Archer Review 8b

A nasogastric tube has been inserted into a client with bowel obstruction for gastric decompression. The nurse should set the suction on which setting? A. Intermittent suction at 70 mmHg [48%] B. Intermittent suction at 100 mmHg [21%] C. Continuous suction at 100 mmHg [11%] D. Continuous suction at 70 mmHg [21%]

Explanation Choice A is correct. Gastric decompression should always be intermittent and at low suction pressure. A suction pressure below 80 mmHg is considered low suction. Choices B, C, and D are incorrect. Continuous and high suction pressure for gastric decompression should be avoided as this predisposes the gastric mucosa to injury and ulceration.

A patient presents with enlarged tonsillar nodes. Acutely infected nodes would be: A. Firm but movable and tender [67%] B. Hard and nontender [11%] C. Fixed and soft [7%] D. Irregular and hard [16%]

Explanation Choice A is correct. Infected lymph nodes are usually tender. Choice B is incorrect. Infected lymph nodes are usually tender. Choice C is incorrect. Lymph nodes are movable. Choice D is incorrect. Lymph nodes are usually not irregular in shape. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Nose, Sinuses, Mouth, and Throat

The nurse is assessing an infant with dark skin for jaundice. The nurse plans on assessing this client's A. hard palate of the mouth. [47%] B. lower back and sacrum. [6%] C. lower legs right below the knee. [2%] D. nail beds. [44%]

Explanation Choice A is correct. The correct technique when assessing an infant (or an adult) with dark skin for jaundice would be to examine the mucous membranes in the mouth, the hard palate, or the sclera. Choices B, C, and D are incorrect. These are not appropriate physical landmarks to assess for jaundice. Additional Info In infants with dark skin, assess the color of the palate and mucous membranes of the mouth and the conjunctivae. Determine the areas of the body affected by jaundice, and document carefully to use for comparison during future assessments. Jaundice begins at the head and moves down the body as the bilirubin level rises.

The nurse is caring for a patient with chronic liver failure who received a live-donor transplant five days ago. She is taking anti-rejection medication and is experiencing headaches and diarrhea associated with the medication. She wants to know how long she will have to take the anti-rejection medication. The nurse tells her that she will take the medication for: A. The rest of her life [70%] B. Until she is discharged from the hospital [2%] C. Six weeks [10%] D. Six months [17%]

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

The nurse is educating a client scheduled for pulmonary function tests. It would indicate effective teaching if the client makes which statement? A. "I should not use my bronchodilator four to six hours before these tests." [64%] B. "I should not eat or drink six to eight hours prior to these tests." [9%] C. "I will need someone to drive me home after I wake up from the anesthesia." [5%] D. "My gag reflex will have to return before I resume eating and drinking." [22%]

Explanation Choice A is correct. Bronchodilator medications are withheld four to six hours prior to the testing. The purpose of holding this medication is to prevent skewing of the results. Choices B, C, and D are incorrect. These statements are incorrect and require follow-up. PFTs do not require a client to be NPO and are non-invasive, so anesthesia is not utilized. PFTs may be performed at the bedside. Additional Info Pulmonary function tests (PFTs) do not require any sedation or invasive machinery and may be done at the bedside. The purpose is to assess lung function and breathing problems. These tests measure lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and ventilation distribution. The results are interpreted by comparing the patient's data with expected findings for age, gender, race, height, weight, and smoking status. Before the testing, the client is instructed to withhold any bronchodilators four to six hours prior, abstain from smoking, and refrain from wearing tight or restrictive clothing.

The nurse is counseling parents concerned about their child experiencing frequent nocturnal enuresis. The nurse should educate the parents to do which of the following? A. Establish and maintain a voiding diary for the child. [84%] B. Discipline the child after each bedwetting episode. [2%] C. Apply diapers or pull-ups routinely at night. [13%] D. Have the child go to bed with a full bladder. [1%]

Explanation Choice A is correct. Establishing a voiding diary/log for the client is an effective strategy as it may track the nights of the enuresis. The amount of enuresis and any precipitating factors should be noted. Choices B, C, and D are incorrect. Disciplining a child for nocturnal enuresis is not an effective strategy as this behavior may be psychologically harmful to the child. A supportive and understanding approach should be taken to manage this condition. Diapers or pull-ups should not be applied as these devices may enable a child to have enuresis and reinforce not waking up. The child should be instructed to empty their bladder before bed. NCLEX Category: Physiological Adaptation Activity Statement: Illness Management Question type: Application Additional Info Nocturnal enuresis usually starts at age five and may continue past age ten. The cause of this is multifactorial and may include genetic predisposition. Behavioral interventions are tried first and include a voiding diary to track the episodes and their frequency, use an enuresis alarm, execute positive reinforcement, and avoid shaming the child. Prescriptive therapies include desmopressin or tricyclic antidepressants such as imipramine.

