask is recommended if aerosolized procedures are performed

The nurse has provided medication instruction to a client who has been prescribed methadone for opioid use disorder. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply. A. "I will need counseling while taking this medication." [25%] B. "I will need periodic blood tests while on this medication." [24%] C. "This medication may lower my risk for Hepatitis C." [6%] D. "This medication will send me into opioid withdrawals." [12%] E. "I may get drowsy while taking this medication." [32%]

Explanation Choices A, B, C, and E are correct. Methadone is an efficacious medication used in the treatment of opioid use disorder, chronic pain, and in the treatment of neonatal abstinence syndrome. This medication requires close monitoring and counseling for opioid use disorder. Periodic blood tests are required as this medication may be hepatotoxic. This medication has been shown to decrease the transmission of blood-borne pathogens such as HIV and Hepatitis C. This is because the reduction of intravenous drug use decreases the risk of the transmission of these pathogens. Drowsiness is a common side effect of this medication as it is an opioid agonist. Choice D is incorrect. This medication does not precipitate opioid withdrawal as this medication is an opioid agonist - not an antagonist. This medication may assist with withdrawal symptoms. Additional Info Treatment for opioid use disorder includes naltrexone, methadone, or buprenorphine. These medications have proven efficacy in this disorder, and when combined with counseling and appropriate monitoring, they may assist a patient in attaining opioid abstinence.

The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure? Select all that apply. A. Blood pressure [29%] B. End-tidal carbon dioxide [ETCO2] level [9%] C. Respiratory rate [29%] D. Blood glucose [4%] E. Oxygen saturation [29%]

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

The nurse is administering prescribed furosemide to a client. Which manifestations would be concerning for fluid volume deficit? Select all that apply. A. Tachycardia [30%] B. Bradypnea [10%] C. Weight gain [4%] D. Decreased urine output [30%] E. Tenting of the skin [26%]

Explanation Choices A, D, and E are correct. Clients prescribed diuretics (such as furosemide) are at risk for fluid volume deficit. Tachycardia would be a finding consistent with a fluid volume deficit that the nurse should indeed monitor. If the client is tachypneic, the heart is beating faster to increase the cardiac output in a low volume setting - hence, the fluid volume deficit. Decreased urine output would be a finding consistent with a fluid volume deficit. If the client is experiencing a fluid volume deficit, they have a decreased circulating blood volume. This leads to a decreased renal blood flow, causing a reduced urine output. Tenting of the skin can occur due to a lack of fluid in the tissues and is a sign of fluid volume deficit. Choices B and C is incorrect. Bradypnea is not an indication of fluid volume deficit that the nurse needs to monitor. Tachypnea rather would be a clinical manifestation of a fluid volume deficit. Weight loss, not gain, indicates fluid volume deficit that the nurse needs to monitor. If the client has used diuretics chronically and is experiencing a fluid volume deficit, such fluid loss will lead to weight loss. Additional Info Furosemide is a loop diuretic for managing hypertension and congestive heart failure. This medication causes wasting of sodium, potassium, calcium, and magnesium. Before administering furosemide, the nurse should assess these electrolytes and the client's blood pressure.

The nurse is preparing morning medications for a client with a nasogastric tube connected to low-intermittent wall suction. Which actions does the nurse take to ensure proper administration of this client's medications? Select all that apply. A. Position the client in Trendelenburg position. [1%] B. Verify correct placement of the tube before medication administration. [41%] C. Turn off the suction during medication administration. [37%] D. Return the NG tube to low-intermittent wall suction after administering the medication. [21%]

Explanation Choices B and C are correct. B is correct. Before medication or food administration, it is crucial always to verify the correct placement of the nasogastric tube ( NGT). The gold standard to verify tube placement is visualization on an x-ray. The American Association of Critical-Care Nurses (AACN) guidelines recommend confirming the position of NGTs by X-ray. However, given the risks of radiation exposure with X-rays and delayed feeding, alternative options are often used to verify the tube placement before feeding or giving medications to the client. The most commonly used first-line verification method is measuring the pH of the NG tube aspirate to make sure it falls in line with that of gastric contents. Most guidelines recommend that the pH of an NGT aspirate should be ≤5.5 (acidic) to confirm proper placement. An alkaline pH ( >7.0) often indicates a lung aspirate rather than gastric. A false-negative pH reading greater than 5.5 may be seen with the use of antacids and proton pump inhibitors. If the pH is greater than 5.5, an X-ray must be performed as a second-line test. After the placement has been initially verified, the nurse may mark where the tube is located at the nare of the client so that the nurse can assess that the tube has not moved and remains in the stomach before each feed. C is correct. It is appropriate to turn off the suction during medication administration. If the client remained on low-intermittent wall suction, the medication would be evacuated from the stomach via suction before it could be absorbed. The nurse should stop the suction and clamp the nasogastric tube for 30 minutes after administering the medications to allow them to absorb fully. Choice A is incorrect. It would be highly inappropriate to place a client in the Trendelenburg position before administering medications through a nasogastric tube. To prevent aspiration, the nurse should sit the patient up as much as tolerated, raising the head of the bed at least 30 degrees. This will allow gravity to help the medication flow into the stomach for absorption. Choice D is incorrect. Returning the NG tube to low-intermittent wall suction is not appropriate after administering the medication. This process would prevent the medications from wholly absorbing. The nurse should clamp the nasogastric tube for 30 minutes after medication administration to allow for medication absorption. Then the nurse may return the NG tube to low-intermittent wall suction.

The nurse is caring for several clients in a long-term care facility. Which interventions should the nurse implement to reduce the risk of injury for these clients? Select all that apply. A. Avoid administering ibuprofen at night. [3%] B. Secure the call button to the side of the bed. [32%] C. Keep the bed in the lowest position. [38%] D. Complete a fall risk assessment within 24 hours of admission. [27%]

Explanation Choices B and C are correct. Falls and injuries can be reduced by ensuring the call button are accessible (Choice B) and within easy reach for the client. The call light can be clipped or secured when the client is in bed to prevent falling out of reach. Most clients in long-term facilities need some assistance and are at risk of falls. The nurse must complete a fall risk assessment at admission or within 2 hours of admission. Setting the bed to the lowest position (Choice C) would reduce the risk of injury in the event of a fall because such positioning keeps the patient at a closer distance to the floor. Choices A and D are incorrect. Evening administration of NSAIDS do not increase the risk of falls. On the other hand, the nurse should avoid administering diuretics and laxatives before the patient's sleep to reduce urgent bathroom needs. Having to push for urgent bathroom needs may lead to falls. The nurse should complete a fall risk assessment upon admission or within 2 hours of admission to promptly implement fall-prevention interventions for high-risk clients. Waiting 24 hours to complete a fall-risk assessment is inappropriate because a preventable fall may have already happened. Additional Info Universal fall precautions involve • Monitor the client's activities and behavior as often as possible, preferably every 30 to 60 minutes. • Teach the client and family about the fall prevention program to become safety partners. • Remind the client to call for help before getting out of bed or a chair. • Help the client get out of bed or a chair if needed; lock all equipment such as beds and wheelchairs before transferring client's. • Teach clients to use the grab bars when walking in the hall without assistive devices or when using the bathroom. • Provide or remind the client to use a walker or cane for ambulating if needed; teach him or her how to use these devices. • Remind the client to wear eyeglasses or hearing aid if needed.

