Archer Review 3a

At her first visit, a prenatal client is found to be suffering from mildly high blood pressure. The nurse should have her client reduce which dietary component? A. Salt [97%] B. Magnesium [1%] C. Potassium [2%] D. Calcium [0%]

Explanation Choice A is correct. Salt should be restricted in the client with mildly high blood pressure. A blood pressure that is considered moderately high is about 140/90 mmHg. These patients should begin treatment by reducing salt intake and assessing behavioral areas that may need adjustment, such as smoking cigarettes or failing to exercise. Choices B, C, and D are incorrect. Magnesium, potassium, and calcium do not need to be reduced when a patient presents with high blood pressure. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care

The nurse is caring for a client who has sickle cell disease (SCD). Which of the following laboratory findings would require follow-up? A. Hemoglobin 11.2 mg/dL [18%] B. Creatinine 2.5 mg/dL [72%] C. BUN 19 mg/dL [3%] D. Platelet count 150,000 mm3 [7%]

Explanation Choice B is correct. One of the many complications associated with sickle cell disease is renal injury. The creatinine being significantly elevated requires follow-up because this is evidence of significant renal insufficiency. Choices A, C, and D are incorrect. The hallmark of sickle cell disease is anemia. Hemoglobin of 11.2 mg/dL illustrates the cardinal sign of this disease. The BUN is normal (10 mg/dL-20 mg/dL) and does not require follow-up. The platelet count is normal and does not require follow-up. Additional Info Sickle cell disease (SCD) is a serious genetic disorder that causes abnormalities in hemoglobin. The client has an increased presence of hemoglobin S compared to a decreased hemoglobin A. Several complications with SCD may occur and include: Stroke Pulmonary hypertension Myocardial infarction Infection Priapism Venous thromboembolism

The nursing diagnosis "[a]t risk for insufficient vascular perfusion" would most apply to which of the following clients? A. An adolescent client undergoing an expected maturational growth spurt [1%] B. A 6-year-old pediatric client with a leg recently placed in a cast following a greenstick fracture [80%] C. A 76-year-old female client with urinary and fecal incontinence [7%] D. A 42-year-old male client who recently sprained his ankle while playing basketball and wrapped the affected ankle in an elastic bandage

Explanation Choice B is correct. The nursing diagnosis "[a]t risk for an alteration in vascular perfusion" is most applicable to this client, as the recently casted extremity following the greenstick fracture places this client at risk for decreased tissue and vascular perfusion, primarily compartment syndrome. Compartment syndrome is always a concern for a client with a newly placed cast. In compartment syndrome, tissue pressure (often due to swelling) occurs within a confined space (i.e., within the cast), leading to restricted blood flow and eventually ischemia. Compartment syndrome is always considered a medical emergency and requires prompt medical intervention. Failure to intervene quickly can result in ischemia, possibly leading to irreversible damage to the tissue(s). Choice A is incorrect. An anticipated maturational growth spurt does not place an adolescent client at risk for insufficient vascular perfusion. Choice C is incorrect. A 76-year-old female client who is incontinent of both urine and feces is not at risk for insufficient vascular perfusion based on the incontinence alone. Although other age-related issues may put this client at risk for insufficient vascular perfusion, nothing about the incontinence places the client at increased risk. Of note, the client is likely at risk for other potential complications, such as skin integrity issues. Choice D is incorrect. Although the 42-year-old male client who recently sprained his ankle while playing basketball and wrapped the affected joint in an elastic bandage is indeed "[a]t risk for an alteration in vascular perfusion," the question asks for the client who is at the most risk for an alteration in vascular perfusion. Although an elastic wrap could alter circulation or perfusion to the tissues, the elastic contained in the wrap is more likely to expand in the event of swelling as opposed to a restrictive cast as worn in the client referenced in Choice B. Learning Objective Identify which client is most at risk for insufficient vascular perfusion. Additional Info A greenstick fracture occurs when a bone is angulated beyond the bending limits, resulting in the compressed side bending and the tension side failing, causing an incomplete fracture similar to the break observed when a green stick breaks. The pliable bones of the growing child are more porous than the adult's, allowing them to bend, buckle, and break in a "greenstick" manner. Compartment syndrome is assessed utilizing the five P's: pain, paralysis, paresthesia, pallor, and pulselessness. Time is of the essence when dealing with compartment syndrome or any other type of insufficient vascular perfusion. Elevating a limb suspected of developing or having developed compartment syndrome is contraindicated. Doing so would reduce the already impaired blood flow by decreasing arterial flow.

The nurse administers dobutamine to a patient with heart failure following a cardiac procedure. Which of the following should the nurse recognize as an intended effect of this medication? A. Increased heart rate [10%] B. Increased vasoconstriction [10%] C. Increased cardiac output [66%] D. Increased blood pressure [14%]

Explanation Choice C is correct. Dobutamine is a positive inotropic and chronotropic drug that helps increase myocardial contractility by selectively acting on the beta-1 receptors in the myocardium. By increasing the heart rate and contractility, dobutamine helps increase cardiac output in acute heart failure settings. Dobutamine is indicated in the short-term management of decompensated congestive heart failure. Choice A, B, and D are incorrect. Stimulation of beta-1 adrenergic receptors in the myocardial tissue results in increased heart rate ( positive chronotropic) and myocardial contractility ( positive inotropic). Dobutamine selectively stimulates these receptors and, therefore, can increase the heart rate. However, the intended therapeutic effect of dobutamine is increased cardiac output, not an increased heart rate ( Choice A). In addition to beta-1 stimulation, dobutamine also has mild beta-2 agonistic action, resulting in peripheral vasodilation. Additionally, increased cardiac contractility causes reflex systemic vasodilation, not vasoconstriction (Choice B). Systemic vasodilation decreases resistance (afterload) and reduces the demand on the heart. Blood pressure is a product of cardiac output and systemic vascular resistance. Therefore, increased cardiac output increases blood pressure. Because of its sympathomimetic activity, dobutamine can substantially increase systolic blood pressure. Increased blood pressure above the normal range would be an adverse effect, not intended ( Choice D). Patients with pre-existing hypertension are even more prone to dobutamine's adverse impacts of increased systolic blood pressure. NCSBN Client Need Topic: Pharmacology - Cardiovascular, Subtopic: Adverse effects/contraindications/side effects/interactions of medications Learning Objective Understand that dobutamine, a positive inotropic and chronotropic drug, is indicated in the short-term management of decompensated left ventricular heart failure and low cardiac output states following cardiac surgery. Additional Info Dobutamine is a complex drug with a range of actions. Dobutamine has selective beta-1 receptor agonistic actions, mild beta-2 agonistic actions, and milder alpha-1 actions. The typical effect of dobutamine is to increase the heart rate and myocardial contractility. However, significant increases in systolic blood pressure may occur from dobutamine infusion, and hence, the patient should be monitored. While increased systolic blood pressure is the most common adverse effect of dobutamine, hypotension can sometimes occur. Hypotension from dobutamine can be due to its exaggerated systemic vasodilatory effects. The nurse should be aware of this while infusing dobutamine in shock states. If dobutamine ends up worsening the hypotension, interventions include decreasing the dose or stopping dobutamine altogether. Other side effects of dobutamine include arrhythmias because of its effect on the heart rate. Dobutamine decreases the renal clearance of lithium and predisposes to lithium toxicity. Monitor carefully if a client is on both lithium and dobutamine.

The nurse caring for a three-year-old with congestive heart failure recognizes which of the following as an early sign of digitalis toxicity? A. Bradypnea [13%] B. Tachycardia [15%] C. Vomiting [65%] D. Failure to thrive [8%]

Explanation Choice C is correct. The earliest sign of digitalis toxicity is vomiting. One episode, however, does not warrant discontinuing the medication. Digoxin increases the force of myocardial contraction, decreases conduction through the SA and AV nodes, and prolongs the refractory period of the AV node. The result is increased cardiac output and reduced heart rate. Therapeutic serum digoxin levels range from 0.5-2 ng/mL. Serum levels may be drawn 6-8 hours after a dose is administered, although they are usually drawn immediately before the next dose. In infants and small children, the first symptoms of overdose are typically cardiac arrhythmias. Choice A is incorrect. Bradypnea is not associated with digitalis toxicity. Choice B is incorrect. Bradycardia, not tachycardia, is associated with digitalis toxicity. Choice D is incorrect. Although children with congestive heart failure often have a related condition of failure to thrive, it is not directly related to digitalis administration. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

A woman in her 38th-week gestation was given MgSO4 for pregnancy-induced hypertension (PIH). The nurse knows that this client should be monitored for: A. Blurring of vision [20%] B. Tachypnea [7%] C. Pain in the epigastrium [3%] D. Respiratory depression [70%]

Explanation Choice D is correct. A common side effect of this medication is respiratory depression, not tachypnea, and the client is carefully monitored for this. Choices A, B, and C are incorrect. Blurring vision and epigastric pain are indicators that pregnancy-induced hypertension (PIH) has become more severe and may precede the eclamptic phase.

The primary healthcare provider (PHCP) prescribes 250 mL of 0.9% saline to infuse over 75 minutes. How many mL per hour will be administered to the client? Fill in the blank. 200 mL/hr

Explanation To solve this problem, the formula of volume / time (hours) will be used. First, convert the minutes to hours 75 minutes / 60 minutes = 1.25 hrs Next, divide the prescribed total volume by the infusion time 250 mL / 1.25 hours = 200 mL/hr Additional Info 0.9% saline is an isotonic solution utilized in the treatment of standard dehydration.

Which of the following medications is contraindicated for a pregnant client? Select all that apply. A. Warfarin [25%] B. Finasteride [15%] C. Celecoxib [15%] D. Clonidine [12%] E. Transdermal Nicotine [19%] F. Clofazimine [13%]

Choices A and B are correct. Warfarin (coumadin) has a pregnancy category X. It is associated with central nervous system defects, spontaneous abortion, stillbirth, prematurity, illness, and ocular defects when given any time during pregnancy and a fetal warfarin syndrome when given during the first trimester (Choice A). Finasteride (Propecia, Proscar) also has a pregnancy category X, which has a high risk of causing permanent damage to the fetus (Choice B). Fetal age affects the type of drug effect: Before the 20th day after fertilization: Drugs that were given at this time typically have an all-or-nothing effect, killing the embryo or not affecting it at all. Teratogenesis is unlikely during this stage. During organogenesis (between 20 and 56 days after fertilization): Teratogenesis is most likely at this stage. Drugs reaching the embryo during this stage may result in spontaneous abortion, a sublethal gross anatomic defect (exact teratogenic effect), covert embryopathy (a permanent subtle metabolic or functional defect that may manifest later in life), or an increased risk of childhood cancer (e.g., when the mother is given radioactive iodine to treat thyroid cancer); or the drugs may have no measurable effect. After organogenesis (in the 2nd and 3rd trimesters): Teratogenesis is unlikely, but drugs may alter the growth and function of customarily formed fetal organs and tissues. As placental metabolism increases, doses must be higher for fetal toxicity to occur. Choice C is incorrect. Celecoxib (Celebrex) in large doses causes congenital disabilities in rabbits, but it is not known if the effect is the same on humans. Choice D is incorrect. Clonidine (Catapres) crosses the placenta, but no adverse fetal effects have been observed. Choice E is incorrect. Nicotine replacement products have been assigned to pregnancy category C (nicotine gum) and category D (transdermal patches, inhalers, and spray nicotine products). Choice F is incorrect. Clofazimine has been assigned to pregnancy category C. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies; The Effects of Medications on Fetal Development

