Archer Review 7a

Which of the following maternal infections may increase the risk of developing congenital heart defects in the fetus? A. Parainfluenza [6%] B. Adenovirus [19%] C. Rubella [55%] D. Measles [20%]

Explanation Choice C is correct. Rubella is a maternal infection that is known to increase the risk that the fetus will have a congenital heart defect. All mothers should be tested for rubella, and if found to be positive, should have a fetal echocardiogram performed to evaluate the fetus' heart more closely. Choice A is incorrect. Parainfluenza is not known to affect the risk for congenital heart disease. Choice B is incorrect. Adenovirus is not known to affect the risk for congenital heart disease. Choice D is incorrect. Measles is not known to affect the risk for congenital heart disease. NCSBN Client Need Topic: Effective, safe care environment; Subtopic: Maternal/Fetal infection control and safety

The nurse is caring for four newborns during her shift in the unit. After performing an assessment, which newborn should the nurse give her attention to? A. A 24-hour old newborn that has not yet passed meconium. [80%] B. A 3-day old infant with mild jaundice and a bilirubin of 3 mg/dL. [13%] C. A 3-hour old infant that has just passed meconium. [2%] D. A 5-day old infant with a positive Babinski reflex. [4%]

Explanation Choice A is correct. A newborn that has not yet passed meconium after 24 hours should be evaluated for Hirschsprung's disease. Choice B is incorrect. An infant with slight jaundice after the first 24 to 48 hours of life should not cause concern to the nurse. The physician should be notified if the disease occurs within the early 24 hours to evaluate if the jaundice is pathological. Jaundice is pathologic if it presents within the first 24 hours after birth, the total serum bilirubin level rises by more than 5 mg/dL/day or absolute level at anytime higher than 17 mg/dL, or an infant has signs and symptoms suggestive of serious illness. Choice C is incorrect. This is entirely normal as meconium is expected to be passed within the first 24 hours of the child's life. Choice D is incorrect. The Babinski reflex is a primitive reflex that is present in newborns. The nurse should not be concerned about this assessment finding.

You are assessing an 8-month-old infant. Which of the following findings are normal for his developmental age? Select all that apply. A. Posterior fontanel is soft and flat [20%] B. Anterior fontanel is closed [16%] C. Negative Moro reflex [30%] D. Positive Babinski reflex [34%]

Explanation Choices C and D are correct. It is considered normal for the Moro reflex to disappear between 3-6 months of age, therefore an 8-month-old being negative for the Moro reflex is a normal finding. The Moro reflex is a response to a sudden loss of support. The infant spreads out the arms and cries (Choice C). The Babinski reflex is also known as the plantar reflex and is usually the last infantile reflex to disappear around 9-12 months (when the infant starts walking). Therefore, a positive Babinski in an 8-month-old would be considered normal. The Babinski reflex occurs after the sole of the foot has been stroked upwards. It causes the big toe to move upward and then the other toes fan out (Choice D). Choice A is incorrect. The posterior fontanel should close between 2 and three months. Although soft and flat is a normal finding for a fontanel, in an 8-month-old infant, it should be closed. This is not a normal finding. Choice B is incorrect. The anterior fontanel should close between 12 and 18 months. In an 8-month-old infant, it should still be open. We would expect the assessment to reveal a soft flat fontanel, not one that has already closed. This is not a normal finding. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Pediatric Development

You are caring for a recently deceased client and preparing for their post-mortem care. Which of the following aspects of this care can you delegate to an unlicensed assistive staff member, like a nursing assistant? A. Wrap the body in a shroud and tag the greater toe, as well as the outer part of the shroud. [44%] B. Wash the body of the deceased without wearing gloves because standard precautions are no longer necessary and the client is dead so they can no longer transmit infection. [1%] C. Cosign the death certificate as the person who has provided the deceased client with post-mortem care and transportation to the morgue. [3%] D. None of the above. [52%]

Explanation Choice A is correct. After the death of the client, the nurse can delegate wrapping the body in a shroud and tagging the higher toe as well as the outer part of the shroud. They can also do other things, such as bathing the deceased's body and transporting the body to the morgue. Choice B is incorrect. Deceased clients are still cared for using standard precautions, including the use of gloves because the transmission of the disease is still possible after death. Choice C is incorrect. After the death of the client, the nurse should not and cannot delegate the cosigning of the death certificate as the person who has provided the deceased client with post-mortem care and transportation to the morgue. This is clearly outside of the scope of practice for the nursing assistant. Choice D is incorrect. This is inaccurate since one of the answer choices for this question is something that the nurse can delegate to an unlicensed assistive staff member like a nursing assistant with respect to post-mortem care.

The nurse is caring for a patient post-coronary artery bypass graft (CABG). The nurse is implementing measures to address the nursing diagnosis, "ineffective airway clearance related to retained secretions and excess secretions." Which nursing intervention is the least appropriate? A. Administering aspirin prior to deep breathing and coughing exercises. [66%] B. Splinting the incision site with "heart pillows" or pillows before coughing. [9%] C. Assisting the client to ambulate as tolerated. [18%] D. Teaching the client the correct use of an incentive spirometer. [8%]

Explanation Choice A is correct. Aspirin is an NSAID that has an antiplatelet property. Administering aspirin to the patient may put the patient at risk for postoperative bleeding. The patient needs opioids to manage his pain, not aspirin. Choice B is incorrect. Splinting the incision site before coughing promotes more intense coughing efforts. Therefore, it is an appropriate nursing intervention. Choice C is incorrect. Respiratory effort is increased with ambulation; therefore, deep breathing occurs, helping to clear chest secretions. Choice D is incorrect. The correct use of an incentive spirometer encourages sustained inspiration to open alveoli, promoting the clearing of chest secretions.

A 7-year-old girl with juvenile arthritis is receiving aspirin daily. Which statement made by her mother indicates the need for further teaching? A. "I make sure she takes her aspirin with meals." [5%] B. "She's been having bleeding gums lately. Maybe she is brushing too hard." [83%] C. "I let her take the aspirin on a regular schedule daily." [5%] D. "Ringing in the ears is one sign of aspirin toxicity." [7%]

Explanation Choice B is correct. Bleeding gums may be caused by decreased clotting capacity and may indicate aspirin toxicity. Choices A, C, and D are incorrect. Aspirin can cause gastric irritation and should not be given on an empty stomach. It is provided on a regular schedule to maintain a satisfactory drug level in the body. Another sign of aspirin toxicity is tinnitus (ringing in the ears) since it has an effect on the cranial nerve VIII.

The clinic nurse is providing teaching to a patient who has been newly prescribed a corticosteroid inhaler. Which of the following information should be included in this teaching? A. Push the canister on the inhaler down, then breathe in slowly and deeply before exhaling [72%] B. Do not use a spacer with this medication [3%] C. You will not need to rinse your mouth after using this inhaler [14%] D. Inhale quickly to prevent the medicine from escaping through the mouth [11%]

Explanation Choice A is correct. Breathing in slowly and deeply while using an inhaled medication is the proper method of medication administration. Choice B is incorrect. Spacers are encouraged because they prevent the accumulation of the medication at the back of the throat. Choice C is incorrect. The patient should rinse their mouth after the administration of this medication to prevent Candida infections. Choice D is incorrect. Inhaling quickly is not the best way to take this medication. NCSBN client need Topic: Physiological Integrity, Pharmacological and parenteral therapies

The nurse is counseling a female client interested in starting contraception. The client tells the nurse a preference for contraception that does not involve pills or any invasive device. Based on the client's preferences, the nurse may recommend which contraceptive product to the primary healthcare provider (PHCP)? A. Depot medroxyprogesterone [66%] B. Intrauterine device (IUD) [8%] C. Hormonal vaginal ring [24%] D. Combined estrogen-progestin pill [2%]

Explanation Choice A is correct. Depot medroxyprogesterone acetate is an injection that provides contraception for 13 weeks. Considering that the client prefers no pills or anything invasive, this would be an appropriate recommendation to the PHCP. Choices B, C, and D are incorrect. An IUD and vaginal ring are invasive and would not be recommended for this client based on their stated preference. The combined estrogen-progestin pill is given orally and is not preferred by the client. Additional Info Several factors play into the appropriate contraception selection for a client. These include her age, current health status, preference on delivery method, and future pregnancy plans. Depot medroxyprogesterone acetate fits the client's preferences by being non-invasive and administered parenterally which allows the client the flexibility of not taking a pill daily. While a client takes depot medroxyprogesterone acetate, calcium and Vitamin D supplementation are recommended, coupled with weight-bearing exercises. Women who have a high risk for cardiovascular disease and a stroke should not take depot medroxyprogesterone acetate.

The nurse is caring for a client who has developed dystonia following the administration of fluphenazine. Which medication does the nurse anticipate that the primary healthcare provider (PHCP) will prescribe? A. diphenhydramine [44%] B. mannitol [11%] C. thiamine [21%] D. haloperidol [24%]

Explanation Choice A is correct. Diphenhydramine is an anticholinergic and is utilized for dystonic reactions associated with antipsychotic use (such as fluphenazine, a typical antipsychotic). Dystonia is one of the earliest adverse effects and should be promptly reported to the prescriber. Choices B, C, and D are incorrect. Mannitol is an osmotic diuretic indicated for increased intracranial pressure. This medication would not be used for dystonic reactions. Thiamin is a B-vitamin and can be helpful for alcohol withdrawal. This is not indicated for the treatment of dystonia. Haloperidol is a typical antipsychotic and would be detrimental in treating dystonia. Medications like fluphenazine include haloperidol which would worsen the effect. Learning Objective NCLEX Category: Pharmacologic and Parental Therapies Related Content: Adverse Effects/Contraindications/Side Effects/Interactions Additional Info Acute dystonia is a sudden, sustained contraction of one or several muscle groups, usually of the head and neck. Acute dystonias can be frightening and uncomfortable, but they are not dangerous unless they involve muscles affecting the airway, which is rare. However, they cause significant anxiety and should be treated promptly with anticholinergics such as diphenhydramine. Dystonia is caused by medications blocking dopamine. Classically, this involves antipsychotic medications (especially the typicals) and metoclopramide. Typical antipsychotics include, fluphenazine, haloperidol, and chlorpromazine

While working in the emergency department, the nurse attends to a client who has overdosed on lorazepam. Which of the following medications does she expect the healthcare provider to order? A. Flumazenil [65%] B. Phenylephrine [6%] C. Epinephrine [7%] D. Naloxone [22%]