The nurse is assessing a patient in active labor. Her contractions are increasing in frequency as well as the duration and presenting 5 minutes apart for 60 seconds each with every contraction. The fetal heart rate begins to slow from 150 to 110 after the decrease starts. Which of the following are priority nursing actions for this situation? Select all that apply. A. Reposition the mother to a supine position [7%] B. Administer 100% FiO2 via face mask [34%] C. Notify the healthcare provider [37%] D. Prepare for delivery [21%]

Explanation Choices B and C are correct. Late decelerations or dips in the fetal heart rate that occur after a contraction are a non-reassuring sign on a fetal heart rate strip. Anytime that the nurse notes this sign, she will need to intervene quickly. Administering 100% FiO2 via a face mask is an appropriate intervention (Choice B). Notifying the healthcare provider is an appropriate intervention (Choice C). Choice A is incorrect. The nurse has observed a late deceleration. Late decelerations or dips in the fetal heart rate that occur after a contraction are a non-reassuring sign on a fetal heart rate strip. Anytime that the nurse notes this sign, she will need to intervene by laying the mother on her left side, not supine quickly. If the nurse were to lay the mother supine, she could further aggravate the uteroplacental insufficiency that is likely contributing to the late deceleration. She needs to increase blood flow to the placenta, therefore positioning the mother on her left side is the correct nursing intervention to do this. Choice D is incorrect. Although the nurse has noted a non-reassuring fetal heart rate, it is unnecessary to prepare for delivery at this time. There are interventions that the nurse and the healthcare team can take to address the fetus's heart rate before needing to do an emergency delivery. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Risk of the potential reduction; Problems with Labor and Delivery

The nurse is developing a plan of care for a client admitted to the mental health unit with significant paranoia. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Plan competitive activities with other clients. [3%] B. Maintain consistent caregivers. [35%] C. Establish a rapport using therapeutic touch. [15%] D. Involve the client in decision-making. [33%] E. Develop a plan of care that is unstructured. [7%] F. Immediately enroll the client in group therapy. [7%]

Explanation Choices B and D are correct. A client experiencing paranoia may be very conspiratorial, and while it is important to reinforce reality, it would be appropriate to acknowledge their feelings. Involving the client in the decision-making process and avoiding any surprises is essential. Consistent caregivers are recommended because this cements the therapeutic relationship with staff. Choices A, C, E, and F are incorrect. Activities should be structured and non-competitive. Competition may enable hostility and decrease a client's self-esteem. Central to caring for a client experiencing paranoia is having a therapeutic relationship without touch. Touch may be misinterpreted and should not be used. The same may be said for direct eye contact. Direct eye contact may raise an individual's suspicion. The plan of care should always be structured and verbalized to the client. This reinforces a trusting relationship. While group therapy may be helpful, this should be done gradually and not right away. Individuals with paranoia may initially resist socialization. Additional Info For a client experiencing paranoia, developing trust with the client may be difficult. Establishing a trusting relationship that does not involve therapeutic touch is important as this may be misinterpreted. Avoiding eye contact is also beneficial because direct eye contact may be misinterpreted. If the client is concerned about poisoned food, provide prepackaged foods. Avoid talking in front of the client and avoid any secretive activities. It would be beneficial to establish a very clear schedule of the tasks ahead and establishes trust and expectations. While group therapy may be helpful, this should be done gradually as the client experiencing paranoia will likely resist socialization.

A mother in a pediatric clinic asks the nurse about the soft spots on her baby's head, and when they are going to harden. The nurse's most appropriate response would be: A. "These soft spots are called fontanels. The one on the front closes at 12-18 months, and the one on the back closes at 2 months." [53%] B. "These soft spots are called fontanels. The one on the front closes at 2 months, and the one on the back closes at 12-18 months." [16%] C. "These soft spots are called fontanels. The one on the front closes at 12-18 months, and the one on the back closes at 6 months." [25%] D. "These soft spots are called fontanels. The one on the front closes at 9 months, and the one on the back closes at 2 months." [6%]

Explanation Choice A is correct. Fontanels are soft. Anterior fontanels close at 12 - 18 months and posterior fontanels close at 2 months age. Fontanels facilitate the bony plates of the baby's skull to flex and allow the baby's head through the birth canal. Choice B is incorrect. This is an inaccurate statement by the nurse. Choice C is incorrect. This is an inaccurate statement by the nurse. Choice D is incorrect. This is an inaccurate statement by the nurse.

You are providing education to a mother who gave birth three weeks ago. She has developed mastitis. Which of the following educational points are appropriate? Select all that apply. A. Continue to breastfeed your child normally. [31%] B. If unable to breastfeed, express milk every 2 hours. [30%] C. Do not take antibiotics. [6%] D. Wear a supportive bra without an underwire. [34%]

Explanation Choices A and D are correct. It is essential to educate mothers with mastitis that they should continue to breastfeed. The infection will not be passed to their child and they do not need to worry about any adverse effects for their infants. By continuing to breastfeed, the clogged milk ducts should become unclogged and mastitis should improve (Choice A). Wearing a supportive bra but one without an underwire is appropriate educational advice for a mother with mastitis. The support will help with the pain and tenderness in the breasts, but an underwire could cause clogged milk ducts, so it should be avoided (Choice D). Choice B is incorrect. While it is important to educate mothers that they should continue to breastfeed, they should only express milk every 4 hours if unable to breastfeed. Expressing milk every 2 hours is too frequent and could cause additional irritation. Choice C is incorrect. Mastitis is sometimes caused by an infection for which some healthcare providers will prescribe antibiotics. Advising mothers not to take medicines is not an appropriate education. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatric Development

The nurse is instructing a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements by the client would require follow-up? Select all that apply. A. "I can take my morning antidepressant with a sip of water." [17%] B. "I may feel a flushing sensation as the contrast dye is given." [20%] C. "I should be able to drive home after this procedure." [31%] D. "I will need one treatment for my depression to go into remission." [27%] E. "I may experience some confusion after this procedure." [6%]

Explanation Choices B, C, and D are correct. ECT is a safe therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder and significant psychosis. Clients do not receive contrast dye ( Choice B) for this procedure; instead, this procedure involves no imaging and requires general anesthesia. Driving home after the procedure is prohibited because of the post-procedural confusion from general anesthesia and the ECT procedure itself ( Choice C). Clients may experience remission after several treatments, but one treatment is highly unlikely to bring remission ( Choice D). Instead, one session of ECT may bring some symptom improvement Choices A and E are incorrect. Antidepressants and antipsychotics may be given concurrently with ECT and may be taken with a sip of water on the day of the procedure ( Choice A). ECT works by producing a minor seizure. Any medications that interfere with ECT seizures such as anticonvulsants and benzo-diazepines ( BZDs) should not be given concurrently. However; antidepressants do not interfere with the ECT mechanism and should be given because holding antidepressants may cause a flare of depression if ECT did not work as expected. Holding anti-depressants may also precipitate withdrawal symptoms. Updated evidence-based information recommends concurrent use of antidepressants with ECT. Post-procedural confusion is the most common unwanted effect of this procedure as it is linked to the general anesthesia used and the procedure itself ( Choice E). NCSBN Client need: Topic: Reduction of Risk Potential; Subtopic: Therapeutic Procedures Learning Objective Understand that electroconvulsive therapy ( ECT) is performed under general anesthesia and used to treat major depression and psychosis. Additional Info A stigma is attached to ECT that it is somehow inhumane. This stigma is false as ECT is highly effective when medications are ineffective. ECT is a safe treatment for various conditions, including major depressive disorder, psychosis, and post-partum disorders. Common side effects associated with ECT include headache and cognitive impairment that may be temporary.