The nurse is teaching progressive relaxation techniques to a client. Which of the following statements by the client indicates that the teaching has been effective? Select all that apply. A. "I will breathe in and out in rhythm." [35%] B. "I expect my pulse to be faster afterwards." [1%] C. "I expect to require less pain medication." [31%] D. "I expect my muscles to feel less tense." [27%] E. "I will report any increased sensitivity." [6%]

Correct Answer 34% of peers have answered correctly. 55 s Time Spent 24-06-2022 Last Updated Explanation Choices A, C, D, and E are correct. Progressive relaxation involves rhythmic breathing and progressive tension and relaxation of one muscle group at a time. When implemented, clients typically experience decreased muscle tension and a reduction in the need for pharmacologic measures to relieve pain and anxiety. Although sensitivity may be normal for clients who are new to progressive relaxation exercises, any sensitivity or exhaustion should be reported and monitored so the nurse can decide whether the client would be better suited for passive relaxation techniques. Choice B is incorrect. When relaxation techniques are properly implemented, the client should experience a decreased pulse rate. Additional Info Clients who are unable to perform progressive relaxation due to advanced disease, immobility, or decreased energy can still benefit from passive relaxation or guided imagery. Passive relaxation involves slow, mindful breathing without tensing and relaxing the muscles. Imagery, or visualization, involves consciously using the mind to call forth mental images such as ocean waves along with the rhythm of the breath. These techniques can stimulate a similar relaxation response without expending additional physical energy.

Which statement about ethical principles is accurate? A. Beneficence and nonmaleficence are different and not antonyms. [53%] B. Beneficence is to treat patients fairly and equitably. [16%] C. Beneficence is the opposite of nonmaleficence. [15%] D. Beneficence is a synonym for nonmaleficence [16%]

Explanation Choice A is correct. Beneficence and nonmaleficence are different ethical concepts, and they are also not antonyms or the opposite of each other. Beneficence is defined as "doing good" to the patients, and nonmaleficence is defined as doing "no harm" to the patients. Choice B is incorrect. Justice is the ethical principle that refers to treating patients fairly and equitably, not beneficence. Choices C and D are incorrect. Beneficence is neither the opposite nor the synonym for nonmaleficence; they are different ethical concepts.

Chadwick's sign is a prenatal assessment performed at the initial visit to verify pregnancy. The obstetric nurse knows that Chadwick's sign presents with: A. A blue to purplish hue of the cervix [81%] B. Softness to the uterine fundus felt through the abdomen [8%] C. A thinning and lengthening of the cervix [8%] D. The absence of menstruation at day 28 in a woman's cycle [2%]

Explanation Choice A is correct. Chadwick's sign presents as a blue to purple hue of the cervix and is considered a "probable" sign of pregnancy. Choice B is incorrect. A soft uterus is not used to verify pregnancy. Choice C is incorrect. The thinning and lengthening of the cervix is known as effacement and occurs just before or during labor. Choice D is incorrect. The absence of menstruation is not an assessment performed by the health care provider. Instead, it is an observation a woman will report.

The nurse is caring for a child who is receiving prescribed methylphenidate. Which of the following findings should be reported to the primary healthcare provider (PHCP)? A. Weight loss of 3 kilograms [56%] B. Dry mouth [12%] C. Trouble falling asleep [17%] D. Occasional headaches [15%]

Explanation Choice A is correct. Children receiving psychostimulant medications such as methylphenidate should be monitored closely for weight loss which may inhibit their ability to meet their growth milestones. This finding of a three-kilogram weight loss is necessary to report to the PHCP. Choices B, C, and D are incorrect. Dry mouth, occasional headaches, and insomnia are common side effects associated with methylphenidate. These findings are concerning but may be mitigated through other interventions. The weight loss is quite concerning as this threatens the child's physiological health. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Adverse Effects/Contraindications/Side Effects/Interactions Question type: Analysis Additional Info Methylphenidate is a psychostimulant effective in treating attention deficit hyperactivity disorder (ADHD). This medication may be used, or an amphetamine may be utilized to treat this disorder. While non-stimulant medications are available, psychostimulant medications may produce rapid results. Adversely, a child's growth pattern needs to be monitored closely as this medication may cause anorexia and weight loss.

The nurse enters a client's room who is found on the ground. The nurse should perform which initial action? A. Assess the client's level of consciousness [78%] B. Examine the client for injuries [8%] C. Call the rapid response team (RRT) [2%] D. Palpate the client's carotid pulse [11%]

Explanation Choice A is correct. For a client found down on the ground, the nurse should immediately implement basic life support measures, including initially assessing the client's level of consciousness. If the client is unconscious, the nurse should stay with the client and shout for help. Choices B, C, and D are incorrect. Assessing the client's level of consciousness is the priority over assessing the client for injuries. Examining the client for injuries is a secondary assessment as their immediate concern is their overall stability. The RRT may need to be activated depending on the outcome of the client's level of consciousness. According to the BLS algorithm, the client's level of consciousness should be prioritized over the assessment of the carotid pulse. NCLEX Category: Physiological Adaptation Activity Statement: Medical Emergencies Question type: Application Additional Info The BLS health care provider algorithm is below. This image is from the American Heart Association.

You are caring for a female client who is 5 foot 2 inches tall and has a BMI of 17. This client is now on a regular diet. You would most likely recommend: A. Continuing their diet as it is [12%] B. Weight reduction with diet and exercise [3%] C. A high caloric diet to gain weight [75%] D. Nothing at all, this client is normal [10%]

Explanation Choice C is correct. You would most likely recommend a high caloric diet to gain weight for this client, who is 5 foot 2 inches tall and has a body mass index (BMI) of 17 because this client is underweight. The ranges for BMI are as follows: Underweight: Under 18.5 Normal: From 18.5 to 24.9 Overweight: From 25 to 29.9 Obesity: From 30 to 39.9 Extreme obesity: Over 40 Choice A is incorrect. A body mass index (BMI) of 17 indicates the need for dietary intake to gain weight. Choice B is incorrect. You would not advise the client to begin a weight reduction diet because a body mass index (BMI) of 17 indicates the need for education about dietary intake to gain weight. Choice D is incorrect. A body mass index (BMI) of 17 indicates the need for dietary intake to gain weight.

A woman is in the labor and delivery suite at 37 weeks gestation. She has been under her obstetrician's care for preeclampsia. The labor nurse notices that the fetus is experiencing heart rate decelerations. You are part of the neonatal resuscitation team that responds to the call from the labor room nurse. The infant is born but does not respond to tactile stimulation. The group moves the infant to the warmer. You evaluate the infant and confirm he is still not breathing. You begin positive pressure blowing with room air. Another team member notes that the heart rate is 72 bpm and the newborn's chest is not moving with PPV on room air. The next appropriate action is to: A. Reposition the infant to open the airway [33%] B. Begin CPR [39%] C. Suction the infant with a bulb syringe [24%] D. Increase the oxygen concentration [5%]

Explanation Choice A is correct. Reposition the infant to open the airway while ensuring that you have a good seal with the mask on the newborn's face. Following that action, a team member should suction the infant's mouth and nose. Until the team establishes sufficient ventilation, there is no indication to increase oxygen concentration or begin CPR. The AHA and AAP focus on positive-pressure ventilation as the single most crucial step in the resuscitation of the newborn. Choices B, C, and D are incorrect. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Alterations in Body Systems, Newborn

The nurse is caring for an elderly patient who has become comatose. The patient's living will specifies that no life-extending procedures are to be done. However, the patient's adult children are troubled and strongly object to this. How would the nurse effectively advocate for the patient in this situation? A. Remind colleagues about the contents of the patient's advance directives. [80%] B. Document the wishes of the patient's adult children. [11%] C. Plan to respond slowly or incompletely should the patient experience cardiac arrest. [3%] D. Develop a plan of care based on the preferences of the patient's children. [7%]

Explanation Choice A is correct. The 'living will' is a legal document expressing the patient's preferences regarding life-extending medical procedures. It is the nurse's responsibility to support the patient's right to autonomy and self-determination, as shown in that document. One strategy to do so is to communicate the patient's wishes to the health care team involved with the patient. Choice B is incorrect. While documentation of the family's objections and wishes may be done, it should not be considered to supersede the patient's preferences, as stated in the living will. Choice C is incorrect. Performing a "slow code," responding slowly or incompletely to a cardiac arrest, is considered unethical, representing a violation of the patient's trust, right to autonomy, and self-determination. Choice D is incorrect. Again, this option is a violation of the patient's trust, right to autonomy, and self-determination. Blooms Taxonomy - Analyzing

A 45-year-old man is rushed to the emergency room with reports of substernal chest pain, shortness of breath, and diaphoresis. Cardiac troponin levels were taken and found to be elevated. Which of the following nursing interventions should be prioritized? A. Increase oxygenation to the heart and reduce the heart's workload [78%] B. Prevent complications and confirm a diagnosis of myocardial infarction [13%] C. Alleviate the patient's anxiety [2%] D. Pain relief [7%]

Explanation Choice A is correct. The client manifests signs and symptoms of myocardial infarction/acute coronary syndrome (ACS). Elevated troponin further supports the diagnosis. While the 2007 acute coronary syndrome guidelines recommend supplemental oxygen to any client diagnosed with acute myocardial infarction, some evidence emerged that routine oxygen administration may be counter-productive by causing coronary vasoconstriction and decreasing coronary blood flow. Hence, the guidelines were modified in 2014 with a recommendation to administer supplemental oxygen only to those acute coronary syndrome patients with symptoms and signs of respiratory distress, cyanosis, hypoxia, or those with oxygen saturation less than 90%. The client's symptoms of shortness of breath and diaphoresis indicate respiratory distress. The priority for nursing care should focus on increasing oxygen delivery to the heart and reducing its workload to prevent further damage. Choice B is incorrect. Confirming the diagnosis should be done; however, since the client is already exhibiting signs of reduced myocardial oxygenation (chest pain) and respiratory distress, the nurse should prioritize oxygen delivery to the client. Choice C is incorrect. It is the nurse's responsibility to alleviate the client's anxiety; however, the nurse should prioritize oxygenation to the client. Choice D is incorrect. Pain relief should be significant in the care of the patient with myocardial infarction; however, it should not take priority over oxygenation in an ACS client with respiratory distress. Patients with ACS and continuing ischemic chest pain should receive sublingual nitroglycerin. Morphine should also be administered for pain relief. Learning Objective: Understand that the evidence-based recommendations support supplemental oxygen in an acute coronary syndrome client when there are signs and symptoms of respiratory distress

The nurse is assigned to care for a client who is on digitalis therapy. A serum digoxin level was taken earlier in the day, and the nurse notes that the result is 2.5 ng/mL. The nurse should take which immediate action? A. Notify the physician about the result. [80%] B. Check the client's file for the latest pulse rate recorded. [7%] C. Record the normal value on the client's flow sheet. [6%] D. Administer the next dose of the medication as scheduled and prescribed. [7%]

Explanation Choice A is correct. The normal therapeutic range for digoxin is 0.5 to 2 ng/mL, and the latest level for this client (2.5 ng/mL) indicates toxicity. The nurse's immediate response should be to notify the client's physician so that prompt action may be taken. Choice B is incorrect. Checking the latest pulse rate in the client's file is pointless at this point since the duration of time that has elapsed since the record was updated is a factor that could lead to confusion. The nurse should check the client's pulse rate at the same time the result was received as additional data he/she can relay to the physician. Choice C is incorrect. The nurse must record the actual result in the client's flow sheet and must never falsely alter the record. Choice D is incorrect. It is also not safe to administer the next dose of the medication because of toxicity in this client.