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

The nurse arriving for their shift is told in a report that the patient has been battling asymptomatic chemotherapy-induced anemia. The nurse recognizes that the patient will likely require a blood transfusion when their hemoglobin drops below: A. 8 [72%] B. 13 [4%] C. 10 [24%] D. 19 [0%]

Explanation Choice A is correct. Hemoglobin levels are considered alarming and may require blood transfusions when below 8 g/dL. Normal hemoglobin is 14-18 g/dL for males and 12-16 g/dL for females. Choice B is incorrect. While 13.0 g/dL is lower on the results of appropriate labs, this level would likely not indicate a blood transfusion. Choice C is incorrect. 10.0 g/dL is considered low hemoglobin for both men and women, but since this patient is not experiencing any symptoms, they'll not likely need a blood transfusion at this time. Choice D is incorrect. 19.0 g/dL is a high result and may require retesting. A patient with a hemoglobin of 19 wouldn't need blood products. NCSBN client need Topic: Physiological Adaptation, Reduction of Risk Potential

The nursing director calls for a meeting of all nurse managers in the facility. She has just come back from a visit to another hospital that was recently commended for its superior patient care. She aims to formulate similar policies to improve patient care in their facility. The nurse manager is performing which management initiative? A. Benchmarking [36%] B. Continuous Quality Improvement [32%] C. Performance Improvement [20%] D. Quality Management [12%]

Explanation Choice A is correct. In Benchmarking, the nurse-manager compares best practices from top hospitals with her unit and adapts the unit's methods to improve unit performance. Choice B is incorrect. Continuous quality improvement continually assesses and evaluates the effectiveness of client care. Choice C is incorrect. Performance improvement establishes a system of formal evaluation for job performance and recommends ways to improve performance as well as promote professional growth. Choice D is incorrect. Quality management is the act of overseeing all activities and tasks needed to maintain a desired level of excellence. This includes the determination of a quality policy, creating then implementing quality planning and assurance, as well as quality control/improvement.

One of the complications associated with the improper use of crutches is: A. Axillary nerve damage [87%] B. Solar plexus nerve damage [3%] C. Carpal tunnel syndrome [8%] D. Trigeminal nerve damage [2%]

Explanation Choice A is correct. One of the complications associated with the improper use of crutches is axillary nerve damage. This damage occurs when the user of the crutches rests and supports their natural weight with their underarms rather than on their hands, and the hand rests on the crutches. Choice B is incorrect. Solar plexus nerve damage is not one of the complications associated with the improper use of crutches. The solar plexus, which is the most massive bundle of nerves in the human body and is also referred to as the celiac plexus. It is located in the abdominal area and is affected/damaged with a blow to the abdomen, not associated with the improper use of crutches. Choice C is incorrect. Carpal tunnel syndrome, also referred to as repetitive stress syndrome, results from the repetitive action of the hands and wrists and not from the improper use of crutches. Choice D is incorrect. Trigeminal nerve damage is not one of the complications associated with the improper use of crutches. Trigeminal nerve damage can occur as the result of a physiologically pathological cause like a tumor, multiple sclerosis, and causes other than the improper use of crutches.

A nursing assistant is feeding a patient with Parkinson's disease who is on aspiration precautions. Which action would require immediate intervention by the nurse? A. The nursing assistant reminds the client to keep his head back when he chews and swallows. [68%] B. The nursing assistant maintains the thickened liquid diet as ordered by the physician. [4%] C. The nursing assistant waits for the patient to finish swallowing before offering another bite. [3%] D. The nursing assistant does not offer fluids until the end of the meal. [25%]

Explanation Choice A is correct. Patients who are at risk for aspiration should be encouraged to swallow with their chin down. The nurse would need to intervene and give direct instructions about the proper way to chew and swallow to prevent aspiration. The risk for aspiration is applied when any patient has increased chances of secretions, solids, or fluids entering the tracheobronchial passages. Following physician orders for and ensuring the patient's food is at the ordered consistency is crucial. Nursing assistants and other ancillary personnel who may feed the client should be instructed on the proper way to feed, which includes allowing the patient to take his/her time and to make sure all food is swallowed before offering another bite. Fluids should be held until the end of the meal, when possible. Choices B, C, and D are incorrect. None of these require immediate nursing intervention. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

Which of the following is the best approach for a nurse on the Quality Improvement (QI) team working on a project to reduce medication errors? A. Ensure that all staff members are educated on how to appropriately fill out an incident report if they make a medication error. [18%] B. Ensure the staff has been educated on the five rights of medication administration. [44%] C. Track the incident reports for repeating offenders and report findings to the next chain in command. [4%] D. Have an in-service to supervise staff members during medication administration to determine if further education needs to be given. [34%]

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

The nurse is caring for a client with bulimia nervosa. Which newly prescribed medication requires clarification with the primary healthcare provider (PHCP)? A. fluoxetine [13%] B. bupropion [41%] C. sertraline [20%] D. fluvoxamine [25%]

Explanation Choice B is correct. Bupropion is contraindicated in the treatment of bulimia because of its weight negative effects. Weight loss is not a treatment goal for a client with bulimia nervosa, and thus, this medication should not be utilized. Choice A, C, and D are incorrect. Serotonergic agents such as fluoxetine are primarily utilized to manage bulimia nervosa. Fluoxetine is the only approved medication for bulimia nervosa. Other SSRIs such as sertraline or fluvoxamine may be used if this medication is not tolerated. Medications such as bupropion should be avoided. Additional Info Fluoxetine is an SSRI and is approved to treat bulimia nervosa. This medication is effective when treating this eating disorder, especially when coupled with psychotherapy. Major side effects of fluoxetine include weight gain, sexual dysfunction, insomnia, and agitation.

The nurse understands that a portion of the pain "assessment" entails the client's subjective, sensory, and emotional comments that indicate the quality or intensity of their pain. The client describes their pain as "crushing and sharp." Select the type of pain a client is experiencing based on this sensory description of their pain. A. Somatic pain [30%] B. Visceral pain [48%] C. Hurt [10%] D. Neuropathic pain [12%]

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

The nurse is observing a newly hired nurse insert a nasogastric tube (NGT). Which action by the newly hired nurse requires follow-up? A. Advances the tube during the client's inspiration. [35%] B. Hands the client a cup of water and straw. [20%] C. Positions the client's head-of-bed at 90 degrees. [9%] D. Washes the client's bridge of nose with soap and water. [36%]

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

The nurse is observing a nursing student prepare to give an intramuscular (IM) injection in a client's deltoid. Which action by the student requires follow-up? A. Depresses the plunger during the insertion of the needle. [75%] B. Locates the upper third of the acromion process. [14%] C. Positions the client either lying or sitting position. [7%] D. Dons clean gloves before administering the injection. [4%]

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

Which of the following is a cause of hyponatremia? A. Sweating [31%] B. Dehydration [23%] C. Diabetes insipidus [29%] D. Salt-water drowning [17%]

Explanation Choice A is correct. When a patient sweats excessively, sodium is lost in sweat and their serum sodium levels will decrease, leading to hyponatremia. Choice B is incorrect. Overhydration, rather than dehydration, would be a cause of hyponatremia. When a patient is overhydrated, there is a dilutional effect in their serum. The actual amount of sodium present does not decrease, but it is diluted due to the excess hydration and causes relative hyponatremia. Choice C is incorrect. Diabetes insipidus (DI) would be a cause of hypernatremia, not hyponatremia. In DI, the client has excessive urination and therefore loses too much water. Their relative amount of sodium in the blood then increases and they become hypernatremic. Choice D is incorrect. Salt-water drowning would be a cause of hypernatremia, due to the client swallowing saltwater. Fresh-water drowning is a cause of hyponatremia. NCSBN Client Need Topic: Physiologic Integrity, Subtopic: Reduction of Risk Potential, Renal

The nurse is formulating a lesson plan for her talk on teenage pregnancy at a local high school. In determining the topics she needs to cover, the nurse must understand that: A. There are lesser complications in a teen pregnancy. [1%] B. Teenage pregnancies are commonly denied and hidden. [94%] C. There are low morbidity rates for teen pregnancies. [2%] D. Teenage pregnancies are planned by teenagers as a form of rebellion. [3%]

Explanation Choice A is incorrect. Teen pregnancies have an increased risk of numerous complications. These include premature labor, low-birth-weight infants, high neonatal mortality, iron deficiency anemia, prolonged labor, and cephalo-pelvic disproportion, as well as multiple psychological crises. Choice B is correct. Teen pregnancies are commonly denied by the teenager early in her pregnancy. The nurse must emphasize the importance of early prenatal care to prevent complications in the teenager's pregnancy. Choice C is incorrect. Teen pregnancies have a high morbidity rate due to their increased risk of complications. Choice D is incorrect. Most teen pregnancies were never planned. Although rebellion in teenagers is a common occurrence, teenage pregnancy is not a part of those rebellious acts.

A client with Raynaud's disease has just been prescribed ephedrine. What is the nurse's most appropriate action? A. Provide dietary instructions to the client. [7%] B. Question and discuss the prescription with the physician. [43%] C. Instruct the client regarding adverse effects. [40%] D. Administer the medication initially to the client. [10%]

Explanation Choice B is correct. Clients with Raynaud's disease or any other peripheral vascular disease are contraindicated to receive ephedrine or any other adrenergic agonist as these diseases could be exacerbated by systemic vasoconstriction. The nurse should question the physician regarding this prescription. Choice A is incorrect. Providing dietary instructions to the patient is an inappropriate action as this medication is contraindicated for the patient's existing disease. Choice C is incorrect. The nurse's most appropriate action would be to question the physician's prescription as the medication is contraindicated in the patient's present condition. Choice D is incorrect. The nurse should not administer the initial dose of a medication that he/she knows will do the patient harm. The nurse should question and discuss with the physician regarding the prescription.