The nurse is assessing a client who is requiring bilateral wrist restraints. Which assessment data is necessary for the nurse to obtain? Select all that apply. A. Previous restraint use [11%] B. Skin integrity [30%] C. Behavioral status [29%] D. Vital signs [21%] E. Urinary continence [9%]

Explanation Choices B, C, and D are correct. Pertinent assessments necessary prior to initiating restraints include the client's skin integrity. If the client has impaired skin integrity, this may inhibit the type of restraint the nurse may utilize (example, sores on the wrists then wrist restraints should not be used). Behavioral status is necessary to assess because it is the client's behavior that determines the need for the restraint as well as the type of restraint (if the client is verbally deescalated, then physical restraints may not be necessary). Vital signs are essential to obtain because if the client is hypoxic, this may cause altered behavior. Choices A and E are incorrect. Previous restraint use should not influence the nurses' ability to determine the need for restraints. Restraint use is episodic and focuses on the client's current behavioral status at the present time. Urinary continence is not pertinent to restraining a client because toileting is offered at certain intervals based on the restraint and facility protocol. Additional Info Restraints should be used as a last resort if alternative methods are not effective. A nurse should never threaten a client with restraints. This is considered assault. The nurse may place a client who is violent in restraints without an order from the primary healthcare provider (PHCP). If this was to occur, the nurse has one hour to inform the provider and obtain an order. Restraints are never as needed (PRN). They should be discontinued at the earliest possible time. When restraining a client, the reason for the restraint must be explained to the client and the behavior the client needs to demonstrate for the restraints to be discontinued. The nurse should observe the client at frequent intervals to offer nutrition & toileting, assess their behavioral status, obtain vital signs, and provide range of motion. These intervals are determined by the facility and the type of restraint—the more restrictive the restraint and the younger the client, the more frequent assessment. Restraints must be able to quickly be removed via a quick release buckle (knots are no longer recommended). The nurses' documentation must be comprehensive, describing the reasoning for the restraints, alternatives utilized, the education provided to the client, the type of restraint utilized, how it was secured, and the ongoing behavior necessary to continue the restraint. The nurse should also document the intervals at which the restraints were released.

The nurse is caring for a client newly prescribed ropinirole. The nurse understands that this medication is prescribed to treat which condition? A. Multiple Sclerosis [21%] B. Parkinson disease [41%] C. Schizophrenia [15%] D. Guillain-barré syndrome [23%]

Explanation Choice B is correct. Ropinirole is a dopaminergic drug used in conjunction with other medications to treat Parkinson's disease. Additionally, this medication is indicated to treat restless leg syndrome. Choices A, C, and D are incorrect. Multiple sclerosis is treated by interferons, muscle relaxers, and steroids. This medication would be detrimental for an individual with schizophrenia because it increases dopamine levels which can trigger psychosis. Guillain-barré syndrome is treated with plasmapheresis or immune globin. Additional Info Ropinirole is used along with other medications to help mitigate the symptoms of Parkinson's disease. This medication is also approved to treat symptoms of restless leg syndrome. Common adverse effects include agitation, delirium, peripheral edema, and gi upset.

The nurse is helping a 7-year-old post-abdominal surgery patient who is attempting to make a pinwheel spin by blowing on it. The child, however, is unable to make it spin. What would be the most appropriate action by the nurse? A. Praise the child for his/her attempts. [36%] B. Call the respiratory therapist and have the child start incentive spirometry. [21%] C. Instruct the child to turn from side to side. [9%] D. Show the child how to make the pinwheel spin. [33%]

Explanation Choice A is correct. Children should be praised for their cooperation even if they did not accomplish the task. Choice B is incorrect. This can be done after praising the child for the attempt. Choice C is incorrect. The nurse should praise the child first before instructing him/her to move. Choice D is incorrect. The nurse should praise the child first for making an attempt and then demonstrate to the child the proper technique.

The nurse plans care for a client experiencing a hyperglycemic-hyperosmolar state (HHS). The nurse should anticipate which prescriptions from the primary healthcare provider (PHCP)? A. 0.9% saline infusion [59%] B. Glargine insulin [27%] C. Sodium polystyrene [5%] D. Sodium bicarbonate [9%]

Explanation Choice A is correct. Hyperglycemic-hyperosmolar state (HHS) is likely to develop in individuals with type II diabetes mellitus. The patient secretes just enough insulin to prevent ketosis in HHS but not enough to prevent hyperglycemia. Severe hyperglycemia causes an individual to experience significant diuresis, causing severe dehydration. Correcting fluid and electrolyte imbalances is essential for an individual with HHS. The clinical guideline is to infuse one liter of saline in one hour and reassess the client's volume status thereafter. Choices B, C, and D are incorrect. Insulin may be utilized in HHS, but the priority treatment is correcting the severe dehydration. If insulin is utilized, regular insulin may be prescribed - not glargine, which is long-acting and has no peak. Sodium polystyrene is indicated for hyperkalemia. The client with HHS commonly has hypokalemia because of the alkalosis they experience. This medication would be contraindicated in HHS and indicated in DKA. Sodium bicarbonate is indicated to treat metabolic acidosis, the client with HHS is in an alkalotic state, so this treatment would be detrimental. Additional Info HHS development is related to residual insulin secretion. The client secretes just enough insulin to prevent ketosis in HHS but not enough to prevent hyperglycemia. The hyperglycemia of HHS is more severe than that of DKA, greatly increasing blood osmolarity, leading to extreme diuresis with severe dehydration and electrolyte loss. HHS is a common complication associated with type II diabetes mellitus. Treatment for HHS emphasizes fluid replacement. Neurological functional needs to be monitored closely as cerebral edema may consequently occur from rapid fluid replacement. Any alteration in mental status needs to be reported. Treatment goals aim to restore circulatory volume at a steady pace.

A 56-year-old female client presents to the emergency department (ED) who reports dyspnea, fatigue, and indigestion. The nurse should take which priority action? A. Obtain a 12-lead electrocardiogram [34%] B. Provide supplemental nasal cannula oxygen [43%] C. Established intravenous (IV) access [5%] D. Auscultate lung sounds [17%]

Explanation Choice A is correct. Obtaining a 12-lead electrocardiogram is the priority as the client is exhibiting classic symptoms of acute coronary syndrome (ACS). Women over the age of 50 are at a higher risk of developing this potentially fatal syndrome. Women may exhibit manifestations other than substernal chest pain. The ECG will help determine if the client has a STEMI or an NSTEMI. Choices B, C, and D are incorrect. Supplemental oxygen, establishing intravenous access, and a respiratory assessment will need to occur. However, they do not prioritize establishing the severity of the ACS as the ECG will determine if the client is having a STEMI. The standard of care is to obtain a 12-lead electrocardiogram within ten minutes of symptom presentation. NCLEX Category: Physiological Adaptation Activity Statement: Illness management Question type: Analysis Additional Info Unstable ACS (STEMI) may present with typical and atypical clinical features. Typical clinical features of ACS include: Substernal chest pain with a gradual onset. Pain that radiates to the arm or jaw. Chest pain that is not relieved with rest. Diaphoresis and pallor may be additional findings. Atypical clinical features of ACS include: Nausea and vomiting Dyspnea Significant fatigue Epigastric pain Atypical features are found in women and individuals with diabetes mellitus. Individuals with diabetes mellitus have attenuated chest pain because of neuropathy.

Your client has just been diagnosed with HIV/AIDS. The client is refusing their HIV/AIDS medications and is stating, "I do not have HIV/AIDS, and the laboratory has made a serious error." Which of these nursing diagnoses is the most appropriate for this client, based on this refusal of medications and this client's statement? A. The lack of adherence to the medication regimen is related to the use of a psychological defense mechanism. [72%] B. Ineffective coping is related to a laboratory error. [6%] C. Knowledge deficit related to the need for HIV/AIDS medication. [14%] D. The lack of compliance with the medication regimen is related to a knowledge deficit and laboratory errors. [8%]

Explanation Choice A is correct. The most appropriate nursing diagnosis for this client is based on the refusal of medications. "The lack of adherence to the medication regimen related to the use of a psychological defense mechanism," fits the best for this client's statement. This client uses denial as a psychological or ego defense mechanism to protect against the stressors associated with the diagnosis of HIV/AIDS. Choice B is incorrect. "Ineffective coping related to a laboratory error" is not an appropriate nursing diagnosis for this client based on the refusal of medications and this client's statement because there is no evidence that a laboratory error has actually occurred. Choice C is incorrect. A "Knowledge deficit related to the need for HIV/AIDS medication" is not an appropriate nursing diagnosis for this client as it is based on the refusal of medications and this client's statement because there is no evidence that this client does not understand the need for these medications. Choice D is incorrect. "The lack of compliance with the medication regimen related to a knowledge deficit and laboratory errors" is not an appropriate nursing diagnosis for this client as based on the refusal of medications and this client's statement because there is no evidence that this client does not understand the need for these medications or that an actual laboratory error has occurred.