A client receiving chemotherapy (Cisplatin) for ovarian cancer suffers nausea and vomiting. The nurse's most important role in this is which of the following? A. Evaluate onset, frequency, and severity of symptoms [75%] B. Ensure food is heated before the client eats [4%] C. Provide venues for relaxation or distraction [6%] D. Limit client's intake to a soft, bland diet [14%]

Explanation Choice A is correct. The nurse needs to assess the symptoms in terms of onset, frequency, and severity to point out patterns and help the nurse collaborate with the physician in scheduling round-the-clock emetic therapy. Choice B is incorrect. Cold food may decrease odor and trigger vomiting, so heating is helpful but this is not the priority at this point. Choice C is incorrect. Relaxation and distraction techniques are also essential but not as important as the assessment of nausea and vomiting patterns. Choice D is incorrect. A bland diet may help decrease the symptoms but is also not the priority at this point.

The patient with a right distal fibula fracture complains of pain and a tingling sensation in the right foot. Upon assessment, the nurse notes the right foot is cold to the touch with a weak dorsalis pedis pulse. Which potential complication should the nurse be most concerned about? A. Compartment syndrome [81%] B. Sepsis [1%] C. Peripheral neuropathy [16%] D. Pressure Injury [2%]

Explanation Choice A is correct. This patient is presenting with early signs/symptoms consistent with compartment syndrome. Later signs of compartment syndrome include paralysis and the absence of pulses in the affected extremity. If not caught and treated early, compartment syndrome can result in permanent muscle and nerve damage. Choice B is incorrect. There is no assessment data that supports a diagnosis of sepsis. Localized pain is expected in fracture patients, but would not be indicative of sepsis without additional symptoms of infection. Choice C is incorrect. Patients with nerve damage/peripheral neuropathy would experience symptoms such as pain and tingling. Still, the other assessment data of cold skin temperature and weak pulse would not support this diagnosis. Peripheral neuropathy would not be a more significant concern than compartment syndrome. Choice D is incorrect. This patient would be at risk of developing a pressure injury due to injury and immobility, but this potential complication would not be a more significant concern than compartment syndrome. NCSBN Client Need Topic: Adult Health - Musculoskeletal, Subtopic: System-specific assessments, medical emergencies, pathophysiology

The patient with history of right mastectomy is receiving maintenance IV fluids via peripherally inserted intravenous line in the left cephalic vein. The patient complains of pain at the IV site, and the nurse notes that the infusion has slowed and assesses swelling and erythema at the IV site. Which action should the nurse take first? A. Stop the infusion and remove the IV catheter [93%] B. Insert new IV in left intermediate basilic vein. [2%] C. Prepare the patient for PICC line placement. [1%] D. Elevate the right arm to reduce swelling. [4%]

Explanation Choice A is correct. This patient's IV site shows signs of phlebitis: redness, swelling, pain, and slowed infusion rate. The first priority action is to remove the current IV catheter to reduce the risk of further complications. Localized symptoms of phlebitis typically resolve after discontinuation of the catheter. Choice B is incorrect. Since this patient is not a candidate for IV access in the opposite arm due to a history of right mastectomy, the nurse should remove the current IV, and then attempt to insert a new IV proximal from the original site, but the current IV site should be discontinued first, prior to initiating any other interventions. Choice C is incorrect. This patient may be a candidate for PICC line placement if attempts to insert IVs at new sites are unsuccessful, but the current IV site should be discontinued first, prior to initiating any other interventions. Choice D is incorrect. Although phlebitis symptoms can be relieved by elevating the affected limb, applying a warm compress application, and administering analgesics, the current IV site should be discontinued first, prior to initiating any other interventions. NCSBN Client need: Topic: Physiological Integrity, Sub-topic: Pharmacological and Parenteral Therapies

You are admitting a new client. During your collection of data for the health history, you ask the client about the medications, including over-the-counter medications, herbs, supplements, and vitamins that they are taking at home. You are performing the: A. Medication reconciliation process as mandated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). [68%] B. Medication reconciliation process as mandated by the Institute for Healthcare Improvement. [24%] C. Unique identifier process as mandated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). [5%] D. Unique identifier process as mandated by the Institute for Healthcare Improvement. [3%]

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

The nurse is preparing a client for angiography using contrast media. The nurse should tell the client that he will experience all of the following when the contrast media is injected, except: A. The client might feel possible nausea. [3%] B. The client might have a headache lasting several days. [65%] C. The client might feel flushing of the face. [11%] D. The client might feel a sudden urge to urinate. [20%]

Explanation Choice B is correct. A headache lasting several days is not an expected effect of contrast media. Therefore, this is the correct answer to the question. Choices A, C, and D are incorrect. The nurse should tell the client that when the contrast media is injected, he will feel possible flushing of the face or a sudden urge to urinate. These are the expected effects of intravenous contrast media. A mild allergic reaction such as nausea may also be experienced.

At 2100, you administered a mildly sedating medication to your client per an order written by the attending health care provider (HCP) earlier today. Upon your reassessment of this client at 2200, you find the client restless, agitated, and hyperactive. Which of the following is the best choice to describe what has most likely occurred? A. An allergic reaction [9%] B. An idiosyncratic reaction [46%] C. An adverse effect [39%] D. A medication error [6%]

Explanation Choice B is correct. An idiosyncratic reaction is an abnormal and unexpected response to a medication, other than an allergic reaction, that is peculiar to an individual client. This type of reaction is nearly always unpredictable. Although a wide variety of idiosyncratic (i.e., unpredictable) drug reactions may occur, some examples include Stevens-Johnson syndrome or exfoliative dermatitis. Based on the answer choices, this is most likely what has occurred in this client. Therefore, Choice B is correct. Choice A is incorrect. An allergic reaction is a type of adverse drug event where an immunologic hypersensitivity reaction results from the unusual sensitivity of a patient to a particular medication. In this type of adverse event, physical manifestations of this response range from skin erythema or mild rash to severe, even life-threatening reactions such as the constriction of bronchial airways and tachycardia. Based on the information provided, this client does not seem to be experiencing an allergic reaction. Therefore, Choice A is incorrect. Choice C is incorrect. The term "adverse effect" is an umbrella term used to describe undesirable effects that are a direct response to one or more medications taken by a client. While an adverse effect did occur, more than one of the answer choices falls under the umbrella term of "adverse effect." Therefore, Choice C is not the correct answer, as the question asks for the best choice to describe what has occurred. Choice D is incorrect. A medication error is any preventable adverse drug event involving inappropriate medication use by a patient or health care professional (HCP). In this case, no evidence indicates a preventable adverse drug event occurred. As described above, an idiosyncratic reaction is an unpredictable and abnormal response to a medication. Here, the medication was administered per the HCP order. This reaction was unanticipated and unforeseeable and, therefore, not a medication error. Therefore, Choice D is incorrect. Learning Objective Utilize the objectives findings provided to determine the type of medication reaction the client is likely experiencing. Additional Info An idiosyncratic reaction is an abnormal and unexpected response to a medication, other than an allergic reaction, that is peculiar to an individual client. This type of reaction is nearly always unpredictable. There is a wide range of idiosyncratic drug reactions which may occur, such as maculopapular eruptions, eosinophilia, Stevens-Johnson syndrome, and exfoliative dermatitis. An allergic reaction (also known as a hypersensitivity reaction) involves the client's immune system. Immune system proteins (immunoglobulins) recognize the drug molecule, its metabolite(s), or another ingredient in a drug formulation and trigger an immune response. At that point, immunoglobulin proteins bind to the drug substance attempting to neutralize the drug. Various chemical mediators, such as histamine, cytokines, and other inflammatory substances are released. Physical manifestations of this response range from skin erythema or mild rash to severe, even life-threatening reactions such as the constriction of bronchial airways and tachycardia. This is considered a type of adverse drug event. Two types of adverse drug reactions are allergic reactions (often predictable) and idiosyncratic reactions (usually unpredictable). A medication error does not need to cause patient harm to be classified as a medication error.

The nurse is caring for a patient with a myocardial infarction who is experiencing tachycardia and coughs up frothy, pink-tinged sputum. Which finding would the nurse expect upon auscultation of lung sounds? A. Wheezing [6%] B. Crackles [71%] C. Rhonchi [11%] D. Diminished sounds [12%]

Explanation Choice B is correct. Crackles are common in cases of pulmonary edema related to myocardial infarction. Choice A is incorrect. Wheezing is common in cases of inflammation and narrowed airways. Choice C is incorrect. Rhonchi occurs in bronchitis and pneumonia. Choice D is incorrect. Diminished breath sounds are usually heard with COPD or pneumonia. NCSBN client need Topic: Physiological integrity, reduction of risk potential

The nurse is admitting a 72-year-old patient hospitalized for a medical diagnosis of Mycoplasma pneumonia. Which transmission-based precaution is necessary? A. Private room with negative pressure airflow [25%] B. Wearing a surgical mask within 3 feet of the patient [59%] C. Wearing gloves when in contact with the patient [11%] D. HEPA filtration for incoming air [5%]

Explanation Choice B is correct. Droplet precautions are indicated for patients with Mycoplasma pneumonia. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, proper hand hygiene, and placement in a private room or with a cohort of patients. Other examples where droplet precautions are indicated include Pertussis, Influenza, Diphtheria, and invasive Neisseria meningitides. There are three types of transmission-based precautions: The model used depends on the mode of transmission of a specific disease. Airborne Contact Droplet Choice A is incorrect. A private room with negative pressure airflow is a component of airborne precautions. Airborne precautions would be indicated for diseases such as Measles, Severe Acute Respiratory Syndrome (SARS), Varicella (chickenpox), and Mycobacterium tuberculosis. Choice C is incorrect. Wearing gloves when in contact with the patient is required with contact precautions. Presence of diarrhea/stool incontinence (i.e. Norovirus, Rotavirus, Clostridium difficile), or skin infections (i.e. MRSA, Vancomycin-Resistant Enterococci (VRE)), open or draining wounds, pressure ulcers, generalized rash, or presence of ostomy tubes and bags draining body fluids. Choice D is incorrect. HEPA filtration for air coming into the patient's room is associated with a protective environment.