The nurse is assigned the case manager role. She understands that case management uses which of the following methods of patient care delivery and documentation? A. A problem-oriented documentation system. [35%] B. A critical pathway documentation system. [30%] C. A source-oriented documentation system. [19%] D. A variance-oriented documentation system. [15%]

Explanation Choice B is correct. Documentation is a written record of (1) the interactions between and among health care professionals, patients, and their families (2) tests, procedures, treatments, and patient education (3) test results or patient's responses to treatment interventions. Several methods are used for documentation. These include narrative charting, source-oriented charting, problem-oriented charting, PIE charting, focus charting, charting by exception (CBE), computerized documentation, and critical pathway documentation. Case management refers to the process of organizing the patient care throughout an episode of illness so that certain clinical and financial outcomes are achieved within an assigned time frame. Case management uses a critical pathway documentation system as a form of patient care delivery and documentation. Critical pathways are time-oriented multidisciplinary plans of care that are established and approved by the interdisciplinary team. Variances are deviations from the expected course that are documented within the critical pathway system. Choice A is incorrect. A problem-oriented medical record (POMR) system is a structured format of charting that enables medical professionals to standardize patient records and store them in an electronic form. An example of POMR charting is "SOAP", where S refers to subjective data, O refers to objective data, A refers to assessment data, and P refers to plan. POMR documentation is not the one used by case managers. Choice C is incorrect. Source-oriented (SO) documentation is a narrative charting by each member of the health care team. For example, all the nursing records are grouped; the physician notes are together; respiratory, physical therapy, etc, are placed together. Since this type of charting is on separate records grouped by source, it is time-consuming and can lead to fragmented care. Choice D is incorrect. Variations (variance) are interventions that are not completed or the goals that are not met within the assigned time frame. There is no separate variance-oriented documentation system. However, the differences (variations) are determined and documented on the critical pathway used with case management. Learning Objective While various documentation methods are used in the health care systems, case management uses critical pathway documentation.

The nurse is caring for a patient who is experiencing early decelerations. Which of the following actions should the nurse take? A. Reposition the patient on her side [41%] B. Document the findings [45%] C. Discontinue oxytocin infusion [12%] D. Prepare for an amnioinfusion [1%]

Explanation Choice B is correct. Early decelerations are a reassuring finding and are caused by head compression, which is a normal part of labor. Choices A, C, and D are incorrect. Repositioning the patient on their side and discontinuing an oxytocin infusion would all be appropriate interventions for a patient experiencing variable or late decelerations. Additional information: Late decelerations are primarily caused by uteroplacental insufficiency, and the patient should be repositioned into a left lateral position. If the left lateral position is ineffective, then the nurse may consider using the right lateral position. The nurse should also consider prescribed intravenous (IV) fluids to restore maternal blood volume. Variable decelerations are usually caused by cord compression, and the patient should be repositioned, and the oxytocin infusion should be discontinued. An amnioinfusion or emergent cesarean delivery may be indicated for this non-reassuring pattern.

The community health nurse is doing a home visit on a client that was admitted to the hospital two weeks ago for hypertension. The nurse notes that the client was prescribed amlodipine 5 mg daily and was advised to lose weight. The nurse should be concerned when the client notes which of the following during his visit? A. The patient states that he has already enrolled himself in a gym and is getting dietary counseling from a nutritionist. [1%] B. The nurse notes the patient drinking grapefruit juice. [77%] C. The patient asks the nurse multiple questions regarding how he can follow his treatment regimen. [9%] D. The patient stated that he has had an episode of dizziness a day after he was discharged but has since been fine. [13%]

Explanation Choice B is correct. Grapefruit juice and calcium channel blockers may combine to cause toxic effects. This should cause concern to the nurse and should necessitate further teaching regarding calcium channel blockers (ie, amlodipine). Choice A is incorrect. The patient stating that he is already starting to exercise and modify his diet is a positive sign that he is complying with his treatment. Choice C is incorrect. The patient asking various questions regarding his treatment signifies to the nurse that the patient is eager and willing to undergo therapy. The nurse should encourage the patient. Choice D is incorrect. The dizziness that the patient has stated is just a common side effect of his medication (calcium channel blocker).

The nurse is preparing to administer haloperidol to a client. The nurse understands that this medication is prescribed to treat which of the following? A. Multiple sclerosis [1%] B. Schizophrenia [94%] C. Hyperthyroidism [1%] D. Parkinson's disease [4%]

Explanation Choice B is correct. Haloperidol is a typical antipsychotic which is indicated for schizophrenia. Choice A is incorrect. Multiple sclerosis is primarily treated with interferons. Choice C is incorrect. Hyperthyroidism would be treated with agents such as methimazole. Choice D is incorrect. Haloperidol is contraindicated for individuals with Parkinson's disease because of the medications' ability to worsen Parkinson's' symptoms.

Which of the following are appropriate secondary prevention strategies to teach your patient for cancer prevention? Select all that apply. A. Eliminate alcohol intake [15%] B. Pap smears [40%] C. Rehabilitation programs [5%] D. Colonoscopies [39%]

Explanation Choices B and D are correct. Secondary prevention strategies are the use of screenings that aim to detect cancer at an early stage. This makes it possible to treat the disease early and increases the chance it will be cured. Pap smears are a secondary prevention strategy because they are a screening used to detect cancer early (Choice B). Colonoscopies are a secondary prevention strategy because they are a screening used to detect cancer early (Choice D). Choice A is incorrect. Eliminating alcohol is a primary prevention strategy. Choice C is incorrect. Rehabilitation programs are a tertiary prevention strategy. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Oncology

This nurse is caring for a client at 29 weeks gestation who is at risk for delivering preterm. Which of the following medications would the nurse anticipate the primary healthcare provider (PHCP) to prescribe? A. Methotrexate [30%] B. Indomethacin [47%] C. Oxytocin [10%] D. Folic acid [12%]

Explanation Choice B is correct. Indomethacin is a cyclooxygenase inhibitor and is indicated as a tocolytic in preterm labor. This medication relaxes the uterus and therefore decreases uterine contractions. Choices A, C, and D are incorrect. Methotrexate would be significantly contraindicated because of its teratogenic effects. This medication is often utilized in an ectopic pregnancy. Oxytocin would be contraindicated for preterm labor since it causes uterine contractions. Folic acid is useful during pregnancy; however, this medication does not suppress uterine contractions. Additional information: Indomethacin is a tocolytic agent indicated for the prevention of preterm labor. This medication is given orally and has maternal side effects such as gastritis and reflux. The adverse effects on the fetus include enterocolitis, cardiac defects, and intraventricular hemorrhage. This medication is contraindicated if the client has renal or peptic ulcer disease. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Expected Actions/Outcomes

How should the nurse assess for the presence of thrombophlebitis in a patient who reports having pain in the left lower leg? A. By palpating the skin over the tibia and fibula [21%] B. By documenting daily calf circumference measurements [67%] C. By recording vital signs obtained four times a day [1%] D. By noting difficulty with ambulation [10%]

Explanation Choice B is correct. Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed by measuring circumference regularly. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative patients. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. Each shift, nurses should assess the legs for swelling and tenderness, measure bilateral calf or thigh circumference, and determine if the patient experiences any chest pain or dyspnea. The patient should be instructed not to massage the legs. Choices A, C, and D are incorrect. These options are not the correct way to assess for the presence of thrombophlebitis. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control; Thrombophlebitis

After talking to her family, an elderly client says that she wants to change the living will she wrote two weeks ago. The nurse's most appropriate reply would be: A. "You can only change your living will a year after it is formulated." [2%] B. "Let me see if I can find someone to help you." [72%] C. "You can only make changes to your will after 3 weeks." [3%] D. "Let's call your lawyer first and see what he thinks." [23%]

Explanation Choice B is correct. It is the nurse's responsibility to be the client's advocate. She should be responsible for finding someone that can help the client with her request. Choice A is incorrect. Living wills can be changed by the client anytime and as many times as they wish as long as they are competent in making decisions. Choice C is incorrect. Living wills can be changed by the client anytime and as many times as they wish as long as they are competent in making decisions. Choice D is incorrect. The client does not need to ask permission from her lawyer to change her living will.

Which of the following formulas would the nurse correctly choose for an infant diagnosed with phenylketonuria? A. Alfamino [17%] B. Lofenalac [39%] C. Enfamil [27%] D. Gentlease [17%]

Explanation Choice B is correct. Lofenalac is a formula that is very low in the amino acid phenylalanine. In phenylketonuria (PKU), there is impaired metabolism of this essential amino acid. When patients eat foods that contain this amino acid, they cannot break it down, so levels of this amino acid can then become toxic to the patient. Therefore, the formula Lofenalac is the appropriate choice for patients with PKU. Choice A is incorrect. Alfamino is a hypoallergenic amino acid-based formula designed to minimize the chance of further allergic reactions in a child that is allergic to cow's milk. It would not be appropriate for the infant with PKU. Choice C is incorrect. Enfamil is a standard formula used for infants without diet restrictions. It would not be appropriate for the infant with PKU. Choice D is incorrect. Gentlease is a formula made with easy-to-digest proteins that are intended to reduce gas and fussiness in infants with gastrointestinal disturbances. Since it is a protein-based formula, it would not be appropriate for the infant with PKU. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Maternity Nursing, Problems with Labor and Delivery

A client is prescribed bed rest by the physician after surgery. The nurse that takes care of the patient always avoids putting pressure on the back of the client's knees. This is done in order to prevent which complication? A. Cerebral embolism [2%] B. Pulmonary embolism [47%] C. Limb gangrene [17%] D. Coronary vessel occlusion [34%]

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

The patient with COPD reports to the nurse that she has trouble sleeping at night. Which question is most important for the nurse to ask next? A. "What do you eat before you go to bed? [18%] B. "How many pillows do you sleep on at night?" [75%] C. "Have you always been a light sleeper?" [6%] D. "Is your partner snoring and keeping you awake?" [1%]

Explanation Choice B is correct. Orthopnea is shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. Asking the patient how many pillows she uses to sleep on is a way to assess if the patient has been educated about measures to prevent orthopnea. COPD causes blocked or narrowed airways that make breathing more difficult. Patients may experience symptoms like wheezing, coughing, mucus production, and tightness in the chest. Smoking or exposure to harmful chemicals can cause COPD. Orthopnea is a common symptom for COPD patients. Choice A is correct. While some foods may aggravate reflux or create a feeling of being too full, which can disrupt sleep, this is not the most appropriate answer choice concerning shortness of breath with COPD. Choices C and D are incorrect. Being a light sleeper or having a partner who snores may interrupt sleep. However, the nurse's assessment should first address ways the client can make adjustments to prevent sleep disruption. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort

The nurse is developing a care plan for a toddler who has autism. What information regarding the child is most important to obtain from the parents? A. Height and weight [6%] B. Bedtime routine [28%] C. Vaccine history [16%] D. Developmental stage [51%]

Explanation Choice B is correct. Routine and rituals are essential to maintain for clients with autism. Hospitalization may be a difficult experience for a toddler and adding autism to the clinical picture makes it essential that home routines and rituals be continued during hospitalization. Choices A, C, and D are incorrect. Height, weight, vaccine history, and developmental stage are not relevant to the management of autism. This information may be obtained during the hospitalization and would have no implications for the client's care and autism. NCLEX Category: Physiological Adaptation Activity Statement: Illness management Question type: Analysis Additional Info The pathogenesis of autism is not well understood. Genetic factors in the development of an individual seem to have a key role in this disorder. Autism tends to occur more in males than in females. Clinical features of this disorder range from mild to severe. These features include language impairments, absent or limited interest in socialization with others, insistence on routine and rituals, and intolerance of high environmental stimulation. Vaccines do not cause autism. Nursing care for a client with autism incorporates routine into their care by having the same caregivers, structure for activities, and maintaining a predictable environment with low stimuli.