After talking to the client's family, the physician in charge writes a Do-Not-Resuscitate (DNR) order on the patient's chart. The nurse understands that a change in code status for the client would entail: A. Prepare the family for the client's imminent death. [4%] B. Continue nursing care to promote comfort and a dignified death to the client. [92%] C. Stop all current medications for the patient. [3%] D. Get the crash cart ready. [1%]

Explanation Choice B is correct. A DNR (Do-Not-Resuscitate) order does not mean nursing care should also stop. It is the nurse's responsibility to provide comfort and dignity to the client in their last moments of life. Choice A is incorrect. A DNR order does not signify the imminent death of the client. Choice C is incorrect. A DNR order means that if a client goes into cardiac arrest, the healthcare team should not resuscitate the client. This does not mean that all medications by the client should be stopped. Choice D is incorrect. A DNR order means that if a client goes into cardiac arrest, the healthcare team should not resuscitate the client. The crash cart is a medication cart where all emergency medications and equipment are kept.

The nurse is caring for a child experiencing a celiac crisis. The nurse should anticipate which prescription from the primary healthcare provider (PHCP)? A. Tap water enema [5%] B. Intravenous (IV) fluids [74%] C. Fluid restrictions [4%] D. Nasogastric tube (NGT) insertion [17%]

Explanation Choice B is correct. A celiac crisis is manifested by severe diarrhea, leading to significant dehydration and electrolyte derangements. A key intervention in the management of a celiac crisis is to replete the lost fluids and correct the electrolyte imbalances. Choices A, C, and D are incorrect. A hallmark of this crisis is severe diarrhea leading to dehydration. During this crisis, an enema and fluid restrictions would be unhelpful, if not harmful. The goal is to rehydrate the client. An NGT is not indicated for this crisis. Additional Info A celiac crisis is a rare event that results in severe unexplained diarrhea and malabsorption. This often triggers testing for celiac disease. The key intervention in a celiac crisis is the repletion of fluids because severe dehydration may occur.

A 90-year-old woman has been bedridden at home for two weeks. Which of the following is not an expected finding due to immobility? A. A decrease in bone density [2%] B. Loss of short-term memory [66%] C. Atelectasis [10%] D. High serum calcium level [21%]

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

A nurse receives a patient who just returned from endoscopy, during which he was sedated. Before resuming the patient's diet, what is the nurse's first priority? A. Check his oxygenation level [4%] B. Assess for the return of his gag reflex [91%] C. Position him on his side [1%] D. Have him take sips of water [3%]

Explanation Choice B is correct. Sedation associated with a procedure, such as an endoscopy, can impair the client's gag reflex. It is essential to ensure that the gag reflex has fully returned before feeding the client to prevent airway obstruction and aspiration. Choices A, C, and D are incorrect. Monitoring oxygenation levels would also be necessary after the endoscopic procedures but is not the first priority for this client. Positioning the client on his side is not required. Offering the client sips of water is not the proper method of assessing the gag reflex.

A patient presents to the emergency department following a motor vehicle accident. The nurse assesses that the patient is unable to move legs and has poor reflexes. What additional assessment data would support the diagnosis of spinal shock? A. Hypotension [37%] B. Decreased sensation [42%] C. Bradycardia [11%] D. Upper extremity motor weakness [9%]

Explanation Choice B is correct. The decreased sensation would support the diagnosis of spinal shock. Spinal shock is a temporary neurologic syndrome that is common in patients with an acute spinal cord injury. Symptoms of spinal trauma include decreased sensation, decreased reflexes, and flaccid paralysis below the level of the spinal cord injury. Choice A is incorrect. Hypotension is not associated with spinal shock but may be a sign of neurogenic shock. Choice C is incorrect. Bradycardia is not associated with spinal shock but may be a sign of neurogenic shock. Choice D is incorrect. Upper extremity motor weakness is a sign of central cord syndrome, not spinal shock. NCSBN Client Need: Topic: Critical Care Concepts (spinal injury), Subtopic: Alterations in body systems, medical emergencies, pathophysiology

The nurse is caring for a client with diabetic ketoacidosis (DKA) receiving intravenous (IV) regular insulin. The most recent potassium was 2.9 mEq/L. The nurse should take which priority action A. Notify the primary healthcare provider (PHCP) [29%] B. Stop the regular insulin infusion. [37%] C. Obtain a 12-lead electrocardiogram (ECG) [30%] D. Assess the client's urine output (UOP) [4%]

Explanation Choice B is correct. The most common complication associated with DKA treatment with regular insulin is hypokalemia and hypoglycemia. Stopping the regular insulin infusion is essential as this is the direct cause of the critically low potassium. Choices A, C, and D are incorrect. The actions of notifying the PHCP, obtaining a 12-lead electrocardiogram, and assessing the UOP are correct. They do not prioritize stopping the regular insulin, which has caused the critically low potassium. The PHCP needs to be notified because a prescription for potassium needs to be obtained. A 12-lead electrocardiogram followed by cardiac monitoring is necessary because of the critically low potassium. UOP should be assessed because IV potassium cannot be administered if the UOP is less than 30 ml/hr. The causative agent must always be stopped before further corrective action. Additional Info Close blood glucose and potassium monitoring are essential for the client receiving a regular insulin infusion. The most common complications of regular insulin therapy are hypoglycemia and hypokalemia. The appropriate clinical action is to discontinue the offending agent until an appropriate remedy may be sought.

The nurse receives an order to give the patient 125 mg of the medication each day. The drug on hand is 250 mg in each tablet. The nurse should administer: A. ¼ tablet [1%] B. ½ tablet [87%] C. 1 tablet [1%] D. 2 tablets [11%]

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

Which information would be inappropriate for the nurse to include when completing an incident report on a patient who recently experienced a fall? A. The patient's explanation of the event. [12%] B. A subjective account of environmental factors preceding the incident. [46%] C. Any injuries sustained as a result of the fall. [9%] D. The names of all witnesses present. [33%]

Explanation Choice B is correct. The purpose of an incident report is to provide an objective account of an incident/accident, in order to identify issues with current practices, improve policies, and potentially investigate situations of negligence/malpractice. A subjective explanation of events would not be appropriate for the nurse to include for this type of report. Choice A is incorrect. An incident report should include the patient's account of the fall (stated in quotations). Choice C is incorrect. An incident report should include any injuries sustained or adverse effects noted as a result of the fall, as well as the monitoring and assessment performed following the event. Choice D is incorrect. An incident report should include the names of any witnesses of the fall.