Which of the following is the first nursing action for a patient experiencing dyspnea? A. Remove pillows from under the patient's head [1%] B. Elevate the head of the bed [97%] C. Elevate the foot of the bed [0%] D. Take the patient's blood pressure [1%]

Explanation Choice B is correct. Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm more room and facilitating lung expansion. Dyspnea is difficult or labored breathing. A dyspneic patient usually has rapid, shallow respirations. Because of this "shallow" breathing, ventilation is affected, and Co2 accumulates. Dyspneic clients can often breathe better in an upright position. When standing or sitting, gravity pulls the abdominal organs down and away from the diaphragm, creating more space in the thoracic cavity. This allows the lungs more room for expansion and allows the client to take more air with each breath ( better ventilation). Choices A, C, and D. None of these answer choices are appropriate as the first nursing action for a patient experiencing dyspnea. Recumbent positions ( Choices A and C) limit expiratory flow and cause a decrease in elastic recoil of the lung. Therefore, such positions do not improve ventilation. The nurse should check the client's blood pressure ( Choice D), but the priority action should be to position the client to reduce breathlessness and the effort of breathing. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential - Respiratory Depth and Rhythm Learning Objective Understand the positioning techniques to help dyspneic patients reduce the work of breathing. Upright and sitting positions provide more room for the lungs to expand and provide mechanical advantage, thereby reducing the work of breathing. Additional Info Patients may be dyspneic because of several reasons. COPD is one of the commonest causes. In clients with Chronic Obstructive Pulmonary Disease ( COPD), the lungs are hyper-inflated. Because of decreased elastic recoil of the lungs, the air is trapped in the lungs leading to poor ventilation. Because the lungs are hyper-inflated, the diaphragm is flattened and functions poorly. Clients with COPD should be educated about forward-lean positions, allowing the diaphragm to assume a more domed position and work better. Such positions include: High side-lying. Forward lean sitting without pillows. Forward lean sitting with pillows. Upright sitting in a chair Forearm support to assist breathing using a trolley. Forward lean standing. Standing with back support.

The nurse is discharging a client following knee arthroplasty. Which of the following information should the nurse include in discharge teaching? A. "After this procedure, you will use a wheelchair to get around." [9%] B. "You will need to resume your anticoagulants." [48%] C. "Placing a pillow under your knee will help with the pain." [31%] D. "You may ice the site for one hour at a time." [12%]

Explanation Choice B is correct. Following a knee arthroplasty, the patients will not be as mobile and require crutches. This may increase their risk of developing venous thromboembolism (VTE). Thus, the nurse should reiterate that the patients resume their prescribed anticoagulants or initiate them if they are newly prescribed. Evidence-based guidelines recommend that patients undergoing total hip or total knee arthroplasty receive anticoagulant prophylaxis for a minimum of 14 days. Choices A, C, and D are incorrect. A wheelchair is not utilized following knee arthroplasty. The nurse should teach the patient to use crutches because some degree of ambulation must be initiated. A pillow underneath the knee may increase the risk for flexion contracture and must be avoided following the procedure ( Choice C). Finally, ice may be applied for no more than twenty minutes for the first twenty-four hours ( Choice D). Prolonged ice application may cause skin damage. Learning Objective Recognize that venous thromboembolism is a significant complication of relative immobility following knee arthroplasty and other major lower extremity surgical procedures. The clients should be on venous thromboembolism prophylaxis. Additional Info Knee arthroplasty is a procedure used to correct problems with the joint. The provider may do certain repairs ( joint resurfacing, reconstruction, or replacement ) during the procedure. The nurse must preoperatively ensure that the patient is NPO, has a completed consent, and has not taken any anticoagulants for a specified amount of time. Total knee replacement is the most common procedure done during knee arthroplasty, where the joint is entirely replaced by a metal prosthesis. Deep vein thrombosis and pulmonary embolism ( venous thromboembolism) are the most significant threats after total hip or total knee arthroplasty. Anticoagulant prophylaxis reduces the incidence of venous thromboembolism after these procedures. Evidence-based guidelines from the American College of Chest Physicians (ACCP) recommend a minimum of 14 days of prophylactic anticoagulation and extending up to 35 days following the surgery.

The nurse is placing the patient with chronic kidney disease on a cardiac monitor. This action is primarily performed because: A. Patients with chronic kidney disease are prone to hypertension [7%] B. Hyperkalemia may result in dysrhythmias [86%] C. Cardiac monitoring is necessary to evaluate the need for hemodialysis [3%] D. Patients with chronic kidney disease may experience false episodes of asystole [3%]

Explanation Choice B is correct. Patients with chronic kidney disease (CKD) retain electrolytes such as potassium, which may lead to imbalances. Hyperkalemia, or excess serum potassium levels, often results in cardiac dysrhythmias. Choice A is incorrect. While patients with chronic kidney disease may experience hypertension, a cardiac monitor does not evaluate the patient for this occurrence. Choice C is incorrect. Cardiac monitoring may show dysrhythmias, which could suggest the need for hemodialysis. However, this is not the primary method doctors use to evaluate this need. Choice D is incorrect. False episodes of asystole are not a concern with chronic kidney disease. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

The nurse is preparing a client with peptic ulcer disease for a barium study of the stomach and esophagus. What should be the initial nursing action? A. Have the informed consent signed by the client for the procedure. [31%] B. Teach the client the importance of increased oral fluids after the procedure. [10%] C. Explain to the client that he or she will have to drink a white, chalky substance. [19%] D. Instruct the client not to eat or drink anything before the procedure. [39%]

Explanation Choice D is correct. The first or initial intervention for the nurse is to inform the client that he or she needs to be on NPO at least 8 to 10 hours before the test. The barium study requires the upper GI tract to be empty during the procedure. Choice A is incorrect. A barium study is a non-invasive procedure and does not require an informed consent form. Choice B is incorrect. A side effect of barium is constipation after the procedure. The nurse, therefore, needs to instruct the client to drink lots of fluids. It is not, however, the initial intervention of the nurse. Choice C is incorrect. The client needs to know that he will need to drink the barium, which is a white and chalky substance during the procedure. However, this is not the initial nursing intervention.

The nurse is caring for a client following a bedside thoracentesis. Which action should the nurse take immediately following the procedure? A. Instruct the client to take slow, shallow breaths [11%] B. Assess the patient's respiratory status. [84%] C. Label the lab specimen for culture. [3%] D. Provide nasal cannula oxygen. [1%]

Explanation Choice B is correct. Respiratory complications following rapid removal of fluid include hypoxemia and pulmonary edema. Assessing the client's respiratory status is a high priority and would be the first action the nurse should take. Choices A, B, C, and D are incorrect. A dressing should be applied following the removal of the needle, and it would be an appropriate action for the nurse to monitor the site and the drainage. A scant amount of blood would be expected following the puncture, not necessarily signifying a complication. The client should be instructed to breathe deep after this procedure to assist with the reexpansion of the lung, but this would not prioritize over an immediate respiratory assessment. Sending specimens to the lab would be an appropriate action but should be done at the time of collection. Supplying nasal cannula oxygen is not necessary unless the respiratory assessment reveals that the client is in distress. Additional Info Following a thoracentesis, immediate assessments include the client's vital signs and listening to the lungs for absent or reduced sounds on the affected side (this could indicate a pneumothorax). Check the puncture site and dressing for leakage or bleeding. Assess for complications, such as reaccumulation of fluid in the pleural space, subcutaneous emphysema, infection, and tension pneumothorax. Urge the client to breathe deeply to promote lung expansion.

Select the barrier to effective medication use among the elderly population that is accurately paired with an effective corrective nursing intervention. A. Poverty and the lack of health insurance: Discontinue medications and suggest over-the-counter remedies [10%] B. Arthritis affecting the hands: Suggest non-child proof medication containers [37%] C. Poor fine motor coordination: Suggest an eye examination [8%] D. Severe confusion and poor memory: Write up a chart for medications [45%]

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

The nurse manager plans to develop a unit-based council to assist in decision-making. The nurse manager is demonstrating which leadership style? A. Authoritative [13%] B. Democratic [70%] C. Laissez-Faire [8%] D. Transactional [8%]

Explanation Choice B is correct. The democratic leadership style is predicated on individuals participating in decision-making. Developing a unit-based council, distributing decision-making responsibilities to individuals, and promoting problem-solving by staff are examples of this leadership style. Choices A, C, and D are incorrect. An authoritative leadership style is when one individual is in complete control. This would be useful during an emergency situation, and clear roles need to be delegated. Laissez-Faire leadership focuses on relying on staff to make decisions, and the manager is viewed as a consultant. This is often viewed as a hands-off approach to leadership. Transactional leadership is when rewards and consequences are based on the actions of an individual. This leadership style is a rigorous approach to managing a team. Additional Info The crux of the democratic leadership style encourages and assists in discussion and group decision-making. The pro of this leadership style is that it encourages shared decision-making, increases staff morale, and brings more viewpoints to issues. Cons of this leadership style include that it takes time to reach a consensus, relies on others to participate, and may cause procrastination in decision-making.

The nurse is taking care of a client with a chest tube due to a flail chest. After 3 days, the water seal compartment is no longer tidaling. What is the most appropriate action of the nurse? A. Assess the tubing for any dependent loops [47%] B. Auscultate the client's back for breath sounds [38%] C. Prepare to remove the chest tube [2%] D. Notify the physician that the lungs have re-expanded [12%]

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

You are providing care to an alert and oriented client who is on complete bed rest. What type of self-care mode, according to self-care theory, reflects this client's need for a range of motion exercises? A. The partly compensatory mode [18%] B. The educative mode [21%] C. The wholly compensatory mode [13%] D. The immobilization mode [49%]

Explanation Choice B is correct. The self-care mode, according to the self-care theory, reflects this client's need for a range of motion exercises, is an educative or supportive mode because the client is alert and oriented. Therefore, this client will need education about the need for a range of motion exercises and how to perform them. Dorothea Orem developed the self-care theory that describes the degree to which our clients can fulfill their self-care needs. Clients are in the educative and supportive mode when they can care for their own self-care needs; they are partly compensatory when they need some physical assistance and help in terms of their individual self-care needs, and they are compensatory when they need complete assistance from another to meet their self-care needs. Choices A and C are incorrect. The information in this question indicates that the client can perform this range of motion on their own without the physical assistance and help of another. Choice D is incorrect. The self-care mode, according to the self-care theory, reflects this client's need for a range of motion exercises but is not the immobilization mode because there is no immobilization mode according to Orem's self-care theory.