The nurse is caring for a patient in the emergency department who has just received a head injury following a car accident. After a hyphema has been noted, which position should the nurse encourage this patient to be in? A. Supine [18%] B. Semi-Fowler's [58%] C. Lateral on the affected side [4%] D. Lateral on the unaffected side [20%]

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

An adult client's insulin dosage is ten units of regular insulin and 15 units of NPH insulin in the morning. When should the client expect the first insulin peak? A. As soon as food is ingested [6%] B. In two to four hours [83%] C. In six hours [9%] D. In ten to twelve hours [3%]

Explanation Choice B is correct. The first insulin peak will occur two to four hours after the administration of regular insulin. Regular insulin is classified as short-acting and will peak within two to four hours after administration. Choice A is incorrect. Even short-acting insulin takes two to four hours after administration to peak. Choices C and D are incorrect. Intermediate-acting insulins, such as NPH, peak between 4-12 hours. Long-acting insulins' peak activity is usually 6-20 hours. NCSBN Client Need Topic: Physiological Integrity Subtopic: Pharmacological Therapies

The patient returns to the surgical unit after surgery. The experienced aide takes the vital signs and reports the following to the RN: BP 84/40, heart rate 120, and respiratory rate of 32 per minute. The highest priority for the nurse is to: A. Ask the patient if he is having pain [14%] B. Notify the surgeon [83%] C. Instruct the aide to continue to monitor the vital signs [1%] D. Continue with post-operative care [2%]

Explanation Choice B is correct. The most important intervention at this time is to notify the surgeon of the abnormal vital signs. Although all of these interventions might be appropriate, the most critical response is to get orders for the unusual vital signs that might indicate illness or intractable pain. Until the underlying issue is resolved, the other interventions can wait. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-Topic: Changes/Abnormalities in Vital Signs, Prioritization

A patient in the medical ward states his frustration over the way his physician is treating his medical condition. He also complains that the physician has been condescending to him a couple of times. What is the nurse's best action? A. Confront the physician about the patient's concern. [18%] B. Report the patient's concern to the unit manager. [77%] C. Talk to the client's family. [3%] D. Suggest another physician to the client. [1%]

Explanation Choice B is correct. The nurse should act as a patient advocate in this situation. A patient who verbalizes dissatisfaction with the physician's care should be reported to the nurse supervisor. The nurse supervisor is ultimately responsible for the care rendered to patients; he/she is the one with the authority to confront the physician regarding the client's concern. Choice A is incorrect. The nurse supervisor is responsible for the care rendered to patients; he/she is the one with the authority to confront the physician regarding the client's concern. Choice C is incorrect. Reporting to the family members violates the proper chain of command. Choice D is incorrect. Suggesting other physicians to the client is an unprofessional measure.

The nurse is caring for a patient following the placement of a gastrostomy tube. The Unlicensed Assistive Personnel (UAP) reports that the patient has thin, pale, and yellow-green drainage with a sour odor and a small amount of blood. Which is the best action for the nurse to take? A. Obtain specimen for culture. [14%] B. Assess the drainage. [71%] C. Instruct the UAP to obtain a full set of the patient's vitals. [4%] D. Assess patient's temperature for fever. [11%]

Explanation Choice B is correct. The nurse should assess the patient's drainage to confirm it is within reasonable expectations for the patient's condition. Up to 1500 mL/day of thin, pale, yellow-green drainage with sour odor and a small amount of blood would be expected for this patient. Choice A is incorrect. There would be no reason to culture this drainage since it is within expectations for the patient's condition. Choice C is incorrect. This would not be an indication to collect a unique set of vitals since this drainage is expected with the placement of a gastrostomy tube. If there is any doubt, the nurse should visualize and assess the patient, not delegate this task to the UAP. Choice D is incorrect. There would be no reason to expect the patient would be febrile since this drainage is usually seen with the gastrostomy tube. NCSBN Client Need Topic: Management of care, Subtopic: Assignment/Delegation

A client is scheduled for gastroscopy at 8:00 AM and has been placed on NPO since midnight. At 6:30 AM, the nurse checks the client's capillary blood glucose level and gets a result of 40 mg/dl on the glucometer. The client is alert, coherent, and reports, "I feel fine. I don't feel anything." The most appropriate action for the nurse is: A. Record the finding in the notes and withhold the client's morning insulin. [9%] B. Take a repeat sample of the capillary blood glucose. [39%] C. Give the client simple sugar by mouth. [17%] D. Administer intravenous dextrose 50 grams STAT. [35%]

Explanation Choice B is correct. The nurse should repeat the test because the client does not display any symptoms of hypoglycemia. The glucometer readings are not always accurate. Many variables such as quality of blood sample, dirt on the meter, humidity, aged test strip, high hematocrit, etc. may affect glucometer readings. In view of so many variables affecting the blood glucose reading in the glucometer, the nurse must be alert while interpreting these values especially, in the absence of any symptoms. The definition of hypoglycemia differs in diabetic patients from that of non-diabetic patients. In diabetic patients, Hypoglycemia is defined as a blood glucose of less than 70 mg/dl. Many diabetics may also have a condition called "hypoglycemia unawareness" where there may not be sufficient autonomic warning symptoms before the onset of neuroglycopenia (impaired cognition, coma). In a diabetic patient, therefore, hypoglycemia needs to be treated as soon as possible based on the lab values even in the absence of overt symptoms. In non-diabetic adults with low glucose levels, one should assess for symptoms. Symptoms may include cold, clammy skin, tachycardia, palpitations, impaired cognition, slurred speech, seizures, and confusion. A low blood glucose at the time of symptoms and improvement as soon as the blood glucose returns to normal confirm the diagnosis. In a non-diabetic client who has been fasting, a blood glucose less than 50 mg/dL can also be used to define hypoglycemia. In the absence of symptoms, however, the first step is to recheck the blood glucose and confirm the result. Choice A is incorrect. Because the first reading was too low, it is appropriate for the nurse to recheck before documenting the findings to confirm accuracy. Choice C is incorrect. The nurse should recheck and validate the results before deciding to administer glucose. Choice D is incorrect. The nurse should recheck and validate the results before deciding to administer glucose. If the patient has significant symptoms, immediate IV dextrose is appropriate.

What is the nurse doing in the picture below? A. Testing the neurological triceps reflex [9%] B. Performing a nutritional assessment [66%] C. Performing a musculoskeletal assessment [12%] D. Testing the neurological biceps reflex [13%]

Explanation Choice B is correct. The picture shown displays a nurse performing a nutritional assessment by measuring the triceps skinfold with a caliper. The triceps skinfold measurement, which measures the underlying skin subcutaneous tissue and not the underlying muscle, is done to assess the number of fat stores. Among other assessments, the triceps skinfold is a part of the anthropometric data that is collected as part of a comprehensive nutritional assessment. Choice A is incorrect. The picture shown does not show the nurse testing the neurological triceps reflex. Triceps reflexes are assessed with a Taylor hammer and not calipers. Choice C is incorrect. The picture shown does not show the nurse performing a musculoskeletal assessment. Musculoskeletal assessments are not done using calipers. Choice D is incorrect. The picture shown does not show the nurse testing the neurological biceps reflex. Biceps reflexes are assessed with a Taylor hammer and not calipers.

You are caring for a client in the community who has just received an order for zolpidem. What would you include in the teaching plan for this client? A. The need for the client and significant others to be aware of the fact that one of the side effects of this medication is insomnia. [29%] B. The need for the client and significant others to be aware of the fact that one of the side effects of this medication is somnambulism. [36%] C. The need to avoid the consumption of leafy green vegetables because these will interfere with the actions of this medication. [11%] D. The need to avoid the consumption of cheese because these will interfere with the actions of this medication. [24%]

Explanation Choice B is correct. The teaching plan for the client who has just received a prescription for zolpidem (Ambien) should include the need for the client and significant others to be aware of the fact that one of the side effects of this medication is somnambulism. Somnambulism is sleepwalking and performing activities while fully asleep which can be quite severe and dangerous to the client and others (for example, pedestrians when the client is driving a motor vehicle). Choice A is incorrect. The teaching plan for this client would not include the need for the client and significant others to be aware of the fact that one of the side effects is insomnia because insomnia is not one of the side effects associated with zolpidem. Zolpidem is used to treat insomnia and promote sleep. Choice C is incorrect. The teaching plan for the client would not include the need for the client to avoid the consumption of leafy green vegetables because these vegetables do not interfere with the actions of this medication. Choice D is incorrect. The teaching plan for the client would not include the need for the client to avoid the consumption of cheese because cheese does not interfere with the actions of this medication.