The nurse is providing a 5-month pregnant woman with her options regarding birthing locations. The nurse would be most correct in suggesting which possibility to a woman who would like freedom of movement with drug-free labor and birth but is not comfortable with a home-birth? A. The nearest hospital to her home [12%] B. A birthing center [78%] C. She should continue with a home-birth if she is low risk [5%] D. A clinician's office with her OB/GYN [5%]

Explanation Choice B is correct. This woman should consider a birthing center. Birthing centers are generally drug-free, allow women to roam around the facility to relieve discomfort, and provide a home-like environment. Choice A is incorrect. The nearest hospital may not be the best location for a pregnant woman concerned about her freedom of movement and drug-free labor. Choice C is incorrect. A woman not comfortable with a home birth should not have one. Home births are more successful when the woman is confident about her birth choice. Choice D is incorrect. Most births do not occur at a clinician's office. NCSBN Client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care

The parent of an 11-year-old client who is receiving chemotherapy for leukemia is concerned because the client's sibling has chickenpox. Which of these actions will you anticipate taking next in caring for this client? A. Teach the parents regarding contact and airborne precautions. [46%] B. Administer varicella-zoster immune globulin to the client. [25%] C. Prepare the client for admission to a private room in the hospital. [27%] D. Educate the parent about the correct use of acyclovir. [2%]

Explanation Choice B is correct. Varicella-zoster immune globulin (VZIG) administration may prevent or reduce the severity of chickenpox in high-risk clients and will typically be prescribed by the provider in this setting. The Centers for Disease Control (CDC) recommends the administration of VZIG to prevent or reduce the severity of infection in high-risk people exposed to varicella or herpes zoster. Such high-risk clients include immunocompromised patients, pregnant women with no evidence of immunity to varicella, or newborn clients with exposure to varicella. VZIG should be administered as soon as the following possible exposure; however, it may be beneficial to administer it up to 96 hours after exposure. VZIG may offer protection up to 3 weeks following administration. Do not confuse Varicella Zoster Immunoglobulin with varicella vaccine. Varicella zoster vaccine is a live vaccine approved for the use in children aged 12 months and older to prevent chickenpox. Live attenuated Varicella vaccines (example: Zostavax; Varivax) are contraindicated in this client with chemotherapy-induced immunocompromise. Live vaccines are also contraindicated in pregnant women as they may cause congenital varicella. Additionally, there is not enough time for a vaccine to elicit an immune response to produce enough antibodies in the host following an exposure. On the other hand, an immunoglobulin (example: Varicella-Zoster Immunoglobulin) refers to a passive immunity where a readymade antibody is administered. It is, therefore, useful in post-exposure prophylaxis. Choice A is incorrect. Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child develops varicella. The client's sibling is at home and exposure has already occurred. Implementation of isolation precautions now is not going to help this client who already had a vulnerability. Avoid the distractor - focus on the client who has been exposed, NOT the sibling. Choices C and D are incorrect. Hospitalization and acyclovir therapy may be required if the child develops a varicella-zoster virus (chickenpox) infection. The child just had exposure, so VZIG should be administered to reduce his chances of getting chickenpox. NCSBN Client Need Topic: Safe and Effective Care Environment; Subtopic: Safety and Infection Control

The nurse is preparing the discharge of a patient with heart failure. The nurse double checks his prescription and notes that the patient has been prescribed digoxin and lasix. Which of the following laboratory tests must the patient have monitored because of the medications prescribed? A. Stool for occult blood [1%] B. Serum electrolytes [92%] C. Urinalysis [4%] D. Glycosylated hemoglobin [2%]

Explanation Choice B is correct. When taken together, digoxin and lasix increase renal perfusion leading to potassium loss. The patient should be instructed to monitor his serum electrolyte levels, notably his serum potassium. Choice A is incorrect. Stool for occult blood is a test that detects blood in the feces. This signifies bleeding in the GI tract, which is unrelated to digoxin and lasix. Choice C is incorrect. Although digoxin and lasix increase urine production, performing a urinalysis is not required unless specified by a physician due to other reasons. Choice D is incorrect. Glycosylated hemoglobin is a test to determine blood sugar control in people with diabetes. This is entirely unrelated to digoxin and lasix.

The nurse cares for a client and is notified by the laboratory department of a critical sodium level of 122 mEq/L. The nurse should take which initial action? A. Notify the primary healthcare provider [23%] B. Implement seizure precautions [52%] C. Read back the result for verification [23%] D. Recollect the laboratory specimen [1%]

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

The nurse educator is talking to a group of RNs regarding the chemical mediators involved in allergic reactions. The nurse tells the RNs that in an allergic reaction, the chemical mediator, histamine, is responsible for the following manifestations, except: A. Erythema, tissue swelling, and shock [14%] B. Shortness of breath and wheezing [11%] C. Mucus plugging [66%] D. Itching and painful skin [9%]

Explanation Choice C is correct. Mucus plugging is caused by slowed smooth muscle contraction brought about by bradykinin, not histamine. Choice A is incorrect. Erythema, tissue swelling, and shock are caused by the dilation of blood vessels and increased vascular permeability brought about by histamine. Choice B is incorrect. Shortness of breath and wheezing are caused by the constriction of smooth muscles in the bronchial airways brought about by histamine. Choice D is incorrect. Histamine release over-stimulates the nerve endings causing itchiness and painful skin.

The nurse in the intensive care unit is caring for a patient that has left-sided heart failure with pulmonary edema as a complication. The nurse identifies a nursing diagnosis of impaired gas exchange related to fluid in the alveoli. Which of the following interventions would be considered the least priority according to the nursing diagnosis? A. Giving oxygen and watching for dry nasal mucus membranes. [3%] B. Placing the client in Fowler's position. [3%] C. Providing a pressure reducing mattress. [87%] D. Encouraging the client to turn, deep breathe, cough, and use the incentive spirometer. [6%]

Explanation Choice C is correct. Pressure reduction mattresses and beds are available to decrease the pressure on the sacrum when the client is in bed. Implementing measures to relieve sacral stress, however, is the least priority when managing clients in acute pulmonary edema. Choice A is incorrect. Oxygen therapy improves oxygenation by increasing the amount of oxygen available for delivery and can help relieve the client's dyspnea. Continuous oxygen administration can dry the patient's mucus membranes. This should be a priority intervention. Choice B is incorrect. This position facilitates the expansion of the diaphragm and should be a priority intervention. Choice D is incorrect. Turning, deep breathing, coughing, and the use of an incentive spirometer will all help clear the airways and facilitate oxygen delivery.

A 28-year-old woman is status-post thyroidectomy and has stayed at the post-anesthesia care unit for several hours. She is now ready to return to her room. Which action demonstrates that the nurse understands the possible complications of a thyroidectomy? A. Dressings are done every 2 hours to best detect postoperative bleeding, so the nurse should place the dressings at the bedside. [7%] B. Pain is managed the moment the client returns to her room by administering narcotics promptly. [2%] C. The bedside is ready with a tracheostomy set, oxygen, and suction. [87%] D. The nurse teaches the client alternative means of communication. [4%]

Explanation Choice C is correct. The most serious complication after a thyroidectomy is ineffective airway and breathing pattern because of tracheal compression and edema. It is essential to have a tracheostomy set, oxygen, and suction available at the bedside for at least 24 hours postoperatively. The client may have difficulty communicating due to laryngeal edema or nerve damage, but it most commonly occurs due to endotracheal intubation. The client will still be able to talk but may experience hoarseness of the voice. Choices A, B, and D are incorrect. Dressing changes are done PRN for bleeding. However, post-thyroidectomy bleeding may not be visible on the dressing, because blood may drain down the back of the neck by gravity. Narcotics are also given PRN. It is not necessary to administer them on the client's return to her room.

The nurse is preparing medications for the shift. Which of the following clients should be prioritized for immediate medication administration? A. Digoxin to a client with an apical pulse of 50 [8%] B. Furosemide to a client with a serum potassium level of 3.0 mEq/L [8%] C. Magnesium sulfate to a client with Torsades de pointes [81%] D. Verapamil to a client with blood pressure of 100/60 mmHg [3%]

Explanation Choice C is correct. Torsades de pointes, a form of ventricular tachycardia, is a life-threatening condition. The nurse should immediately administer the medication to the client to prevent the disease from progressing into ventricular fibrillation. Choice B is incorrect. Furosemide is a loop diuretic used to treat congestive heart failure and edema. The drug predisposes the client to hypokalemia. In this case, the client already has a low serum potassium level. Therefore, the nurse needs to notify and question the prescribing physician whether he/she should still proceed with administering the medication. Choice A is incorrect. When the nurse is administering digoxin, she should check the patient's apical pulse and withhold the dose if the pulse falls below 60 beats per minute. Choice D is incorrect. The blood pressure of the client is at 100/60 mmHg. Verapamil is a calcium channel blocker and is often used to treat high blood pressure and angina. It can be administered as ordered. Typically, physicians order blood pressure medications to be held at a systolic blood pressure of 90 mmHg or below. However, in this case, the nurse should prioritize administering magnesium to the client with Torsades de pointes.