Which of the following would be a priority action for a nurse who has suffered a needlestick while working with a patient who is positive for AIDS? A. Contact a social worker right away [5%] B. Start prophylactic zidovudine [70%] C. Start prophylactic pentamidine treatment [24%] D. Make an appointment with a psychiatrist [0%]

Explanation Choice B is correct. Zidovudine is the most critical intervention. It is an antiretroviral medication that is used to prevent and treat HIV/AIDS by reducing the replication of the virus. Choice A is incorrect. A social worker consultation is not the most emergent action at this point. Choice C is incorrect. Pentamidine is a synthetic antibiotic used chiefly in the treatment of pneumocystis carinii pneumonia. Choice D is incorrect. A psychiatric appointment is not indicated. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control - Exposure to Blood-Borne Pathogens

The charge nurse is making patient assignments for the day. Which client should they assign to a new graduate registered nurse(RN)? A. A 35-year-old client with myocardial infarction. [8%] B. A 56-year-old client with unstable angina. [4%] C. A 75-year-old client scheduled for an angiogram. [80%] D. A 60-year-old client with chest pain. [8%]

Explanation Choice C is correct. A client that is getting an angiogram needs a pre-procedure checklist to be completed. This task is appropriate to be delegated to a newly registered nurse. This action is a routine intervention that is necessary before this client undergoes this test. Choice A is incorrect. The client has necrotic myocardial tissues and is prone to complications. A patient with a myocardial infarction is at risk for life-threatening complications. The client will need the expertise of an experienced nurse in assessing, intervening, and teaching in his care. Choice B is incorrect. A client with unstable angina is at risk for complications that are serious and life-threatening. This client is at risk for a myocardial infarction. The client needs an experienced nurse to care for him. Choice D is incorrect. A client with chest pain may be having a myocardial infarction (MI). The client needs to be taken care of by an experienced nurse. If this client is having a MI this patient will need their care expedited by an experienced nurse who can direct this patient to getting to the cath-lab as soon as possible for the stunting of their blocked artery. This client would need a nurse who is experienced in critical care. Learning Objective Identify interventions that are appropriate to be delegated to a new graduate RN. Additional Info The delegation process is multifaceted. It beings with decisions made at the administrative level of the organization and trickles all the way down to the staff responsible for delegating. Delegation involves effective communication and empowers staff to made decisions based on their judgement. The nurse retains responsibility for all tasks delegated. It is imperative to understand that states/jurisdictions have different laws and rules about delegation and it is the responsibility for all registered nurses to know what is permitted within their state's/jurisdictions individual nurse practice act.

The nurse has just finished assisting the physician in performing a paracentesis. What should be the priority nursing intervention in the client's plan of care following the procedure? A. Administer analgesics to control pain. [6%] B. Monitor for signs of infection. [16%] C. Monitor for signs of hypovolemic shock. [70%] D. Ensure that the ascetic fluid is sent to the lab for analysis. [7%]

Explanation Choice C is correct. A major complication of paracentesis is hypovolemic shock secondary to fluid drainage from the peritoneum; resulting in a fluid shift from intravascular to interstitial space and the sudden change in intraabdominal pressure on the vessels. The nurse should observe for pallor, tachycardia, hypotension, oliguria, and dyspnea. Choice A is incorrect. Abdominal pain after paracentesis can be treated with NSAIDs; however, it is not a significant complication of the procedure. Choice B is incorrect. Infection may occur after a paracentesis; however, signs of infection will not be apparent until after 24 hours. Choice D is incorrect. After the procedure, the primary concern of the nurse is to assess and prevent complications in the client. The nurse may ensure that the aspirated fluid is sent to the lab for analysis, but it should not take priority over the patient.

The nurse in the emergency department is taking care of a patient diagnosed with left ventricular failure. The patient presents with fatigue, muscular weakness, and dyspnea. The patient is seen coughing and sitting in a "three-point position". The nurse understands that manifestations of left-sided heart failure present themselves as respiratory problems because: A. There is venous congestion in the liver. [1%] B. There is hypoperfusion of tissue cells. [9%] C. There is pulmonary congestion. [78%] D. Despite the normal cardiac output, the heart is still not able to meet the accelerated demands of the body. [12%]

Explanation Choice C is correct. Due to the inability of the left ventricle to pump blood, there is an accumulation of blood behind it, leading to congestion in the pulmonary veins down to the lungs. Choice A is incorrect. Venous congestion in the liver occurs because of a decrease in the functioning of the right ventricle. Choice B is incorrect. Hypoperfusion of tissues is a consequence of most forms of heart failure. However, the manifestations of left heart failure occur because of pulmonary congestion. Choice D is incorrect. The heart being unable to meet the accelerated needs of the body despite its standard cardiac output is a description of high output heart failure. This occurs in sepsis, Paget's disease, beriberi, anemia, and other conditions.

One nurse is assigned to do dressing changes for all patients in their unit for the entire shift. Another nurse is assigned to give medications, while another one is assigned to monitor the vital signs for the entire unit. Which nursing delivery system does this exemplify? A. Case management [2%] B. Team [37%] C. Functional [58%] D. Primary [3%]

Explanation Choice C is correct. Functional nursing involves assigning each nurse with a specific task to perform for the shift. Choice A is incorrect. Case management covers all aspects of care. Choice B is incorrect. Team nursing involves a group of nurses or staff being assigned to a limited number or group of patients. Choice D is incorrect. Primary nursing requires a nurse to take care of all the nursing care needs of a patient.

The nurse is teaching a client who has Graves' disease about self-management. Which of the following should the nurse include in the teaching plan? A. Stool softeners can be taken daily to prevent constipation. [7%] B. Thyroid replacement should be taken first thing in the morning. [43%] C. Report any significant weight gain while taking the antithyroid medication. [40%] D. Maintain the prescribed fluid restriction to prevent fluid overload. [10%]

Explanation Choice C is correct. Graves' disease is the most common cause of hyperthyroidism. When a client is taking antithyroid medication, such as methimazole, they should be taught about the warning signs of hypothyroidism (weight gain, constipation, anorexia). This could indicate that the dose needs to be decreased. Choices A, B, and D are incorrect. Constipation is a hallmark finding of hypothyroidism (Choice A). This would not be expected of Graves' disease. Thyroid replacement (Choice B) would be contraindicated for Graves' disease as this would worsen hyperthyroidism. Thyroid replacement should be taken first in the morning by patients with hypothyroidism, not hyperthyroidism. Fluid restrictions are not indicated for Graves' disease (Choice D). Additional Info Graves' disease is an autoimmune disease and is the most common cause of hyperthyroidism. A hallmark finding of this disease is heat intolerance. Other manifestations of hyperthyroidism include exophthalmos, weight loss, irritability, and the thinning of scalp hair. The course of treatment is antithyroid medications or surgery.

When evaluating developmental milestones for a 6-month-old child, which of the following should the nurse screen during a routine office visit? A. Standing while holding onto something/someone [4%] B. Creeping [8%] C. Rolling over [46%] D. Sitting up [42%]

Explanation Choice C is correct. Rolling over begins between 4 and 6 months of age. The early years of a child's life are crucial for their health and development. Healthy development means that children of all abilities, including those with special health care needs, can grow up where their social, emotional, and educational needs are met. It is important to encourage regular well-child visits so that healthcare professionals can help monitor for expected developmental milestones. If a milestone is missed or delayed, this could indicate an underlying problem. When the screening tool is used, a formal developmental evaluation may be necessary if an area of concern is found. During the developmental evaluation, a specialist looks more closely at the child's development and performs a more in-depth assessment to try and pinpoint the cause of the problem. Choice A is incorrect. Standing occurs between 8 and 10 months of age. Choice B is incorrect. Creeping begins between 9 and 10 months. Choice D is incorrect. Sitting up without support occurs between 8 and 9 months of age. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Developmental Milestones Learning Objective Understand the normal developmental milestones in a child. A 6-month-old can roll over and sit up, taking support from hands and leaning forward but can not sit up without support.

The nurse and the LPN are working a busy shift at the pediatric ward. The nurse, to provide efficiency in the ward, should delegate which task to the LPN? A. Administration of a medication in syrup form to an infant with a cleft palate. [25%] B. Provide discharge instructions to the mother of a child with epiglottitis. [1%] C. Change a colostomy bag for a toddler with anal atresia. [73%] D. Assess a child's developmental level. [1%]

Explanation Choice C is correct. The LPN can perform a colostomy change. This is a routine nursing procedure that the LPN can perform adequately. An LPN's (Licensed practical nurse) scope of practice includes providing ostomy care, monitoring the findings of the registered nurse, reinforcing patient education, administration of most medications in stable patients, caring for ostomy sites/tubes; enteral feeding, and checking for feeding tube patency. An LPN may not perform an initial assessment: Initial assessments are to be performed by a Registered Nurse (RN). The first assessment is to be used to determine a patient's baseline and develop an initial nursing plan of care. Once the first assessment has been completed, and the nursing plan has been developed, the LPN may assist the RN in the nursing process. The LPN is to communicate any change of a patient's status to the RN. Choice A is incorrect. The LPN cannot administer medications in this case to a child with a cleft palate. This is because a child's cleft palate poses a risk for aspiration to the infant. This needs the expertise and assessment of the registered nurse. Choice B is incorrect. The LPN cannot provide discharge instructions. Choice D is incorrect. Assessment of a child's developmental level needs the skills and expertise of the RN.

The nurse is caring for a client who is taking prescribed venlafaxine. Which statements made by the client would be highly concerning to the nurse? A. "I have trouble sleeping at night." [8%] B. "I experience diarrhea at least once a day." [4%] C. "I just cannot go on like this anymore." [81%] D. "I am using artificial tears for my dry eyes." [6%]

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

recommended that the entire family and members of the extended family who live in the family's home begin family therapy. The grandparents tell you that their grandson, who is addicted to prescription painkillers, is the cause of the problem. Since he is not their son, they feel that they do not have to participate in this group therapy. How should you respond to these grandparents? A. "You should try to come to a few sessions at least because they may be very informative to you." [8%] B. "You are probably correct. This really is not your problem." [0%] C. "Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of the family, including grandparents who live in the home." [90%] D. "You should attend because the doctor has ordered family therapy for you as extended family members." [2%]

Explanation Choice C is correct. You should respond to the grandparents' statement with, "Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of the family, including grandparents who live in the home." After this statement, you should also educate the grandparents about the fact that group and family therapy is often indicated when the family unit is affected with stressors and dysfunction because family members may not fully understand the need for the entire family unit to participate when only one member of the family is adversely affected with a stressor and poor coping; in reality, all family members are affected. Choice A is incorrect. You would not state, "You should try to come to a few sessions at least because they may be very informative to you" since these sessions are therapeutic and not educational. Choice B is incorrect. You would not state, "You are probably correct. This really is not your problem" since this statement is not true. Choice D is incorrect. You should not state, "You should attend because the doctor has ordered family therapy for you as extended family members" since this is not the real reason why attending these sessions is needed. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Family Communication Patterns

The nurse reviews a client's medical record taking prescribed isoniazid for pulmonary tuberculosis. Which laboratory data is most important to monitor? A. PT and PTT [4%] B. CBC [10%] C. BUN [14%] D. Liver enzymes [72%]

Explanation Choice D is correct. Liver toxicity is a severe adverse effect of isoniazid. Healthcare providers should monitor for signs of jaundice, fatigue, elevated liver enzymes, and loss of appetite. Liver enzyme tests are usually performed monthly during therapy to identify early hepatotoxicity. Isoniazid is a bacteriocidal for actively growing organisms and a bacteriostatic for dormant mycobacteria. It is selective for M. tuberculosis. Isoniazid is used alone for chemoprophylaxis, or in combination with other antitubercular drugs when treating active disease. Choices A, B, and C are incorrect. While the physician may order these tests periodically, they are not indicated as a monitoring tool during isoniazid therapy. Additional Info INH is the first-line therapy for pulmonary tuberculosis. This agent is often combined with another antitubercular medication because of the emerging drug resistance. Hepatotoxicity is the most common adverse effect of most antitubercular drugs. The client should immediately report signs of hepatotoxicity such as jaundice and clay-colored stools.