The RN is taking vital signs on an infant diagnosed with total anomalous pulmonary venous return (TAPVR) and then the mother starts crying. Which of the statements by the nurse is most therapeutic? A. "Don't cry, your baby will be fine!" [0%] B. "I can see you are upset. Sometimes it helps to talk about it." [95%] C. "I'm sure this is hard, but your baby is doing so well!" [4%] D. "You think this is bad, you should see some of the other babies here." [1%]

Explanation Choice B is correct. This is a good example of therapeutic communication. The nurse has validated the mother's feelings and encouraged further dialogue to understand what the mother is upset about. Choice A is incorrect. This is not a therapeutic statement. The nurse does not know that the baby will be fine and should not brush off the mother's concerns. Choice C is incorrect. This is not a therapeutic statement. The nurse should encourage further dialogue with the mother instead of pushing her concerns aside. Choice D is incorrect. This is not a therapeutic statement. It is not appropriate to compare the infant to other patients on the unit. Furthermore, this does not encourage conversation with the mother to help address her concerns. NCSBN Client Need Topic: Psychosocial Integrity; Subtopic: Pediatrics - Cardiac; communication

The nurse is counseling a client who has prediabetes. The nurse understands that the client is meeting the treatment goal as evidenced by A. total cholesterol of 215 mg/dL. [1%] B. hemoglobin A1C of 5.4%. [85%] C. fasting blood glucose 128 mg/dL. [12%] D. random blood glucose of 210 mg/dL. [3%]

Explanation Choice B is correct. This is an optimal hemoglobin A1C as it is less than 5.7%. A hemoglobin A1C of 5.7% to 6.4% is prediabetes. This is a concerning finding as the client is on a negative trajectory toward diabetes mellitus. A hemoglobin A1C of 6.5% is the diagnosis of diabetes mellitus. Choices A, C, and D are incorrect. Total cholesterol of 215 mg/dL is a concerning finding. The goal is to have total cholesterol of less than 200 mg/dL. Elevated total cholesterol contributes to metabolic syndrome, which is the driver of diabetes mellitus. Fasting blood glucose of 128 mg/dL is elevated (this is impaired fasting glucose), and a level greater than 126 mg/dL requires further testing for diabetes mellitus. Random blood glucose of 210 mg/dL is concerning as this is a provisional diagnosis for diabetes mellitus. Additional Info The following are diagnostic criteria for diabetes mellitus A1C >6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay. AND Fasting blood glucose greater than or equal to 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours. OR Two-hour blood glucose equal to or greater than 200 mg/dL (11.1 mmol/L) during oral glucose tolerance testing. The test should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. OR In a client with classic manifestations of hyperglycemia or hyperglycemic crisis, a casual or random blood glucose concentration greater than 200 mg/dL (11.1 mmol/L). Casual is defined as any time of the day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.

A client who has a gastrostomy tube in place is being discharged. Enteral feedings will be continued at home. While educating the client and family, which statement made by a family member indicates the need for further teaching? A. "If he gets diarrhea for 2-3 days, I will call the doctor or nurse." [8%] B. "I should expect a weight gain of about 1 lb/day now that he is on continuous feedings." [63%] C. "When feeding, I should keep the head of his bed elevated or sit him in the chair." [4%] D. "Prepared or open formula should be used within 24 hours and unused portions should be stored in the fridge." [24%]

Explanation Choice B is correct. This statement needs further teaching. A weight gain of more than 1lb/ day is not an expected finding for a client on tube feedings. Such excessive weight gain indicates fluid retention. A consistent weight gain of more than 0.5 lb/day over several days should be promptly reported to the health care provider so that the client may be evaluated for excess fluid volume. Choices A, C, and D are incorrect. These statements reflect accurate understanding and do not need further teaching. Enteral feedings are best administered with the client's head elevated to prevent reflux and aspiration pneumonia. The unused formula should be placed in the refrigerator to avoid bacterial proliferation. If the formula is contaminated, it may lead to gastroenteritis and even sepsis. Diarrhea is a common complication of tube feedings. Hypertonic formulas draw fluid into the bowel and precipitate osmotic diarrhea. Other causes may be bacterial contamination, fecal impaction, medications, and low albumin. Diarrhea can lead to dehydration and should be promptly reported. Learning Objective Understand the common side effects and complications of tube feedings. The nurse should monitor the clients for excessive weight gain, electrolyte imbalances, and diarrhea. Excessive weight gain on tube feedings indicates fluid retention and must be promptly addressed.

The student nurse is demonstrating competency for an indwelling foley catheter insertion on a female patient. Of the following actions, which would the experienced nurse who is observing recognize as a break in sterility due to contamination of the sterile field? A. The student nurse applies sterile gloves, then removes the fenestrated drape from the sterile kit and places it over the patient. [24%] B. The student opens the antiseptic swabs, applies sterile gloves, then cleans the patient. [40%] C. The patient's labia closes over the catheter during insertion. [14%] D. After inserting the catheter and noting the absence of urine, the nursing student determines the catheter has accidentally been placed in the patient's vagina. [21%]

Explanation Choice B is correct. Though several of the options are examples of incorrect aseptic technique, the question specifically focuses on contamination of the sterile field, which occurs whenever non-sterile items (i.e. bare/non-sterile gloved hands, stethoscope, shirt sleeve) come into contact with the sterile field. The student nurse should re-start the entire procedure and apply sterile gloves prior to touching the antiseptic swabs. Choice A is incorrect. Sterile gloves may be worn to hold the edge of the sterile drape and place it over the patient. This action would not contaminate the sterile field unless the student's gloved hands came into contact with the patient in the process. Choice C is incorrect. This would be an example of contamination of the catheter, not contamination of the sterile field. Any contact between the catheter and the patient's labia or outer genitalia prior to being introduced into the urethra would require the nurse to obtain a new catheter. Choice D is incorrect. This would not be an example of contamination of the sterile field. If no urine is noted after insertion, the catheter is likely in the patient's vagina and should be left in place as a landmark. The student should obtain new equipment and perform the procedure again, ensuring no contact is made with the first catheter.

The nurse is talking to the mother of a 3-year-old in the emergency room. The toddler is suspected of being abused by the mother. Which finding from the conversation would support the suspicion of child abuse by the mother? A. The mother has a healthy self-esteem [1%] B. The mother talks about how her childhood was happy [6%] C. The mother complains that her toddler seems to be different from others [89%] D. The mother complains to the nurse that her child seems to grow up too fast [3%]

Explanation Choice C is correct. Children that are seen by their parents as different are usually the ones that are chosen to be abused. Choice A is incorrect. Abusive parents have low self-esteem, not a healthy one. Choice B is incorrect. Most abusive parents are also products of child abuse and did not experience a happy childhood. Choice D is incorrect. Abused children are usually perceived as slow and developmentally delayed by their abusive parents.

The process of absorbing drugs before elimination after they have been excreted into bile and delivered to the intestines is called: A. Hepatic clearance [32%] B. Total clearance [8%] C. Enterohepatic cycling [31%] D. First-pass effect [29%]

Explanation Choice C is correct. Drugs and drug metabolites with molecular weights higher than 300 may be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their half-life and duration of action in the body. Before drugs can be clinically useful, they must be absorbed. Absorption is the process of a drug moving from its site of delivery into the bloodstream. The chemical composition of a drug, as well as the environment into which a drug is placed, work together to determine the rate and extent of drug absorption. Absorption can be accomplished by administering the drug in a variety of different ways (orally, rectally, intramuscularly, subcutaneously, inhalation, topically, etc.). If a drug is administered intravenously, the need for absorption is bypassed entirely. For drug absorption to be most efficient, the properties of the drug itself and the pH of the environment where the drug is located must be considered. Most drugs are either weak acids or weak bases. Drugs that are weak acids will pick up a proton when placed in an acidic environment and will be un-ionized. Other factors that also impact drug absorption include the following: Physiologically, a drug's absorption is enhanced if there is a large surface area available for absorption (villi/microvilli of the intestinal tract) and if there is a large blood supply for the drug to move down its concentration gradient. The presence of food/other medications in the stomach may impact drug absorption - sometimes enhancing absorption and other times, forming insoluble complexes that are not absorbed (it depends on the specific drug). Some drugs are inactivated before they can be absorbed by enzymes, acidity, bacteria, etc. Choice A is incorrect. Hepatic clearance is the amount of drug eliminated by the liver. Choice B is incorrect. Total clearance is the sum of all types of removal, including renal, hepatic, and respiratory. Choice D is incorrect. The first-pass effect is the amount of drug absorbed from the GI tract and then metabolized by the liver; thus, reducing the amount of medicine, making it into the circulation. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies, What Happens After a Drug Has Been Administered

When experiencing conflict with another nurse (that is not resolvable between the parties), what is the most appropriate action for the nurse moving forward? A. Report the conflict to the director of nursing over the unit. [1%] B. Report the conflict to the nurse manager of the unit. [34%] C. Report the conflict to the assigned charge nurse of the unit. [61%] D. Discuss the conflict with another nurse to attempt resolution of the issue. [3%]

Explanation Choice C is correct. It is essential to follow the appropriate chain of command in a professional setting and not to overstep any levels when moving the issue up the ladder. Relationships among healthcare staff can have a powerful influence on how well important information is communicated. Disruptive behaviors may be displayed as aggressive, which is a more natural type of action to observe, but may also be demonstrated as passive or passive-aggressive. These behaviors may threaten patient safety and quality of care. Nurses and other clinicians who witness these behaviors may be hesitant to point them out because of the fear of retaliation. Additionally, nurses may be reluctant or may refuse entirely to communicate with a disruptive clinician. Delays in patient care, disruptive behaviors, and recurring communication problems may occur due to ongoing or unresolved disputes between clinicians. When any problematic issue arises, it is essential to follow the proper chain of command and to report the problem as well as attempt a resolution so that patient outcomes are not negatively affected. Chain of leadership in healthcare refers to an authoritative structure established to resolve administrative, clinical, or other patient safety issues by allowing healthcare clinicians to present a matter of concern through the lines of authority until a resolution is reached. Choices A and B are incorrect. The director of nursing and nurse manager of the unit are not the most immediate to notify in the chain of command. Choice D is incorrect. It would be inappropriate to discuss the conflict with a nurse on your level of authority. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Coordinated Care, Communicating with the Healthcare Team

The patient is using topical glucocorticoids. The nurse should assess for all the following systemic effects of the medication, except: A. Mood changes [27%] B. Osteoporosis [22%] C. Liver toxicity [31%] D. Adrenal insufficiency [20%]

Explanation Choice C is correct. Liver toxicity is not a systemic effect associated with the use of glucocorticoids. Topical glucocorticoids or corticosteroids are used in cases of dermatitis and eczema to treat symptoms of burning, itching, and inflammation. They may also be used in conjunction with other medical therapies for the treatment of psoriasis. Choices A, B, and D are incorrect. In cases of long-term use, adverse effects of glucocorticoids may include irritation, redness, and thinning of the skin membranes. Also, if absorption occurs, topical glucocorticoids may produce undesirable systemic effects including adrenal insufficiency, mood changes, bone defects, and serum imbalances. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

The nurse is working in the newborn nursery. Which assessment finding in a newborn would lead the nurse to suspect cystic fibrosis and notify the healthcare provider of the finding? A. Steatorrhea [40%] B. Hyperhidrosis [9%] C. Meconium ileus [33%] D. Barrel chest [18%]