The emergency department nurse is caring for a patient who presents with sudden onset of edema of the lips and acute shortness of breath following a bee sting. The provider's diagnosis is anaphylaxis. The nurse knows that the first-line medication for this diagnosis is: A. Oral diphenhydramine [8%] B. Nebulized albuterol [4%] C. Oral prednisone [2%] D. Parenteral epinephrine [86%]

Explanation Choice D is correct. Parenteral epinephrine. Although all of these medications might be appropriate in anaphylaxis, the first-line drug is parenteral epinephrine. Anaphylaxis is an acute antibody-antigen reaction that can be life-threatening. In this case, the patient is at risk for airway compromise. This requires an immediate injection of epinephrine to prevent airway closure. Once the team stabilizes the patient, the nurse might administer the other medications to control the other symptoms. Choices A, B, and C are incorrect. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-topic: Expected Actions/Outcomes; Immune

You are caring for a 3-month old child. He was born at term in an uncomplicated delivery. If the child is developing normally, you would expect him to be able to: A. Sit without support. [5%] B. Creep on hands and knees. [24%] C. Follow simple commands. [3%] D. Reach for objects. [67%]

Explanation Choice D is correct. It is essential to understand the normal growth and development of children. In this scenario, the 3-month-old was born at term, and the nurse should expect that his development will follow the normal pattern. A normal 3-month old should be reaching for objects. Choice A is incorrect. A typical child will not sit without support until 8-9 months. Choices B and C are incorrect. A normal child will not creep on hands and knees or follow simple commands until 9-11 months. Learning Objective Understand the normal growth and development in children. A normal 3month old will not be able to sit without support but can reach for objects.

A patient receiving intermittent feedings through a nasogastric tube must have their residual volumes checked before administering more formula. Which is the best rationale for checking residual capacity? A. Evaluate electrolyte status [3%] B. Observe the color of the stomach contents [8%] C. Confirm placement of the nasogastric tube [25%] D. Evaluate absorption from the last feeding [64%]

Explanation Choice D is correct. Stomach contents should be aspirated before administration of the next feeding to ensure absorption is occurring as expected. Overfilling a stomach could lead to enlargement and increased risk of aspiration. Choice A is incorrect. Checking residual volume will not aid a nurse in evaluating a patient's electrolyte status. Choice B is incorrect. While the nurse needs to note the color of the residual volume to rule out any abnormal findings, such as frank bleeding, this is not the best rationale for checking residual capacity. Choice C is incorrect. Confirming nasogastric tube placement is an essential step in administering more formula to a patient. However, it is not the best reason for checking residual volume. NCSBN Client need Topic: Reduction of Risk Potential / Potential for Complications of Diagnostics Tests, Treatments or Procedures

Your pediatric client has just begun an intravenous course of antibiotic therapy with a cephalosporin TID rather than penicillin because this child has a known allergy to penicillin but not to cephalosporins. When you enter the child's room during his first treatment with the cephalosporin, you see that the client is short of breath. What is the first thing that you should do? A. Call the doctor. [1%] B. Elevate the client's head of the bed to ease the shortness of breath. [27%] C. Slow the IV rate down because of possible fluid overload. [5%] D. Discontinue the IV and the cephalosporin administration. [67%]

Explanation Choice D is correct. The first thing that you should do is discontinue the IV and the cephalosporin administration because it is possible that this client is experiencing anaphylactic shock. Anaphylactic shock is a life-threatening emergency and is a high priority when considering airway, breathing, and cardiovascular status. Many people who have an allergy to penicillin also have a sensitivity and allergy to cephalosporins. Once the life-saving intervention is done, the nurse would fully assess the client, raise the head of the bed, and call the doctor for the possible administration of epinephrine. Choice A is incorrect. Although you would notify and call the child's doctor, this is not the first thing that you would do. There is another higher priority action that you would do before calling the doctor. Choice B is incorrect. Although you would elevate the client's head of the bed to ease the shortness of breath, this is not the first thing that you would do. There is another higher priority action that you would do before this. Choice C is incorrect. You would not slow the IV rate because of possible fluid overload since there is another possible life-threatening event that could be occurring.

The client is admitted to the surgical ward after being treated initially in the ER for a femur fracture due to a motor vehicle accident. The client is being interviewed by the nurse for his surgery when he suddenly reports a sharp pain in his chest, displays difficulty breathing, and becomes restless. The nurse suspects a fat embolism; which action of the nurse should take priority? A. Prepare for intubation and mechanical ventilation [24%] B. Administer IV fluids [3%] C. Check vital signs and respiratory status [24%] D. Notify the physician [49%]

Explanation Choice D is correct. The nurse suspects a fat embolism. The question provides enough information regarding the client's distress and sudden change in his clinical status. The mortality rate from a fat embolism is about 10%. Early recognition and treatment are crucial. The nurse should immediately inform the physician to initiate medical interventions. Fat embolism is a potentially life-threatening complication that occurs from long bone fractures that result in the dislodging of fat emboli and then travel into the bloodstream, up into the pulmonary circulation. Symptoms mimic that of a pulmonary embolism. The client may report chest pain, respiratory distress (dyspnea), and may have mental status changes (confusion). Other signs include tachypnea, low oxygen saturation, fever, tachycardia, and low blood pressure. Petechiae (axillary or subconjunctival petechiae) are characteristic of a fat embolism and help differentiate it from other etiologies. Treatment includes intravenous hydration, oxygenation, immobilization, and fixation of the fractured limb. In severe cases of hypoxia and neurological deterioration, intubation and ventilation may be required. Choice A is incorrect. The client may eventually need intubation and mechanical ventilation, depending on the respiratory and neurological condition. However, this is not the initial action of the nurse. Choice B is incorrect. IV fluids may be necessary to prevent hypovolemic shock in the client, but this should be done after informing the physician. Choice C is incorrect. There is sufficient information in the question to indicate the client's distress. The client may need his vital signs checked and monitored; however, this does not take priority over informing the physician and starting emergency interventions.

What is the highest priority nursing goal for a client whose hemoglobin is 10 g/dL and hematocrit is 30%? A. Encourage mobility [7%] B. Promote skin integrity [11%] C. Prevent constipation [8%] D. Conserve the client's energy [75%]

Explanation Choice D is correct. These test results indicate anemia. The impaired oxygen-carrying capacity of red blood cells causes cellular hypoxia and results in fatigue. Conserving energy limits oxygen expenditure and minimizes fatigue. Hemoglobin, abbreviated Hb or Hgb, is the iron-containing oxygen-transport metalloprotein in the red blood cells of almost all vertebrates as well as the tissues of some invertebrates. Hemoglobin in the blood carries oxygen from the lungs or gills to the rest of the body. Normal hemoglobin is 14-18 g/dL for males and 12-16 g/dL for females. The hematocrit, abbreviated Hct, is a blood test that measures the volume percentage of red blood cells in the blood. The measurement depends on the number and size of red blood cells. Normal hematocrit is 42-52% for males and 37-47% for females. Choice A is incorrect. Increased mobility increases the demand for oxygen and contributes to fatigue. Choice B is incorrect. Although hypoxic tissues are more vulnerable to breakdown, protecting the integumentary system is not as high of a priority as is the promotion of the body's overall oxygenation. Choice C is incorrect. Constipation is not a problem in anemia. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential, Blood Tests

The patient is recovering from a chest tube insertion. Which interventions are appropriate for the nurse to include in this patient's care plan? Select all that apply. A. Change the dressing every 48-72 hours as needed. [38%] B. Maintain the drainage container at heart level at all times. [6%] C. Observe and document the drainage color, volume, and consistency. [47%] D. Clamp the chest tubes during transport. [9%]