You are working in the delivery room. The physician has inserted an endotracheal tube (ETT) in a newborn who did not respond to initial treatment. The most reliable method for confirming the placement of the ETT is: A. Observe for the rise and fall of the chest with ventilations [19%] B. Observe for increased heart rate [2%] C. Auscultate for bilateral breath sounds [50%] D. Observe for CO2 exhalation using a CO2 detector [29%]

Explanation Choice D is correct. Observe for CO2 exhalation using a CO2 detector. A CO2 sensor is the most reliable indicator of successful intubation. Following intubation, the team should connect a CO2 detector to the ETT. Within 8 to 10 breaths, the sensor should begin to detect exhaled CO2. If an indicator is not available, the team should observe for an increased heart rate. Choices A and C are incorrect. Observing for the rising and fall of the chest and auscultation for breath sounds are less reliable methods of confirming ETT placement. Choice B is incorrect. A rising heart rate is a positive sign that the infant is receiving oxygen with good saturation. NCSBN Client Need Topic: Basic Care and Comfort, Sub-topic: Assistive Devices; Newborn

A client was brought into the emergency department by his wife because he has been vomiting for three days. The wife is worried because he has grown weak and seems to be having a hard time breathing. The nurse notes that he is hypoventilating and has a respiratory rate of 10 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/min. Consequently, arterial blood gases are drawn, and the nurse reviews the results, expecting to note which of the following? A. A decreased pH and an elevated CO2 [45%] B. An elevated pH and a decreased CO2 [18%] C. A decreased pH and a decreased HCO3- [12%] D. An increased pH with an increased HCO3- [25%]

Explanation Choice D is correct. Persistent nausea and vomiting would most likely lead to metabolic alkalosis because of the loss of gastric acid, thus causing the pH and HCO3_ to increase. Hypoventilation and tachycardia are some symptoms the patient may experience. Choice A is incorrect. This reflects a respiratory acidotic condition. Choice B is incorrect. This reflects a respiratory alkalotic state. Choice C is incorrect. This reflects a metabolic acidotic state.

The nurse is discharging the client that has been admitted due to subarachnoid hemorrhage. The client still has some speech and balance deficits. Which referral should the nurse make? A. Refer the client to hospice care. [2%] B. Refer the client to speech therapy. [37%] C. Refer the client to physical therapy. [27%] D. Refer the client to a home health agency. [34%]

Explanation Choice D is correct. The client is going home, thus the client needs to be referred to a home health agency so that there is continuity of care even at home. Choice A is incorrect. Hospice care is for clients that are terminally ill. This client is not terminally ill. Choice B is incorrect. Speech therapy aids clients in regaining speech and swallowing abilities. Speech therapy should have been initiated and ongoing while the client was in the hospital. Choice C is incorrect. Physical therapy aids clients in regaining muscle strength and balance. Physical therapy should have been initiated and ongoing while the client was in the hospital.

When providing bowel training education to a 65-year-old woman with chronic constipation. Which of the following indicates that the nurse needs to continue gathering information? A. The client's fluid intake is between 2500-3000 mL per day. [4%] B. The client's dietary habits include foods high in bulk. [23%] C. The client engages in moderate exercise each day. [1%] D. The client states that she can use a laxative 4-5 times weekly until bowel regularity is achieved. [71%]

Explanation Choice D is correct. The consistent use of laxatives inhibits natural defecation reflexes and is thought to cause, rather than cure, constipation. The frequent user of laxatives eventually requires larger or stronger doses because the effect is progressively reduced with continual use. Laxatives may also interfere with the body's electrolyte balance and decrease the absorption of specific vitamins. The reasons for constipation can range from lifestyle habits (e.g. lack of exercise) to severe malignant disorders (e.g. colorectal cancer). The nurse should evaluate any complaints of constipation carefully for each individual. A change in bowel habits over several weeks with or without weight loss, pain, or fever should be referred to a primary care provider for a complete medical evaluation. See clinical manifestations for risk factors and symptoms of colorectal cancer. Choices A, B, and C are incorrect. These are all measures that help promote healthy bowel habits and indicate that the client understands steps to help reduce constipation. Adequate fluid intake helps prevent dry, hard stools. High bulk in the diet helps promote the absorption of water. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort

Which of these is the best example of an ethical principle in nursing? A. Fidelity: the nurse should maintain honesty with patients during any education and care. [18%] B. Veracity: the nurse followed through with any promises made to the patient during his or her care. [8%] C. Beneficence: the nurse encourages the patient to be involved in his or her care. [7%] D. Nonmaleficence: the nurse did not cause harm to the patient. [67%]

Explanation Choice D is correct. The nurse did not cause harm to the patient, which is known as nonmaleficence. The ethical principles that nurses must adhere to are the principles of justice, beneficence, nonmaleficence, accountability, fidelity, autonomy, and veracity. Justice is fairness. Nurses must be fair when they distribute care. Care must be fairly, justly, and equitably distributed among a group of patients. Beneficence is doing good and the right thing for the patient. Nonmaleficence is doing no harm, as stated in the historical Hippocratic Oath. Harm can be intentional or unintentional. Accountability is accepting responsibility for one's own actions. Nurses are accountable for their nursing care and other actions. They must accept all of the professional and personal consequences that can occur as a result of their actions. Fidelity is keeping one's promises. The nurse must be faithful and true to their professional promises and responsibilities by providing high-quality, safe care in a competent manner. Autonomy and patient self-determination are upheld when the nurse accepts the client as a unique person who has the innate right to have their own opinions, perspectives, values, and beliefs. Nurses encourage patients to make their own decision without any judgments or coercion from the nurse. The patient has the right to reject or accept all treatments. Veracity is being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to patient distress. A is incorrect. Fidelity is keeping one's promise. B is incorrect. Veracity is being truthful with clients. C is incorrect. Beneficence is doing what is good and right for the patient. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care, Nursing Ethics

The nurse is working in the emergency department caring for a client with diabetic ketoacidosis (DKA). Which of the following arterial blood gas (ABG) results would be expected? A. pH = 7.50; PaO2 = 90 mm Hg; PaCO2 = 37 mm Hg; HCO3- = 31 mEq/L [8%] B. pH = 7.31; PaO2 = 90 mm Hg; PaCO2 = 56 mm Hg; HCO3- = 23 mEq/L [19%] C. pH = 7.51; PaO2 = 94 mm Hg; PaCO2 = 31 mm Hg; HCO3- = 24 mEq/L [4%] D. pH = 7.31; PaO2 = 90 mm Hg; PaCO2 = 37 mm Hg; HCO3- = 15 mEq/L [69%]

Explanation Choice D is correct. Thie ABG depicts metabolic acidosis, which is an expected finding with DKA. Metabolic acidosis develops with DKA because fats are used as the source of fuel because of the absence of insulin. This causes ketones to be produced, creating a state of acidosis. Choices A, B, and C are incorrect. These ABGs do not depict metabolic acidosis which is a consistent finding with DKA. Choice A depicts metabolic alkalosis, choice B depicts respiratory acidosis, and finally, choice c depicts respiratory alkalosis. Additional Info The treatment of metabolic acidosis caused by DKA is the administration of prescribed insulin. Insulin therapy is used to lower serum glucose by about 50 to 75 mg/dL/hr, which will mitigate acidosis. If this is not effective, parenteral sodium bicarbonate may be administered.

A client tells the nurse, "I have never disagreed with anyone I've known and probably never will." Which of the following is the most appropriate way for the nurse to respond? A. "Wow, how is that even possible?" [1%] B. "Really? I find that unbelievable. A lot of people can't do that." [1%] C. "How do you deal with your feelings of dissatisfaction or anger?" [79%] D. "How did you develop such a way of life?" [19%]

Explanation Choice D is correct. This response is an open-ended question about the client's way of life and allows the client to express himself or openly talk about himself. It is important to obtain detailed information regarding the issue at hand before proceeding to specific questions. Choices A, B, and C are incorrect. The options in choices A and B imply disbelief and may be misinterpreted by the client as a challenge and may make the client defensive. The nurse should not ask about feelings of dissatisfaction or anger ( Choice C) because the nurse should not identify the client's feelings for him. The client has not mentioned he is dissatisfied or angry so, such assumptions should not me made during therapeutic communication or an interview.

Which of the following practices does the nurse recognize as typical in the Amish community? Select all that apply. A. Health is viewed as a gift from God. [44%] B. They commonly use alternative healthcare. [41%] C. Women and men are equal and can both make healthcare decisions. [9%] D. Most of the Amish community choose to have health insurance. [6%]

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

The nurse is developing a plan of care for a client with an impairment to the hypoglossal cranial nerve. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Observe the client during meals [35%] B. Keep suction at the bedside [30%] C. Provide large print education materials [15%] D. Teach the client to scan the room [17%] E. Alternate the use of an eye patch [2%]

Explanation Choices A and B are correct. The hypoglossal cranial nerve (XII) is central to the skeletal muscles of the tongue and assists with swallowing. If a client has an impairment of this cranial nerve, aspiration precautions should be implemented. These precautions include observing the client during meals and having patent suction at the bedside. Choices C, D, and E are incorrect. The hypoglossal nerve has no relevance in vision. Thus, providing large print education materials, teaching the client to scan the room, and alternating the use of an eye patch are not relevant to this cranial nerve. An eye patch is an effective intervention for a client experiencing diplopia. Additional Information: Aspiration precautions involve collaborating with the registered dietician and/or speech therapist to determine which would be appropriate. In general, aspiration precautions involve supervised mealtimes, having the head of the bed elevated during a meal, thickening the liquids as directed, and coaching the client through swallowing. If the nurse is feeding a client with aspiration precautions, the nurse should not mix any food consistencies and always have oral suction available. NCLEX Category: Physiological Adaptation Related Content: Alterations in body systems Question type: Application

Which of the following are correct statements about the proper administration of polyethylene glycol prescribed for constipation? Select all that apply. A. Mix the powder with any beverage the patient enjoys. [22%] B. Administer it at the same time every day. [32%] C. Administer it with meals. [12%] D. Dilute the powder with 8 oz of water. [34%]

Explanation Choices A and B are correct. This statement is correct. It is appropriate to mix polyethylene glycol, or Miralax, with any beverage the patient enjoys. Soda and juice are common choices due to their ability to mask the flavor better than water (Choice A). It is preferable to administer polyethylene glycol at the same time every day. This promotes a bowel regimen/routine, which maximizes the success of the medication. It is also useful to help the patient remember to take their medication with a routine established (Choice B). Choice C is incorrect. It is not necessary to administer polyethylene glycol with meals. The patient may choose to do this, but there is no increased effectiveness related to the time of day or if the medication is taken with or without food. Choice D is incorrect. It is not necessary to dilute polyethylene glycol with water unless that is what the patient chooses. The amount of liquid used to dilute will depend on the dose. The package will indicate the quantity of liquid to use depending on the dose of polyethylene glycol. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological therapies; Pediatrics - Gastrointestinal

The nurse is caring for a client diagnosed with atrial fibrillation. The nurse should anticipate a prescription for which of the following medications? Select all that apply. A. Diltiazem [32%] B. Nitroglycerin [17%] C. Clonidine [15%] D. Atorvastatin [11%] E. Warfarin [26%]

Explanation Choices A and E are correct. Diltiazem is a rate lowering calcium channel blocker used in the management of atrial fibrillation. This medication assists in maintaining rate control. While not always indicated, an anticoagulant such as warfarin or rivaroxaban is used in the management of atrial fibrillation as this arrhythmia puts the patient at high risk for a stroke. Choices B, C, and D are incorrect. Nitroglycerin is not indicated in the management of atrial fibrillation. This medication is approved for angina. Clonidine is an effective treatment for hypertension and ADHD. The medication is not indicated for atrial fibrillation. Atorvastatin is indicated for hyperlipidemia but is not utilized in the management of atrial fibrillation. Additional Info The primary goal for a client with atrial fibrillation is to maintain rate control (60-100). Medications such as diltiazem, digoxin, amiodarone, and dronedarone may be utilized to achieve rate control. Anticoagulants are also indicated as ischemic strokes are commonly associated with atrial fibrillation. Anticoagulants commonly used include rivaroxaban, apixaban, and warfarin.