Explanation Choice C is correct. Meconium Ileus is very frequently the first sign of cystic fibrosis in a newborn. Meconium ileus refers to a small bowel obstruction that occurs when the infant's first stool is thicker and stickier than usual, causing a blockage in the ileum. Often, it presents within a few hours of birth with bilious vomiting as soon as feedings are initiated. Abdominal distension may be present. Some infants may manifest with just delayed passage of meconium rather than acute symptoms of obstruction. Meconium peritonitis may occur if there is perforation and may manifest with abdominal tenderness, fever, and shock. Choice A is incorrect. Steatorrhea is described as stools that are bulky, frothy, and foul-smelling. Steatorrhea is caused by the excretion of abnormal quantities of fat in the stool. This occurs in cystic fibrosis, but would not be present yet in a newborn. Choice B is incorrect. Hyperhidrosis is a medical condition in which a person sweats excessively and unpredictably. This is not a sign of cystic fibrosis in the newborn. Newborns with cystic fibrosis will have elevated levels of chloride in their sweat, causing it to taste salty, but they will not sweat excessively. Choice D is incorrect. Barrel chest is a long-term complication of cystic fibrosis, but not a sign that would be present at birth in the newborn. A barrel chest refers to a broad, deep chest that is large and cylindrical. It occurs when the patient has been suffering from hypoxemia due to cystic fibrosis for a prolonged period of time. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Coordinated care

The nurse is caring for a client who has septic shock and has failed to respond to initial treatment. Which of the following infusions would the nurse anticipate if the client has a mean arterial pressure (MAP) of 54 mmHg? A. Milrinone [8%] B. Amiodarone [24%] C. Norepinephrine [62%] D. Lidocaine [6%]

Explanation Choice C is correct. Norepinephrine is a common prescription in treating septic shock. It increases vascular tone and the mean arterial pressure (MAP). One of the critical guidelines in treating sepsis is to maintain a mean arterial pressure ( MAP) of 65 mm Hg or more. Initial steps include isotonic fluid boluses to help increase the MAP. If the client does not respond to the initial fluid bolus, vasopressors such as Norepinephrine is used to achieve and maintain the MAP at the target level. Choices A, B, and D are incorrect. Milrinone is an afterload reducing agent effective in the treatment of congestive heart failure. This medication lowers blood pressure and would be detrimental in the management of septic shock. Amiodarone and lidocaine are indicated for ventricular dysrhythmias. These medications are not utilized for septic shock. Additional information: Septic shock is a distributive shock caused by the client failing to respond to the initial fluid challenge. The nurse should focus on implementing prompt interventions for sepsis which include: 1. Establishing large-bore IV access 2. Collecting prescribed laboratory work such as CBC, CMP, lactic acid, blood cultures, urine culture (if applicable), and procalcitonin (if applicable) 3. Implementing an isotonic fluid bolus of 30 mL/kg 4. Infusing an empirical antibiotic NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Subtopic: Indications and Expected Actions

The nurse is caring for a client who is receiving newly prescribed salmeterol. Which of the following prescribed medications requires notification to the primary healthcare provider (PHCP)? A. Lithium [40%] B. Captopril [11%] C. Labetalol [40%] D. Clonidine [9%]

Explanation Choice C is correct. Salmeterol is a long-acting beta-agonist indicated in the maintenance treatment of chronic respiratory illnesses. This medication causes bronchodilation by innervating the adrenergic receptors. Blocking these receptors by beta-adrenergic blockers is contraindicated because it may lead to bronchospasm. Thus, labetalol would be contraindicated because of its risk of this adverse effect. Choices A, B, and D are incorrect. Lithium, a mood stabilizer used in bipolar disorder, captopril, an ACE inhibitor used in heart failure, and clonidine, used in hypertension, is not contraindicated while a client receives salmeterol. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Adverse Effects/Contraindications/Side Effects/Interactions Question type: Analysis Additional Info Long-acting beta-agonists (LABAs) are indicated in the maintenance treatment of asthma. The client should be taught that this medication is not indicated for acute exacerbations. Contraindications for salmeterol include beta-blockers which may cause bronchospasm.

The client comes into the emergency department complaining of unusual tiredness, ankle swelling, and seeing yellow rings all around. Upon assessment, the client has been experiencing loose bowels as well. A review of medications reveals that the client is taking digoxin. What is the nurse's initial action? A. Reassure the client that he will be okay. [0%] B. Obtain an ECG. [35%] C. Notify the physician about the findings. [62%] D. Obtain a stool specimen. [2%]

Explanation Choice C is correct. Signs of digoxin (digitalis) toxicity include an unusual slow irregular pulse, rapid weight gain, yellow vision, unusual tiredness, ankle swelling. Loose bowel movements may lead to hypokalemia, which increases the toxic effects of digitalis. The nurse should immediately notify the physician so appropriate treatment can be started. Choice A is incorrect. The client presents with signs of digitalis toxicity exacerbated by dehydration and hypokalemia brought about by loose bowel movements. The nurse would reassure the patient but should address his physiological problems beforehand. Choice B is incorrect. An ECG would be helpful to assess the cardiac status of the patient; however, the patient is showing clear signs of digitalis toxicity. The initial action of the nurse would be to inform the physician. Choice D is incorrect. Obtaining a stool specimen can be useful in ascertaining the cause of the patient's loose stools. This is not, however, a priority nursing action.

Select the category of pain medication that is accurately paired with the level of pain medication indicated for it AND an example of a pain medication that is included in this category of pain medication. A. Co-analgesic medications: Severe pain: A tricyclic antidepressant medication [3%] B. Opioid analgesic medications: Severe pain: Tramadol [25%] C. Opioid analgesic medications: Moderate pain: Tramadol [35%] D. Non-opioid analgesic medications: Moderate pain: Ibuprofen [36%]

Explanation Choice C is correct. The appropriate answer is opioid analgesic medications: moderate pain: tramadol. Opioid analgesic medications like tramadol are used for moderate pain. Choice A is incorrect. Although analgesic medications like tricyclic antidepressants are used for severe pain, these analgesic medications are used for all levels of anxiety in combination with a non-opioid or opioid medication. Choice B is incorrect. Although opioid analgesic medications are indicated for severe pain, a drug other than tramadol is used to manage acute pain. Choice D is incorrect. Non-opioid analgesic medications like ibuprofen are not indicated for moderate pain; ibuprofen is indicated for minor pain.

A nurse is preparing a newborn with a myelomeningocele sac for surgery. The most appropriate intervention to keep the site sterile and protected is to: A. Leave the sac as it is, exposing it to air [3%] B. Apply petroleum as a protective covering for the sac [5%] C. Cover the sac with moist, saline dressings [84%] D. Apply dry dressing over the sac [8%]

Explanation Choice C is correct. The sac should be kept moist before surgery to maintain its integrity. Choices A, B, and D are incorrect. Exposing the sac to open air, especially in an incubator, can cause drying. Prolonged use of ointments can cause the breakdown of the tissue while dry dressings are irritating to the sac.

Upon assessment, the nurse noticed that the site of a client's peripheral intravenous (IV) catheter is red, warm, painful, and slightly edematous near the insertion point of the IV catheter. After taking appropriate steps to address the issue and care for the client, the nurse documents in the medical record that the client experienced: A. Hypersensitivity to the IV solution [1%] B. Infiltration of the IV line [32%] C. Phlebitis of the vein [66%] D. Allergic reaction to the IV catheter material [1%]

Explanation Choice C is correct. The symptoms of phlebitis at an IV site include redness, warmth, and swelling of the area proximal to the catheter. If this occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. If the IV catheter were infiltrated, the area around the site would be cool (Choice B is incorrect). An allergic reaction produces a rash, redness, and itching (Choice D is incorrect). Choice A is incorrect. This does not describe what happened to the client.

The nurse is caring for a client who is receiving prescribed trazodone. Which of the following findings would indicate the client is having an adverse effect? A. Dizziness [19%] B. Sedation [17%] C. Priapism [47%] D. Dry mouth [17%] Incorrect

Explanation Choice C is correct. Trazodone is a serotonergic medication indicated in the treatment of insomnia. Adversely, this medication may cause priapism which is a prolonged, painful erection of the penis. Prompt treatment is necessary because this may result in ischemia. Choices A, B, and D are incorrect. Trazodone exerts central nervous system depressive effects, and those with trazodone often experience dizziness. This medication is indicated for insomnia, and sedation would be a therapeutic (not adverse) effect. Dry mouth is a benign effect associated with the medication. Additional Info Trazodone is a serotonergic agent used frequently for the treatment of insomnia. It is essential that the nurse implement fall precautions with this medication because sedation and dizziness is likely to occur with this medication.

You are taking care of a client with moderate to severe dementia. Select the nursing intervention that insures and protects the client's safety in terms of bathing. A. Ensure that there is a scatter rug outside the shower to prevent the collection of water which could lead to a slip and fall. [7%] B. Check and ensure that the bathing water for the client is no more than 101 F degrees in order to prevent client burns. [14%] C. Clients with dementia should be encouraged to shower in privacy and without supervision so they do not become hostile. [1%] D. Never allow the client to remain in the tub alone without monitoring and supervision so that accidents do not occur. [78%]

Explanation Choice D is correct. Bathing safety is highly important. Many accidents occur in the bathrooms of healthcare facilities and the homes of clients. You should never allow the client to remain in the tub alone without monitoring and supervision because accidents can and do occur. Other aspects of bathing safety include the presence and use of assistive bathing devices like grab bars and shower chairs, checking and ensuring that the water in the shower is at an appropriate temperature (less than 110 F degrees to prevent burning), and monitoring the client when they are taking a tub bath or shower bath. Choice A is incorrect. You would not ensure that there is a scatter rug outside the shower to prevent the collection of water because scatter rugs are a safety hazard in themselves so they would only increase the risk of slipping and tripping. Choice B is incorrect. You would not check and ensure that the bathing water for the client is no more than 101 F degrees to prevent client burns, but you would ensure that the temperature is no more than 110 F degrees. 101 F degrees is an uncomfortable, cold temperature for bathing water, and water that is too hot can be harmful and can even cause burns. Choice C is incorrect. Clients with dementia should not shower in privacy and without supervision; they must be closely monitored and supervised at all times.

A nurse is assigned to care for 4 clients who are 1-day postpartum. The nurse performs an initial assessment. Which assessment finding would prompt the nurse to evaluate further? A. A client complaining of mild pain [2%] B. A client with a pulse rate of 65 bpm [6%] C. A client with colostrum discharge from both breasts [1%] D. A client with red, foul-smelling lochia [91%]

Explanation Choice D is correct. For day one postpartum clients, it is reasonable to have mild pain; therefore, further assessment is not required. A pulse rate of 65 bpm is also standard, as well as colostrum discharges for clients who are day one postpartum. Choices A, B, and C are, therefore, incorrect. Lochial discharges are expected to be red, similar to menstrual discharges, and should have a fleshy odor. A foul-smelling lochia may indicate the presence of pus and could be a sign of infection. This should alert the nurse to conduct a further evaluation.