Explanation Choices A and C are correct. Chest tube dressings should be changed every 48-72 hours as needed to visualize/assess the site and to protect from pathogens. The patient is at risk for infection, so the color, amount, and consistency of drainage should be monitored and documented to detect any signs of infection. Choice B is incorrect. The drainage container should be kept below the heart level to reduce the risk of pneumothorax. Choice D is incorrect. Chest tubes should only be clamped when checking for leaks or assessing the patient's readiness to have the tubes removed. Clamping during accidental disconnection or transport is not appropriate due to the risk of a tension pneumothorax. NCSBN Client Need Topic: Respiratory, Subtopic: Illness management, pathophysiology, the potential for complications from surgical procedures and health alterations

The nurse is reviewing a client's laboratory data. Which laboratory data requires follow-up? See the image below. Select all that apply. A. Sodium [48%] B. Potassium [3%] C. Calcium [37%] D. BUN [6%] E. Creatinine [6%]

Explanation Choices A and C are correct. These laboratory values require follow-up because they are not within the normal limits. The labs depict hyponatremia and hypocalcemia. Causes of hyponatremia include dehydration, diuretics (especially thiazides), and SIADH. Causes of hypocalcemia include hypoparathyroidism, chronic renal failure, and vitamin D deficiency. Choices B, D, and E are incorrect. These laboratory values are within normal limits and do not require follow-up by the nurse.

A 13-year-old girl diagnosed with acute lymphoblastic leukemia (ALL) is worried about the side effects of her new steroid medications. Which of the patient's following statements indicates to the nurse that the adolescent understands the steroids' side effects? Select all that apply. A. "I will have more water in my body, so I might look puffier." [37%] B. "It might hurt to go to the bathroom." [3%] C. "I might soon get bruises more easily than before." [26%] D. "This medicine might make me moody." [33%]

Explanation Choices A and D are correct. Steroids can cause fluid retention (Choice A) and often result in "puffiness" from the excess fluid. This is often seen in the face and sometimes described as a moon face. The nurse should validate this concern of her adolescent patient and explain why she might experience this. It is essential, to be honest with teenage patients to help them cope with the side effects. Mood swings (Choice D) are a known side effect of corticosteroids. They can cause irritability, anxiety, and depression. It is essential to educate the adolescent client about this side effect and reinforce that she should ask for help if she feels overwhelmed. The parents should also be educated about this side effect to know to expect mood swings and are ready to help their adolescent. Choice B is incorrect. Steroids do not cause constipation, dysuria, or any other pain related to going to the bathroom. The nurse should reinforce education with this adolescent and assure her that she should not experience this. Choice C is incorrect. Steroids do not directly cause bruising. Long-term steroids may thin the skin and predispose to easy bruising. However, newly started steroid therapy should not thin the skin immediately. More immediate side effects include fluid retention, steroid acne, hyperglycemia, and mood swings. Steroids do not cause a decrease in platelets or clotting factors that would cause more frequent bruising immediately. However, due to her acute lymphoblastic leukemia (ALL) diagnosis, she may have decreased platelets because of her cancer. This could cause her to bruise more often, so she may misunderstand the cause of this. The nurse should educate this adolescent about her disease process and what could occur and ensure that the steroid medication does not immediately increase bruising. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Pharmacological therapies

The nurse is caring for a client with advanced cirrhosis of the liver. Which of the following medications would the nurse clarify with the primary healthcare provider (PHCP) prescribe? Select all that apply. A. Isoniazid [28%] B. Valproic Acid [23%] C. Amiodarone [14%] D. Lithium [25%] E. Thiamine [10%]

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

You are performing a thorough assessment of a client to determine all responses to stress. Which of the following are examples of cognitive responses to stress? Select all that apply. A. Difficulty concentrating [26%] B. Poor judgment [23%] C. Depression [11%] D. Forgetfulness [22%] E. Lethargy [6%] F. Aggressiveness [12%]

Explanation Choices A, B, and D are correct. These are examples of cognitive responses to stress. Psychological responses are both emotional and cognitive. They include feelings, thoughts, and behaviors. Emotional responses usually involve anxiety, fear, anger, and depression; whereas, cognitive responses affect thought processes. Choices C and E are incorrect. Depression and lethargy are emotional responses to stress. Choice F is incorrect. Aggression is a behavioral response to stress. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Psychological Responses to Stress

Which of the following assessment findings does the nurse expect to observe in a patient with Celiac disease? Select all that apply. A. Dehydration [24%] B. Constipation [16%] C. Nausea and vomiting [30%] D. Abdominal distention [29%]

Explanation Choices A, C, and D are correct. A is correct. In Celiac disease, patients have large amounts of diarrhea. This puts them at risk for dehydration. The nurse should always be aware of her patient's fluid volume status and quick to intervene if her patient becomes dehydrated. IV fluid administration will be a priority for this patient. C is correct. The patient with Celiac disease may present with nausea and vomiting if they have not been following a gluten-free diet. Their body will not be able to absorb gluten and therefore the consumption of it can cause nausea, vomiting, and diarrhea. D is correct. Abdominal distention is an expected finding in the patient with Celiac disease due to their intolerance of gluten and malabsorption. Their abdomen will not only be distended but uncomfortable and tender to palpation. Choice B is incorrect. Patients with Celiac disease are prone to diarrhea, not constipation. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care; Pediatrics - Gastrointestinal

Which of the following electrolyte imbalances should the nurse monitor for in her patient with Celiac disease? Select all that apply. A. Hyperkalemia [14%] B. Hypomagnesemia [31%] C. Hyperphosphatemia [20%] D. Hypocalcemia [35%]

Explanation Choices B and D are correct. The nurse should monitor for signs of hypomagnesemia in a client with Celiac disease. A large volume of diarrhea and malabsorption may lead to severe hypomagnesemia. Signs and symptoms would include twitches, hyperreflexia, tachycardia, confusion, and irritability (Choice B). The nurse should also monitor for signs of hypocalcemia in a patient with Celiac disease. This is due to large amounts of diarrhea and malabsorption. Signs and symptoms would include confusion, muscle spasms, numbness, cramps, Chvostek's sign, and Trousseau's sign (Choice D). Choice A is incorrect. The nurse should monitor for hypokalemia, not hyperkalemia in her patient with Celiac disease. This is due to large amounts of diarrhea and losses of potassium from the GI tract. Choice C is incorrect. The nurse should monitor for hypophosphatemia, not hyperphosphatemia in her patient with Celiac disease. This is due to large amounts of diarrhea and malabsorption associated with Celiac disease. Usually, when clients present with hypocalcemia, hyperphosphatemia is also present due to their inverse relationship. However, this is not the case in Celiac disease. Because the patient has large amounts of diarrhea and malabsorption, neither calcium nor phosphorus are well absorbed and both are expected to be low. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Basic care, comfort; Pediatrics - Gastrointestinal

Your client asks you which foods he can eat so that he gets the recommended daily allowance of vitamins. Select the vitamins that are accurately paired with major food sources. Select all that apply. A. Niacin (B3): Corn and other grains [10%] B. Riboflavin (B2): Citrus and milk [6%] C. Folate (B9): Liver and legumes [22%] D. Vitamin K: Liver and leafy green vegetables [28%] E. Vitamin D: Fish and fortified milk [25%] F. Pantothenic acid (B5): Grains and legumes [9%]

Explanation Choices C, D, E, and F are correct. Folate is found in liver, legumes, and leafy green vegetables. Vitamin K is found in leafy green vegetables and liver. Vitamin D is found in fortified milk and fish. Pantothenic acid (B5) is found in whole grains, avocado, beans, legumes (lentils), lean chicken, beef, pork, and broccoli. Pantothenic acid is ubiquitous and hence, a deficiency is very rare except in severe malnutrition. Choice A is incorrect. Niacin (B3) is found primarily in meats, liver, fish, legumes, peanuts, coffee, and tea. It is deficient in corn and refined grains. Choice B is incorrect. Riboflavin (B2) is found in leafy green vegetables and milk, but not in citrus.