A 34-year-old female arrives at the emergency department after developing pain in her left calf. What are the important questions to ask this patient while assessing her? Select all that apply A. Is your left calf bigger than your right calf? [22%] B. Are you pregnant? [21%] C. Have you been on any long car or plane rides recently? [27%] D. Do you take any birth control? [24%] E. Do you take any antidepressants? [5%]

Explanation Choices A, B, C, and D are correct. This patient needs to be assessed for a deep vein thrombosis because of her risk factors like age, possible birth control use, and long travel. Asking these questions can be crucial in diagnosing the patient and obtaining further ultrasound imaging. Choice E is incorrect. This question is not pertinent to deep vein thrombosis. NCSBN Client Needs Topic: Reduction of Risk Potential, Sub-Topic: Potential for Alterations in Body Systems, Hematologic System

The nurse is developing a discharge plan for a client who had a phacoemulsification procedure. Which of the following should the nurse include? Select all that apply. A. Teach the client how to instill eye drops. [24%] B. Instruct the client not to lie on the affected side. [23%] C. Remind the client that a reduction of vision is normal. [7%] D. Provide the client with an eye patch for the affected eye. [23%] E. Educate the client to avoid bending at the waist. [23%]

Explanation Choices A, B, D, and E are correct. Post-procedure, the client should be taught how to instill eye drops. If not the client, then a family member or friend. The client should not lie on the operative side, and an eye patch may be given to protect the eye from injury while they are sleeping. Any activities such as bending at the waist, coughing, or vomiting should be avoided as they raise the intraocular pressure. Choice C is incorrect. A reduction of vision after the procedure is highly concerning. This report should be reported to the surgeon. The client often experiences an enhancement of vision following this procedure - not a reduction. Additionally, if the client starts to exhibit purulent drainage from the operative site, that should be reported to the surgeon. Additional Info A phacoemulsification procedure is utilized for clients with cataracts. This procedure often is combined with an intraocular lens implant. The crux of the procedure is that it utilizes sound waves to break up the clouded lens, which is then removed by suction. The client should be taught that intraocular eye drops will be needed after this procedure, avoid doing any activities that raise the intraocular pressure (bending at the waist, coughing, vomiting), and that a reduction of vision should be reported promptly.

What findings are expected when assessing a patient with atelectasis? Select all that apply. A. Decreased breath sounds [27%] B. Increased tactile fremitus [8%] C. Hyperresonance [7%] D. Shortness of breath [29%] E. Decreased oxygen saturation [29%]

Explanation Choices A, B, D, and E are correct. With atelectasis, lung tissue has collapsed, which leads to less mass that provides oxygenation. The oxygen saturation is decreased, as well as breath sounds. Additionally, the patient will experience shortness of breath. When lung tissue is consolidated, tactile fremitus is increased. Incomplete lung expansion or the collapse of alveoli, known as atelectasis, prevents pressure changes and the exchange of gas by diffusion in the lungs. Areas of the lung with atelectasis cannot fulfill the function of respiration. Coughing, chest pain, cyanosis, dyspnea, and tachycardia are common symptoms of atelectasis. Choice C is incorrect. The percussion sound may be dull, but not hyperresonant, as a result of consolidation. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Respiration

The nurse is caring for a terminally ill 8-year-old boy with leukemia. The health care provider expects he will only live for another 2-3 months. The nurse should know which of the following when explaining to him about the concept of death and illness? Select all that apply. A. School-age children do not understand their own mortality. [21%] B. School-age children feel very vulnerable when dealing with an illness. [34%] C. Each child is unique in how they process their diagnosis. [36%] D. The child will express their desire to tie up loose ends. [7%]

Explanation Choices A, B, and C are correct. Choice A is correct. Children understand the four main concepts (Irreversibility, finality, inevitability, and causality) of death differently at each age group. Understanding how children perceive death at different stages helps the nurse adequately support the child in coping with the illness. School-age children from 6 to 9 years of age do not understand the concept of mortality well. They start developing some understanding regarding the permanence/irreversibility of death but see it as something that only applies to older adults. Therefore, discussions around their "own" death will be confusing for them since they do not think abstractly; these children also do not understand the causality of death. At the age of 10 to 12 years, most children fully understand permanence (death is permanent), inevitability (death is universal for all living beings including themselves), causality (the causes of death), and finality of death (all functioning stops with death). Choice B is correct. School-age children feel very vulnerable when dealing with an illness. They are curious about the physical and biological aspects of death. They have fears that death will hurt and about what they may experience after death, and worry about what will happen to their body. Choice C is correct. Each child is unique in how they process their diagnosis. There is no perfect pattern of how a child handles a terminal diagnosis and no handbook to teach them to cope with grief. The nurse should be aware that each child will be unique and require support differently. Choice D is incorrect. It is unlikely that a school-age child will express a desire to tie up loose ends in processing their terminal diagnosis. Because of a lack of abstract thinking, they do not often have "loose ends" to tie up. This would be more characteristic of an adolescent/adult processing their terminal diagnosis. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatric oncology

For a nonstress test to be considered reactive, several factors have to be present. Which of the following are components of a reactive nonstress test? Select all that apply. A. The test occurs over a 20-minute period [20%] B. There are 2 or more accelerations [31%] C. Accelerations are 15 beats/minute lasting 15 seconds [33%] D. Moderate variability is present [16%]

Explanation Choices A, B, and C are correct. A standard nonstress test occurs over 20 minutes. If the required two accelerations of 15 beats/minute over 15 seconds are not met in 20-minutes, the analysis is extended to 40 minutes (Choice A). There must be at least two accelerations in a 20-minute time frame for the nonstress test to be reactive (Choice B). The accelerations must be at least 15 beats/minute and last 15 seconds during the nonstress test for the test to be reactive (Choice C). Choice D is incorrect. Although moderate variability is a reassuring sign, variability is not a component of a nonstress test and is therefore not a part of it's reading. NCSBN Client Need: Topic: Health Promotion and Maintenance, Subtopic: Antepartum

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing pulmonary tuberculosis (TB)? Select all that apply. A. Human Immunodeficiency Virus (HIV) [35%] B. Organ transplant [25%] C. Chronic corticosteroid use [30%] D. Influenza vaccination [2%] E. Obesity [7%]

Explanation Choices A, B, and C are correct. According to the Centers for Disease Control (CDC), risk factors for TB include immunosuppression, organ transplant, chronic corticosteroid use, substance use, diabetes mellitus, and residing in environments such as nursing homes, prisons, and homeless shelters. Choices D and E are incorrect. Obesity is not a risk factor for TB. Low body weight is a risk factor for TB. Influenza vaccination is not relevant to pulmonary tuberculosis and does not raise or lessen the risk for infection. Additional information: Pulmonary tuberculosis is a pathogen spread via aerosolized droplets. If TB is suspected, the patient should be placed in airborne precautions. This includes a room with negative pressure or a specialized HEPA filter. When an individual is symptomatic with TB, they have a high risk of transmitting it to others. Once the symptoms recede, the risk of transmission significantly decreases. Signs and symptoms of TB include chest pain, fever, chills, night sweats, lethargy, and bloody sputum.

The nurse is in charge of a surgical unit with 2 LPNs on duty. The nurse understands that LPNs can be delegated to perform certain tasks unsupervised. Select all the tasks that LPNs can perform unsupervised. A. Routine dressing of a 5-day post-operative hip replacement wound [37%] B. Assisting a post-BKA patient to the bathroom for a bath [24%] C. Dressing of a suspected infected abdominal wound [10%] D. Accompanying a patient for an x-ray after an orthopedic cast was applied [28%]

Explanation Choices A, B, and D are correct. The procedure to be done to the patient is routine and does not require further assessment and decision making by the RN and can thus be delegated to the LPN. Accompanying a stable patient to the x-ray department can be delegated to an LPN. It does not require any further assessment or decision-making. Choice C is incorrect. Dressing of a suspected abdominal wound should be done by the RN so that it can be assessed thoroughly, and other measures for management can be initiated. Thus, the procedure cannot be delegated to the LPN.

The nurse has provided medication instruction to a client who has been prescribed sucralfate. Which of the following statements, if made by the client, would require further teaching? Select all that apply. A. "I should take this medication one hour after meals." [25%] B. "I will remain upright for 30 minutes after taking this medicine." [16%] C. "This medication will help with my peptic ulcer disease." [13%] D. "I may get drowsy after I take this medication." [23%] E. "I may dissolve this medication in warm water." [23%]

Explanation Choices A, B, and D are correct. These statements are false and require further teaching. Sucralfate is a medication indicated in peptic ulcer disease. This medication should be taken one hour before meals as the medication will coat the ulcer allowing a client to eat meals without pain. The client is not required to be upright 30 minutes after taking this medication. This would be applicable instruction for a patient prescribed a bisphosphonate. Drowsiness is not a side-effect of sucralfate. This would be a common side-effect associated with histamine blockers such as famotidine. Choices C and E are incorrect. Sucralfate is a gastric fortifier intended to help with peptic ulcer disease. The pills are rather large and may be dissolved in water to improve the client's ability to swallow. Additional Info Sucralfate is a gastric fortifier intended to help with peptic ulcer disease. This medication should be taken one hour before meals and at bedtime. This medication allows the client to eat their meal without the pain of the ulcer. Constipation is the most common side-effect associated with this medication.

The nurse is caring for a client who is receiving prescribed quetiapine. Which of the following findings would indicate the client has an adverse effect? Select all that apply. A. Fever [18%] B. Drowsiness [21%] C. Stooped posture [27%] D. Shuffling gait [30%] E. Increased appetite [4%]

Explanation Choices A, C, and D are correct. Quetiapine is an atypical antipsychotic used to treat schizophrenia and bipolar disorder. Fever is an adverse reaction because this could be strongly suggestive of Neuroleptic Malignant Syndrome (NMS). Stooped posture and shuffling gait are quite concerning because these are symptoms of an extrapyramidal syndrome (EPS). These symptoms should be reported to the primary healthcare provider. Choices B and E are incorrect. Quetiapine is a sedating antipsychotic that may cause drowsiness. This is a common side effect associated with this medication. Increased appetite is a common side effect, and weight gain, increased glucose levels, and high cholesterol has been implicated with this class of medications. Additional Info Quetiapine is an atypical antipsychotic used in the management of bipolar and schizophrenia. Adversely, antipsychotics may cause Neuroleptic Malignant Syndrome (NMS), which is manifested by fever, muscle rigidity, and tachycardia. Additionally, antipsychotics may cause extrapyramidal side effects, including dystonia, akathisia, or pseudo parkinsonism, such as stooped posture, bradykinesia, and shuffling gait.