The nurse has become aware of the following client situations. The nurse should first follow up with which client? A. A client with a chest tube that has tidaling in the water seal chamber. [2%] B. A client that is receiving mechanical ventilation and is occasionally biting on the tube. [8%] C. A client that is receiving albuterol via a nebulizer and reports headache and nervousness. [4%] D. A client with pneumonia that has become restless and confused. [85%]

Explanation Choice D is correct. One of the dreaded complications of pneumonia is acute respiratory distress syndrome (ARDS) which is manifested by hypoxia. The client demonstrating confusion and restlessness is quite concerning for hypoxia. The nurse should quickly assess the client and intervene by calling a rapid response if this should occur in the acute care setting. Choices A, B, and C are incorrect. Tidaling in the water seal chamber is a normal finding when a client has a chest tube. Biting on an endotracheal tube is a common finding and does require follow-up as the client could be in pain. Headache and nervousness are common effects associated with albuterol treatments. Additional Info For a client with pneumonia, the nurse must constantly monitor for ARDS since this syndrome is characterized by an inflammatory injury to the lungs. Classic findings include hypoxemia, progressive dyspnea, and adventitious lung sounds. Medical treatment includes positive airway pressure with oxygen, prone position, glucocorticoids, glucose control, and antimicrobials or antivirals. The prone position is preferred because this position improves ventilation in the dorsal region of the lung, therefore improving oxygenation.

The nurse is preparing a presentation on Cushing's disease. It would be correct if the nurse states that Cushing's disease is caused by A. destruction to pancreatic beta cells. [1%] B. excessive discharge of thyroid-stimulating hormone (TSH). [14%] C. decrease in the secretion of androgens and glucocorticoids. [12%] D. increase in the secretion of adrenocorticotropin hormone (ACTH). [72%]

Explanation Choice D is correct. Primary Cushing's disease is characterized by hypersecretion of ACTH from the pituitary gland that is usually due to a pituitary adenoma. This causes the client to experience multisystem manifestations such as sodium and water retention leading to weight gain, elevated blood glucose, delayed wound healing, and increased gastric acid secretion. Choices A, B, and C are incorrect. Destruction of pancreatic beta-cells is a statement describing the pathophysiology of diabetes mellitus. An excessive discharge of TSH describes the pathophysiology of hyperthyroidism. A decrease in the secretion of androgens and glucocorticoids is cardinal to adrenal insufficiency (Addison's disease). Additional Info Hypercortisolemia in Cushing's disease is usually due to corticotropin (ACTH)-producing pituitary tumor (Cushing's disease), ectopic ACTH secretion by a nonpituitary tumor, or cortisol secretion by an adrenal adenoma or carcinoma. Clinical features of Cushing's disease include sodium and water retention, weight gain, fatigue, hyperglycemia, truncal obesity, and sexual dysfunction.

You are caring for an 84-year-old woman with severe osteoporosis. You are providing discharge instructions to the patient and her 60-year-old son. A primary prevention intervention that you recommend to them is to: A. Take a calcium supplement [21%] B. Take a bisphosphonate daily [3%] C. Wear a back brace [2%] D. Survey the home to identify fall risks [74%]

Explanation Choice D is correct. Survey the home to identify fall risks. Primary prevention interventions are those that prevent the exacerbation of a disease. In this case, if she falls, the patient is at risk for fractures due to osteoporosis. If we can prevent falls, the patient will not have the suffering and cost associated with the potential breach. Secondary prevention measures are interventions that focus on patients without the specific disease process but with risk factors for the condition. Secondary prevention includes screening tests such as mammography or blood pressure screening in an individual without the disease. Choices A, B, and C are incorrect. These are all tertiary prevention measures. Tertiary measures are those prescribed for the treatment of a known disease. In this case, calcium, bisphosphonates, and a back brace may be treatments for the patient, but because they are providing direct treatment of osteoporosis, they are classified as tertiary interventions. NCSBN Client Need Topic: Health Promotion and Maintenance, Sub-Topic: Health Promotion/Disease Prevention, Musculoskeletal

A 25-year-old female client is at the emergency department with complaints of severe pain in the right lower quadrant of the abdomen; she was assessed and found to have appendicitis. She is being scheduled for an appendectomy. Which question is most relevant for this presentation? A. "Are you breastfeeding?" [0%] B. "Have you ever been under general anesthesia?" [22%] C. "Do you have any allergies to medication?" [25%] D. "Is there any chance that you are pregnant?" [52%]

Explanation Choice D is correct. Taking into consideration that the client is female and is of childbearing age, the nurse needs to ask the client if she is pregnant so that appropriate interventions can be made to ensure the safety of the fetus. Since it is already determined clinically that the patient has appendicitis, she may be scheduled for surgery. It is important to know if the client is pregnant before pursuing general anesthesia. If imaging is necessary to confirm the diagnosis, it is important to know whether the woman is pregnant to avoid harmful exposure from radiation due to unnecessary imaging. Choice A is incorrect. The question does not indicate that the client has an infant. This can be asked by the nurse; however, it is not the most relevant to the situation. Choice B is incorrect. The question can be asked by the nurse and is relevant to the situation. However, given that the client is of childbearing age, the nurse should ask if she is pregnant to ensure that the fetus she is carrying is not harmed from anesthesia. Choice C is incorrect. This is a general question for all clients. Regarding the situation, given that the client is of childbearing age, the nurse should ask if she is pregnant to ensure that the fetus she is carrying is not harmed from anesthesia.

The nurse is caring for a 26-year-old patient who is unable to meet their nutritional needs by mouth. The interdisciplinary team decides it would be best to insert an NG tube for enteral feedings. After inserting the tube, the nurse knows that which of the following is the most accurate way to verify the placement of the tube? A. Aspiration of stomach contents [2%] B. pH verification of the aspirate [4%] C. Injecting air into the tube and then auscultating the left upper quadrant (LUQ) [3%] D. Visualization on an x-ray [91%]

Explanation Choice D is correct. Visualization on an x-ray is the gold standard for verification of nasogastric tube placement. This allows the radiologist to visualize the tip of the tube in the stomach and recommend any changes in placement that may be needed, such as pulling the tube back or advancing further. Choice A is incorrect. The aspiration of stomach contents is one way the nurse can independently check the placement of a nasogastric tube, but it is not the most reliable indicator. Visualization on x-ray is considered the "gold standard" for verification of tube placement. Choice B is incorrect. A pH verification of the aspirate is not always accurate. Although a pH lower than 4.5 may suggest stomach contents being aspirated from the nasogastric tube, it is important to recognize that multiple other factors such as the tube feed formula and prescribed medications may also affect the pH. Since these factors can cause variable pH, it is not considered a reliable method of verifying nasogastric tube placement. Choice C is incorrect. Auscultation of air in the LUQ, when injected into the tube, is an old practice that is no longer recommended as a reliable nasogastric tube placement verification method. Air auscultation is highly subjective and can sometimes be appreciated even if the tube was incorrectly placed into the lungs. It is even more challenging on smaller-sized pediatric patients, as the sound of the air can resonate throughout their abdomen and thorax, making it impossible to verify the nasogastric tube placement. NCSBN Client Need Topic: Health promotion and maintenance, Subtopic: GI/nutrition

The nurse is caring for a 5-year-old girl diagnosed with hemophilia with a recurrent episode of hemarthrosis. Which of the following would the nurse expect on their assessment? Select all that apply. A. Joint pain and swelling [36%] B. Decreased level of consciousness [8%] C. Bruising [39%] D. Melena [16%]

Explanation Choices A and C are correct. Hemarthrosis is defined as bleeding into a joint cavity. Most commonly affected joints include knees, ankles, and elbows. Hemarthrosis is a frequent complication of hemophilia because of the deficiency of clotting factors and prolonged clotting times. When the nurse has a patient with hemarthrosis, she can expect joint pain and swelling, and external bruising in the hemarthrosis area due to the accumulation of blood in that joint cavity. Choice B is incorrect. A decreased level of consciousness (LOC) is not a finding expected with hemarthrosis. Hemarthrosis is defined as bleeding into a joint cavity, which would not cause a decreased LOC. Decreased LOC may be seen in patients with hemophilia if they develop a brain bleed. Other symptoms to look out for if a brain bleed is expected include slurred speech, vision changes, and headaches. Choice D is incorrect. Melena is not a finding expected with hemarthrosis. Hemarthrosis is defined as bleeding into a joint cavity, which would not cause melena. Melena is characterized by black, tarry stools and is due to upper gastrointestinal bleed. Melena is a symptom of hemophilia as well but is not associated with hemarthrosis. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatrics - Hematology

When caring for an Amish patient, what does the nurse know to be true? Select all that apply. A. They use traditional and alternative health care. [27%] B. Funerals are conducted in the home. [18%] C. The authority of women and men are equal. [3%] D. Many choose to live without health insurance. [23%] E. Health is believed to be a gift from God. [29%]

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

The nurse is providing discharge instructions to a client prescribed nasal cannula oxygen. Which of the following instructions should the nurse include? Select all that apply. A. Keep a pulse oximetry device readily available. [29%] B. Pad the tubing in areas that put pressure on the skin. [22%] C. Have a sign on your door indicating the presence of oxygen. [28%] D. I should use the oven and not the stovetop to cook. [9%] E. You may apply petroleum jelly to your nares to prevent drying. [12%]

Explanation Choices A, B, and C are correct. A pulse oximetry device should be provided to the client, and they should be encouraged to log their oxygen saturations as directed. If the client experiences dyspnea or tachypnea, the client should be instructed to seek medical attention for a level less than 95% (unless otherwise directed). Padding the tubing around pressure ears (back of the ears) is recommended to avoid injury. A sign posted on the door should be visible to alert visitors of the oxygen and extinguish and open flames. Choices D and E are incorrect. Stovetop and oven cooking is highly discouraged as the presence of oxygen may accelerate any fire that may ignite. Rather, if cooking is to be done using heat or flames, another individual should do the cooking, and the oxygen should be greater than six feet away from the flame source. Petroleum jelly should not lubricate the nares as it may be aspirated. Water-soluble jelly is recommended. NCLEX Category: Physiological Adaptation Activity Statement: Illness management Question type: Application Additional Info For a client being discharged with oxygen therapy, important teaching points to emphasize include: Have a pulse oximetry device readily available. Avoiding any open flame or heat. This includes an oven, stovetop, candles, matches, and cigarettes. Flammable products such as alcohol and oil should be avoided. Have working smoke detectors in the home as well as fire extinguishers. Use a water-soluble jelly to lubricate the nasal passages and mouth to prevent drying.