The client is prescribed 3 g/hr of intravenous magnesium sulfate via continuous infusion. The label reads 20 g of magnesium sulfate in 1000 mL of normal saline. How many mL/hr should the nurse set the pump to deliver the prescribed dose? Fill in the blank. 150 mL/hr

Explanation To solve this problem, the formula of dose ordered / dose on hand x volume will be used. 3 grams (ordered) / 20 grams (on hand) x 1000 mL (volume) = 150 mL/hr

The nurse is caring for a client that is hypothermic and receiving warmed IV fluids. The nurse understands that rewarming must be done slowly due to which primary reason? A. To prevent burns in the patient. [13%] B. To prevent ventricular fibrillation and cardiovascular collapse. [64%] C. To prevent frostbite. [4%] D. To avoid muscle spasms. [19%]

Explanation Choice B is correct. Rewarming must be done slowly because the hypothermic client is especially susceptible to the development of ventricular fibrillation and cardiovascular collapse if warmed blood is returned rapidly to a cold heart. Choice A is incorrect. Preventing burns is a responsibility of the nurse when warming a patient but it is not the main reason why rewarming should be done slowly. Choice C is incorrect. Frostbite is a product of hypothermia to the extremities, not rewarming. Choice D is incorrect. Muscle spasms cannot be caused by rewarming.

A 28-week pregnant client is advised by her physician to receive a RhoGam injection. She asks the nurse the reason for the medication. What should be the most appropriate response from the nurse? A. "RhoGam prevents measles during pregnancy." [1%] B. "This prevents you from forming antibodies against your baby." [94%] C. "RhoGam prevents jaundice in your baby." [1%] D. "RhoGam prevents autosomal abnormalities." [5%]

Explanation Choice B is correct. RhoGam prevents the sensitization of an Rh-negative mother to her Rh-positive, ABO-compatible child. This prevents her from forming antibodies against Rh-positive blood cells she may be exposed to during delivery. Choice A is incorrect. RhoGam is not a rubella vaccine. Rubella vaccine prevents measles; however, it cannot be given to the pregnant woman until after delivery. Choice C is incorrect. RhoGam does not prevent neonatal jaundice. Choice D is incorrect. RhoGam does not prevent autosomal abnormalities.

A 4-year-old boy is recovering from abdominal surgery at the pediatric unit. As the nurse caring for the child, which of the following activities do you recommend that he prioritize? A. Blowing bubbles [46%] B. Peek-a-boo [3%] C. Building blocks [28%] D. Playing with clay [22%]

Explanation Choice A is correct. Letting the child blow bubbles will stimulate lung expansion, preventing respiratory problems arising from surgery. Following the abdominal surgery, respirations are not as efficient because anesthesia hampers it, and it hurts to breathe. Consequently, mucus builds up, and the lung may collapse fully or partially ( atelectasis). Pneumonia may follow. The collapsed lung may result in dyspnea and respiratory failure and complicate the post-operative recovery. Therefore, primary health care providers ( PHCP) order incentive spirometers to reduce the risk of respiratory problems after surgery. However, if the child is under the age of five or is unable to use the incentive spirometer for another reason, they should blow bubbles for two to three minutes every hour. Blowing bubbles will serve as an alternative to incentive spirometry in these children. Choices B, C, and D are incorrect. Peek-a-boo is appropriate for infants, not preschool children. Furthermore, peek-a-boo ( Choice B) does not promote lung expansion. While playing with building blocks ( Choice C) is suited for preschool children, this activity does not promote lung expansion. Clay ( Choice D) is suited for toddlers to play with but does not serve as an alternative to incentive spirometry. Learning Objective Recognize that incentive spirometry is a vital intervention to help the post-surgical clients breathe deeply and prevent lung collapse. In preschool children, blowing bubbles can be an alternative to incentive spirometry.

The nurse is checking the physician's order for intravenous fluids. He notes that the patient has been receiving morning blood transfusions and will need a compatible fluid to accompany the transfusion. The nurse should question all of the following intravenous fluids, except: A. Lactated Ringers [6%] B. Normal Saline [70%] C. Dextrose in Water [19%] D. Ringers Solution [5%]

Explanation Choice B is correct. Normal saline is the most appropriate intravenous fluid for blood transfusions. Normal saline is an isotonic solution that will not cause blood hemolysis or red blood cell clumping. Choice A is incorrect. Lactated Ringers can cause RBC binding and hemolysis. Choice C is incorrect. Dextrose may cause red blood cell aggregation and should not be used in conjunction with blood transfusions. Choice D is incorrect. Ringers solution contains citrate which may cause blood coagulation and because of this should never be prescribed along with blood products. NCSBN client need Topic: Pharmacologic and Parenteral Therapies: Blood and Blood Products

The nurse is in the postpartum unit assessing a client who gave birth 2 hours ago. The nurse notes that the client's fundus is soft and boggy. Her perineal pads have been changed twice over the past 2 hours. What is the initial action of the nurse? A. Apply pressure on the fundus. [2%] B. Massage the fundus until it is firm. [83%] C. Notify the physician. [13%] D. Elevate the client's legs. [1%]

Explanation Choice B is correct. The initial action of the nurse when she finds that the fundus is soft and boggy is to massage it until it is firm. Massaging the fundus stimulates it to contract and expels blood clots. Choice A is incorrect. Applying pressure on the fundus that is not contracting can lead to an inversion of the uterus and result in massive hemorrhaging. Choice C is incorrect. Notifying the physician is an inappropriate action. The nurse should implement nursing interventions first before informing the physician. Choice D is incorrect. Elevating the client's legs can help in shunting blood from the extremities to the vital organs. However, it does not help in managing uterine atony in this client.

The nurse has received the following prescriptions for newly admitted clients. The nurse should first administer which of the following? A. Enoxaparin to a patient with a platelet count of 165,000 mm3 [2%] B. Warfarin to a patient with an international normalized ratio of 2.4 [4%] C. Packed red blood cells to a patient with a hemoglobin of 6.8 g/dL [63%] D. Regular insulin to a patient with a blood glucose of 285 mg/dL [31%]

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

The patient is presenting with a fever, nausea, and dysuria. Which action would the nurse take first? A. Administer as needed antipyretic. [21%] B. Call the physician to obtain an antibiotic order for a suspected UTI. [6%] C. Collect a midstream, clean-catch urine specimen. [53%] D. Collect STAT blood cultures. [20%]

Explanation Choice C is correct. The nurse should recognize that this patient is presenting with symptoms of urinary tract infection (UTI) or pyelonephritis. The most appropriate first action would be to assess the patient and check the urine for infection. Choice A is incorrect. In a patient who is not in distress or severe pain, the nurse should not administer medication until the assessment is complete. Choice B is incorrect. The nurse should finish the assessment prior to calling physicians since there is no data to support a medical emergency scenario to immediately notify the physician without a complete assessment. Besides, a urine specimen should be collected before administering an antibiotic in a suspected UTI. Choice D is incorrect. The patient's symptoms are consistent with urinary tract infection and would not necessarily warrant blood cultures. A complicated UTI may evolve into sepsis. If signs of sepsis are present, blood cultures would be appropriate. NCSBN Client Need Topic: Prioritization, Subtopic: Establishing priorities, system-specific assessment

The nurse performs a head-to-toe assessment on an assigned client. Which of the following client conditions are examples of subjective data? Select all that apply. A. The client reports feeling nauseated. [26%] B. The client's lower extremities are swollen. [1%] C. The client expresses nervousness about test results. [25%] D. The client reports an itchy rash on the leg. [22%] E. The client rates pain at a 6 on a scale of 1 to 10. [24%] F. The client vomits twice after eating dinner. [2%]

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