Which statements describe the action of the medications? Select all that apply. A. Diazepam is given to alleviate anxiety. [32%] B. Ranitidine is given to facilitate patient sedation. [4%] C. Atropine is given to decrease oral secretions. [22%] D. Morphine is given to depress respiratory function. [11%] E. Cimetidine is given to prevent laryngospasm. [11%] F. Fentanyl citrate-droperidol is given to facilitate a sense of calm. [21%]

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

Select the standard physiological changes associated with the aging process that can adversely affect the transportation of medications in the human body. Select all that apply. A. Diminished cardiac output [18%] B. Decreased motility [22%] C. Decreased peristalsis [22%] D. Lower blood flow [17%] E. Low functioning nephrons [21%]

Explanation Choices A, D, and E are correct. As people age, several physiological changes occur. Many of these changes impact the pharmacokinetics and pharmacodynamics of medications. The regular physiological changes associated with the aging process that can adversely affect the transportation of drugs in the human body are the aging population's diminished cardiac output and decreased blood flow. Choice B is incorrect. Decreased motility of the gastrointestinal system, as associated with the aging process, affects the absorption of oral medications, and not the transportation of drugs in the human body. Choice C is incorrect. Decreased peristalsis, as associated with the aging process, affects the absorption of oral medications, and not the transportation of drugs in the human body.

You are providing education to a mother regarding the cognitive development of her 6-year-old child. She expresses frustration that her daughter never listens to her when she tells her that she can play for 15 minutes before dinner. What is an appropriate response to the mother? Select all that apply. A. "Don't be so mad. All kids are bad at listening." [1%] B. "Your daughter is still in the preoperational stage. She does not have a concept of time yet." [51%] C. "6-year-olds are not able to think abstractly yet. Try using a more concrete way to communicate with her." [48%] D. "That is frustrating, my 6-year-old always listens." [0%]

Explanation Choices B and C are correct. According to Piaget's theory of cognitive development, 2-7-year-olds are in the preoperational stage. During this stage, children use symbolic thinking. Their imagination and intuition are developing, but they cannot think abstractly yet. Children create a concept of time, space, and quantity in the operational stage, between 7 and 11 years of age. This information will give the mother reason for why her six-year-old daughter is unable to understand her request and help her communicate more efficiently (Choice B). According to Piaget's theory of cognitive development, 2-7-year-olds are in the preoperational stage. During this stage, children cannot communicate abstractly; they are concrete thinkers. Making this suggestion will help the mother communicate with her daughter (Choice C). Choice A is incorrect. This is not a therapeutic response and will not do anything to help the frustrated mother with her situation. The nurse should refrain from telling her patients how to feel and what to do, as that is not therapeutic communication. Choice D is incorrect. This is inappropriate and not therapeutic communication. Offering personal advice and bringing her own life into the conversation is not recommended. The nurse should refrain from making these types of comments. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Pediatric Development

Which of the following are true regarding an electronic medical record? Select all that apply. A. It cannot be used as a legal document in a lawsuit. [3%] B. Nurses can enter data by checking boxes and adding free full text. [35%] C. It allows primary care providers to directly order from the computer. [37%] D. It is economical as well as easy to learn and implement. [24%]

Explanation Choices B and C are correct. Computerized records have boxes to check and choices to make so that nurses do not have to write assessment findings by hand each time they evaluate a patient. They also have room for adding free text (Choice B). Computerized Provider Order Entry (CPOE) allows providers to enter all orders directly into the computer, electronically communicating requests to the pharmacy, laboratory, and nursing unit (Choice C). Choice A is incorrect. Although there is no hard copy of the medical record, the computerized medical history is still considered a legal document and can be used in a lawsuit. Choice D is incorrect. Implementing a computerized record system is expensive, and it requires much planning and education. However, it does significantly increase patient safety concerns. NCSBN Client Need Topic: Safe and Effective Care Environment; Subtopic: Coordinated Care; Electronic Medical Record

The supervising nurse watches a newly hired nurse take care of a client who is at risk of developing a pressure ulcer. Which of the following interventions by the newly hired nurse requires follow-up? Select all that apply. A. Applies zinc oxide to the client's perineal skin. [15%] B. Provides a donut pillow while the client is sitting in the chair. [16%] C. Maintain the head of the client's bed at 90 degrees. [31%] D. Encourages the client to consume foods rich in carbohydrates. [29%] E. Uses a pillow to float the client's heels. [8%]

Explanation Choices B, C, and D are correct. If the newly hired nurse provides a donut pillow while the client is sitting in the chair, this will require follow-up because this pillow creates pressure and damages capillary beds. Maintaining the client's position at 90 degrees would require follow-up because this contributes to the client sliding, therefore creating shearing. It is recommended that they be kept at 30 degrees (if not medically contraindicated). A diet rich in carbohydrates is unhelpful to a client at risk for a pressure ulcer. A diet dense in protein is recommended to maintain skin integrity and mitigate any edema. Choices A and E are incorrect. Applying zinc oxide to the client's skin is recommended. This product is a common ingredient in topical creams because of its ability to repel moisture. Floating the client's heels is essential as it helps with offloading pressure. This can be done using a device comprised of foam or a pillow. NCLEX Category: Basic Care and Comfort Activity Statement: Mobility/Immobility Question type: Application Additional Info Recommended interventions for a client at risk for developing a pressure ulcer include the following: ▪ Utilize standardized assessments to evaluate a client's risk for a pressure ulcer. ▪ Ensure that nutritional goals are being met by providing adequate fluid and protein in the diet. ▪ Keep the head of the bed at 30 degrees or less to prevent shearing. ▪ Offload bony prominences using foam or pillows. Reposition the client at least every two hours. ▪ Do not use any products comprised of plastic and avoid using donut pillows. ▪ Moisturize the skin with products containing zinc oxide. ▪ Do not massage reddened areas.

The nurse is counseling a patient with opioid use disorder. The nurse understands that treatment choices for opioid use disorder include which of the following? Select all that apply. A. Selegiline [7%] B. Naltrexone [32%] C. Methadone [31%] D. Buprenorphine [17%] E. Bupropion [13%]

Explanation Choices B, C, and D are correct. Naltrexone, Methadone, and Buprenorphine are three agents approved for the management of opioid use disorder. These medications have various mechanisms of action. Naltrexone is an opioid receptor antagonist and may be administered as a single dose injection. Buprenorphine is a partial agonist and is available in preparations such as sublingual tablets or film. Methadone is a full agonist that may be used daily. Choices A and E are incorrect. Selegiline is a monoamine oxidase inhibitor and is used in depression and Parkinson's disease. Bupropion is indicated in the treatment of depressive disorders. This medication may be useful in the management of nicotine addiction. Additional information: Medications used in opioid use disorder are efficacious when combined with appropriate counseling. The nurse should advocate for appropriate treatment choices such as buprenorphine, methadone, or naltrexone. Caution must be taken with methadone and buprenorphine as these two medications may cause respiratory depression when combined with other CNS depressants.

The nurse is reviewing a list of clients' laboratory findings and notes that one client has a serum calcium level of 7.2 mg/dL. Which of the following clients are most likely to have this lab result? Select all that apply. A. The patient with breast cancer and bone metastases [23%] B. The patient with obesity [7%] C. The patient with Vitamin D toxicity [15%] D. The patient with hypoparathyroidism [33%] E. Patient with chronic renal failure [22%]

Explanation Choices D and E are correct. D is correct. The client with hypoparathyroidism is most likely to suffer from hypocalcemia. The normal calcium level is 8.4-10.2 mg/dL, so with this client's level of 7.2, they have too little calcium in the blood. The client who experiences hypoparathyroidism has too little parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones, kidneys, and intestines. When there is too little PTH, there are decreased calcium levels (hypocalcemia). E is correct. Hypocalcemia is a common problem in chronic renal failure and end-stage renal disease (ESRD). There are two reasons for hypocalcemia in kidney disease: increased phosphorus and decreased renal production of activated Vitamin D (1,25 Dihydroxy-vitamin D). Phosphorus accumulates in renal failure. Hyperphosphatemia results in binding to calcium and precipitates as calcium phosphate in tissues and bones, causing hypocalcemia. The kidney is responsible for activating vitamin D and restoring calcium balance. In the setting of renal diseases, one loses the capacity to activate vitamin D, then the calcium level drops. For these reasons, physicians often order phosphate binders to reduce phosphorus and calcitriol (activated vitamin D, 1,25 Dihydroxy-vitamin D) in chronic renal failure/ESRD. Choice A is incorrect. Clients with malignancy and bone metastases are more likely to have hypercalcemia, not hypocalcemia. This is due to bone destruction from osteoclasts and the leaking of calcium into the blood. In addition, malignancies often cause "paraneoplastic hypercalcemia" by secreting substances called PTH-related peptides (PTHrP) that have actions similar to parathyroid hormone (PTH). Choice B is incorrect. Obesity is not a risk factor for hypocalcemia. Malnutrition and malabsorption, such as in Celiac and Crohn's disease patients, can cause hypocalcemia due to decreased absorption, but obesity would not cause this. Choice C is incorrect. The patient with vitamin D toxicity would be at risk for hypercalcemia, or a serum calcium level greater than 10.2 mg/dL. This is due to the relationship between vitamin D and calcium; vitamin D enhances the absorption of calcium. Therefore, Vitamin D toxicity would lead to increased absorption of calcium and a hypercalcemic state. NCSBN Client Need: Topic: Reduction of Risk Potential; Subtopic: Diagnostic Tests, Fluids & Electrolytes

The primary healthcare provider (PHCP) prescribes dopamine at 5 mcg/kg/minute. The client weighs 178 lbs. The medication label reads dopamine 800 mg in 500 mL of dextrose 5% water (D5W). How many mL per hour will be administered to the client? Fill in the blank. Round your answer to the nearest whole number. 15 mL/hr

Explanation To solve this multistep problem, the formula of dose ordered / dose on hand x volume will be used First, convert the weight to kilograms 178 lbs / 2.2 = 80.9 kg Next, determine the hourly dosage 5 mcg x 80.9 kg x 60 minutes = 24270 mcg Next, convert the micrograms to milligrams 24270 mcg / 1000 mg = 24.27 mg Next, divide the dose ordered by the amount on hand x the volume 24.27 mg / 800 mg x 500 mL = 15.16 mL/hr Finally, round the answer to the nearest whole number 15.16 mL/hr = 15 mL/hr Additional Info Dopamine is a vasopressor used in the treatment of significant hypotension. It is essential that dopamine be infused through a patent intravenous line because of the risk of extravasation.

The primary healthcare provider (PHCP) prescribes a regular insulin infusion. for a client. The prescription is for 2 units/hr. The label on the medication reads 250 mL of 0.9% saline containing 100 units of regular insulin. How many mL/hr should the client receive? 5 mL/hr

vExplanation The formula of dose ordered / dose on hand x volume will be utilized to solve this problem. Divide the prescribed amount of medication by what is on hand 2 units / 100 units = 0.02 units Next, take the amount of the medication and multiply it by the volume 0.02 units x 250 mL = 5 mL/hr Additional Info Regular insulin intravenously is prescribed to correct the acidosis and hyperkalemia. During the infusion of regular insulin, the client should be monitored for hypoglycemia and hypokalemia. Regular insulin is the only insulin that may be administered intravenously.