Select the minerals that are accurately paired with major food sources. Select all that apply. A. Iodine: Seafood and table salt [27%] B. Chloride: Table salt [18%] C. Calcium: Kale and broccoli [18%] D. Phosphorus: Leafy vegetables and peas [18%] E. Sulphur: Peas and kale [4%] F. Magnesium: Seafood and citrus [14%]

Explanation Choices A, B, and C are correct. Iodine is found in seafood and table salt. Chloride is found in table salt. Calcium is found in kale and broccoli. Choice D is incorrect. Phosphorus is found in peas and dairy products, not leafy vegetables and peas. Choice E is incorrect. Sulfur is found in meat and dried fruits, not peas and kale. Choice F is incorrect. Magnesium is found in nuts and green leafy vegetables, not seafood and citrus.

Which of the following educational points would be helpful for optimizing feedings in an infant with heart failure? Select all that apply. A. Small frequent feedings [42%] B. Feeding every 5 hours [3%] C. Feed for a maximum of 30 minutes [21%] D. Increased calorie formula [33%]

Explanation Choices A, C, and D are correct. A is correct. It is appropriate advice to feed an infant with heart failure in small, frequent feedings. These infants will have a difficult time feeding and are working very hard during their feeds. They will need to be paced so that they conserve their energy and do not burn too many calories while feeding. Small, frequent feeds are the best way to optimize their nutrition. C is correct. It is appropriate advice to feed an infant with heart failure for only 30 minutes at a time. After 30 minutes of feeding, the infant is using too much energy to gain calories and grow due to the feeding. Conserving energy is very important for infants experiencing heart failure. D is correct. It is appropriate advice to feed an infant with heart failure an increased calorie formula. This will allow them to get a maximum amount of calories for growth in as little work as possible. Infants who are breastfed may require additional supplementation to grow. Choice B is incorrect. Feeding an infant with heart failure every 5 hours is not frequent enough. Small, frequent feedings should be initiated to maximize caloric intake and conserve energy. A baby with heart failure should be fed on a schedule every 3 hours. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatrics - Cardiac

Which of the following statements made by a TB patient being prepared for discharge indicate his understanding of the education provided? Select all that apply. A. "Everyone in my family needs to go and see the doctor for TB testing." [29%] B. "I will continue to take the isoniazid until I am feeling completely well." [6%] C. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." [36%] D. "I will change my diet to include more foods rich in iron, protein, and vitamin C." [28%]

Explanation Choices A, C, and D are correct. A: Family members should be tested because of their repeated exposure to the patient C: Covering the mouth and nose when sneezing or coughing and placing the tissue in plastic bags helps to prevent transmission of the causative organism. D: The dietary changes in this answer choice are recommended for patients with TB. TB, tuberculosis, is a severe bacterial disease. It is spread from person to person through the air. TB may scar the lungs and other parts of the body, including the kidneys, bones, or brain. However, medications are available to treat TB; not every person affected responds within the same time frame. Nurses are responsible for providing patient education and making sure that the patient understands what he/she is being taught to help prevent the spread of disease. To help prevent the spread of TB, patients should be instructed to: Make sure that family, friends, and close co-workers are tested. Avoid close contact with others until the physicians say it's okay. Keep hands clean. Cover the mouth and nose with a tissue when sneezing. Put used tissue in a closed bag and throw it away. Choice B is incorrect. Patients taking isoniazid must continue the drug for six months, regardless of whether symptoms seem to have improved or not. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies, Antitubercular Drugs

You are teaching a student nurse about various types of pain. The student nurse should realize which of the following types of pain are accurately paired with one of their signs or symptoms? Select all that apply. A. Chronic pain: The vital signs are normal. [14%] B. Chronic pain: The sympathetic nervous system is activated. [9%] C. Acute pain: The pulse, blood pressure, and respiratory rate are increased. [25%] D. Acute pain: The parasympathetic nervous system is activated. [7%] E. Somatic pain: A type of neuropathic pain. [11%] F. Somatic pain: Pain sensation originates from the bones, skin, and muscles. [17%] G. Visceral pain: A type of neuropathic pain. [13%] H. Visceral pain: The vital signs are normal [4%]

Explanation Choices A, C, and F are correct. Chronic Pain is characterized by typical vital signs (Choice A), whereas acute pain is characterized by increased pulse, blood pressure, and respiratory rate (Choice C). In chronic pain, pupils can be healthy or dilated, and the client can be withdrawn and depressed. In chronic pain, the parasympathetic nervous system is activated. In acute pain, the sympathetic nervous system is activated. Therefore, the presentation includes the features of sympathetic activation. Pulse, blood pressure, and respiratory rate are increased. The pupils are dilated; the client can be restless and show pain behaviors such as guarding the painful area and crying. Somatic pain originates from the bones, the skin, and the muscles (Choice F) and somatic pain is a type of nociceptive pain, rather than neuropathic pain. It is essential to understand the terminology of pain based on: Onset and duration (Acute pain vs. Chronic pain). Origin (Somatic pain vs. Visceral pain) - The fully functional nervous system transmits messages that a part of the body is damaged. Somatic pain occurs when the damage involves the bones, the skin, and the muscles. Visceral pain occurs when the injury involves the internal organs in the central cavities of the body (also called the viscera). Physical pain may be described as sickening, deep, or dull in quality. In visceral pain, vital signs are increased. Cause of the pain (Nociceptive vs. Neuropathic) Nociceptors are pain receptors present in many parts of the body, including internal organs. Nociceptive pain arises secondary to damage/injury caused to the body part by an external stimulus or condition. This is often acute but may also be chronic. Examples include burns, bee stings, stab wounds, tumors, inflammatory arthritis, etc. Both Somatic and Visceral pain are types of Nociceptive pain. Neuropathic pain is mediated by the nerves and is from damage to the nervous system itself. It may be because of injury secondary to the central or peripheral nervous system from different causes. Examples: Multiple sclerosis, peripheral neuropathy, etc. It may be stabbing, shooting, or aching in nature. This type of pain is often chronic. Choice B is incorrect. In chronic pain, the parasympathetic nervous system, rather than the sympathetic nervous system, is activated. Choice D is incorrect. In acute pain, the sympathetic nervous system, rather than the parasympathetic nervous system, is activated. Choice E is incorrect. Somatic pain is a type of nociceptive pain, not neuropathic pain. Choice G is incorrect. Visceral pain is a type of nociceptive pain, not neuropathic pain. Choice H is incorrect. The vital signs are not normal with visceral pain. They are often increased.

Which of the following statements regarding the anatomy of pediatric patients are true? Select all that apply. A. Pediatric patients have a smaller body surface area compared to adult patients. [33%] B. Pediatric patients have a larger head in proportion to their body. [35%] C. Pediatric patients have enlarged airway passages. [2%] D. Pediatric patients have an immature blood brain barrier. [30%]

Explanation Choices B and D are correct. B is correct. This is correct. Pediatric patients have a more massive head in proportion to their bodies than adults do. When babies are born, their head makes up about 25% of their total length. As they grow, this proportion lessens until the head is about 12% of the overall body height around ten years of age. D is correct. This is correct; pediatric patients have an immature blood-brain barrier. The blood-brain wall is a filtering mechanism built into the blood vessels that carry blood to the brain. They are meant to block out the passage of substances that could be harmful to the brain, but this mechanism is immature in pediatric patients. This means that pediatric patients are more at risk of drugs or toxins entering their circulation, as these could pass into the brain and cerebrospinal column, causing damage. Choice A is incorrect. It is not true that pediatric patients have a proportionally smaller body surface area compared to adult patients. Pediatric patients have a proportionally larger body surface area compared to adult patients. The body surface area is merely the total surface area of the human body. The smaller your patient is, the larger the ratio of surface area to the size of their body is. This means that younger children with proportionally large body surface areas will be more susceptible to medications and drugs that affect or are absorbed through their skin. Choice C is incorrect. Pediatric patients do not have enlarged airway passages; they have smaller airways than adults. Also, pediatric patients have immature lungs. This is why pediatric patients are at risk for respiratory illnesses such as asthma, RSV, and bronchiolitis. NCSBN Client Need: Topic: Health promotion and maintenance; Subtopic: Pediatrics - Development

The nurse is caring for a client who is receiving prescribed olanzapine. Which of the following findings would indicate that the client is having an adverse effect? Select all that apply. A. Weight loss [9%] B. Hyperglycemia [25%] C. Weight gain [22%] D. Hyperlipidemia [23%] E. Nystagmus [19%]

Explanation Choices B, C, are D are correct. Olanzapine is a second-generation antipsychotic (SGA). SGAs such as olanzapine and clozapine have a high risk of causing a client to develop metabolic syndrome. Metabolic syndrome includes hyperglycemia, overweight or obesity, abdominal obesity, hyperlipidemia, and hypertension. Olanzapine and clozapine are implicated in causing some of the worse metabolic effects. Choices A and E are incorrect. Weight loss is not a feature associated with olanzapine. By far, the most common effect associated with olanzapine is weight gain. Nystagmus is not an adverse effect associated with olanzapine. Additional Info Second-generation antipsychotics (risperidone, olanzapine, quetiapine, clozapine, lurasidone, ziprasidone, aripiprazole, brexpiprazole, cariprazine) are commonly utilized in the management of psychotic and some mood disorders. The two pines of olanzapine and clozapine are quite efficacious in psychotic disorders but also have the highest risk of a client developing metabolic syndrome.

A nurse is preparing to administer gentamycin to a child. The order is for 3 mg/kg IV daily in three divided doses. The client weighs 97 lbs. How many milligrams should the nurse administer per dose? Fill in the blank. Round your answer to the nearest whole number. 44 mg

Explanation First, convert the client's weight from pounds to kilograms 97 lbs = 44.1 kg Next, determine the total daily dose for this child 3 mg x 44.1 = 132.3 mg Next, determine the individual dose. Divide the daily dose by 3. 132.3 mg/day / 3 doses/day = 44.1 mg Finally, round the dose to the nearest whole number 44.1 mg = 44 mg Additional Info Gentamycin is a nephrotoxic and ototoxic antibiotic. The nurse must monitor the creatinine while the client is receiving this medication.