The nurse is caring for a client who is receiving prescribed varenicline. Which of the following statements would indicate a therapeutic response if made by the client? A. "I am not smoking cigarettes anymore." [42%] B. "My depression has gotten better." [21%] C. "I am sleeping eight hours a night." [18%] D. "I can focus on one task at a time." [19%]

Explanation Choice A is correct. Varenicline is a medication intended to reduce nicotine withdrawal symptoms and cravings. Following the initiation of varenicline, the client's comments that they are not smoking cigarettes anymore indicate varenicline has been therapeutically effective. Clients go back to resuming tobacco smoking if the withdrawal symptoms are not appropriately treated. Choices B, C, and D are incorrect. Varenicline may cause depression and suicidal ideation. It does not therapeutically assist with depressive symptoms, insomnia, or focus. Another medication used for smoking cessation called bupropion assists with depression. Additional Info A combination of medications and behavioral therapy works best for smoking cessation rather than either treatment alone. Most smoking cessation medications work by reducing nicotine withdrawal and craving. Medicines for smoking cessation include nicotine replacement therapy (NRT), varenicline, and bupropion. Varenicline is a preferred option for most patients. Varenicline is administered as an oral pill. It works by relieving nicotine withdrawal symptoms and blocking the smoking-related reward feeling. For a patient taking varenicline, starting the medication one week before quitting cigarettes is recommended. The patient may continue the treatment for up to twelve weeks. The most common side effect of varenicline is nausea. Adversely, neuropsychiatric effects such as vivid dreams, depression, and suicidal ideation have been reported. Varenicline should not be used in patients with a history of suicidal ideation or unstable psychiatric illness. Nicotine replacement therapy (NRT) is available in various forms ( patch, lozenge, gum, inhaler, and nasal spray). NRT may be prescribed as a first-line choice based on the client's preference. Adverse effects include insomnia and vivid dreams. Bupropion is less effective compared to NRT or varenicline. However, it's a preferred choice for patients with depression because bupropion can work as an anti-depressant. Additionally, bupropion promotes weight loss and may be preferred for clients wishing to avoid weight gain following smoking cessation. Bupropion reduces the seizure threshold, and consequently, it is contraindicated in patients with a seizure disorder. Ongoing counseling should be pursued to enhance a patient's success at smoking cessation.

While the nurse uses Nagele's rule to determine the prenatal clients' estimated due date (EDD), they know that their calculations are limited by the fact that they assume: A. Ovulation occurs on day 14 [34%] B. Pregnancy lasts 9 months [26%] C. Amenorrhea is the first sign of pregnancy [20%] D. Cycles are 30 days in length [19%]

Explanation Choice A is correct: Naegele's rule is limited in calculating the EDD as it assumes that all women ovulate around day 14 of their menstrual cycle. Women all vary biologically and may ovulate on varying days within their cycle. Naegele's rule also incorrectly assumes that all women have cycles that last 28 days. Choice B is incorrect: Pregnancy lasts 40 weeks. The term "month" assumes 4 weeks. 9 months would roughly equal 36 weeks. This is not how pregnancy is calculated. The average pregnancy lasts for 282 days which equals 40 weeks. Choice C is incorrect: Naegele's rule in factoring the estimated due date does not have to do with what the first sign of pregnancy was in the woman. Each individual client experiences different pregnancy symptoms. Amenorrhea is not always the first symptom women experience when they become pregnant. What is important to know when calculating Naegele's rule is to know the first day of the last menstrual period. Choice D is incorrect: Naegele's rule is based on a cycle that lasts 28 days, not 30 days. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care Learning Objective Learning Objective: Understand, educate on, and provide antepartum, intrapartum, postpartum and newborn care. Additional Info Source : Archer Library Gestation refers to the amount of time from fertilization of an egg (ovum) until the estimated date of delivery. This term holds true for all mammals. The typical gestation age for a human is 280-282 days. Naegele's rule is utilized to calculate the estimated date of delivery (EDD). Use of Naegele's rule requires that a woman's menstrual cycle only lasts 28 days. Naegele's rule works by subtracting 3 months from the start of the patients last menstrual cycle and then adds 7 calendar days. A year is then added and the user is left with the estimated date of delivery. Here is an example: First day of last menstrual cycle: February 5th, 2022 Subtract 3 months: November 5th, 2021 Add 7 days: November 12th, 2021 Add 1 years: November 12th 2022.

The nurse has instructed a client who is scheduled to have a transesophageal echocardiogram (TEE). Which of the following statements by the client would indicate a correct understanding of the teaching? A. "I will need to take antibiotics for one week following this test." [3%] B. "This test will determine if I have any blood clots in my heart." [36%] C. "I will receive general anesthesia for this procedure." [17%] D. "I may feel a flushing sensation when the contrast dye is given." [45%]

Explanation Choice B is correct. A transesophageal echocardiogram (TEE) is advantageous because of its view of the left atrial appendage, which is the major reservoir for thromboembolism. This test may be done before cardioversion to determine if anticoagulation is necessary. Choices A, C, and D are incorrect. Antibiotics are not necessary before, during, or after this procedure. Moderation sedation is typically utilized for this procedure as the client maintains their airway. Contrast dye is not utilized for this exam as an ultrasound is used to capture images of the heart. Additional information: A TEE is a test completed to visualize the posterior heart valves and chambers. Since the heart sits on top of the esophagus, this allows more direct visualization of the heart. This test is often used to visualize the left atrial appendage to determine if any clots exist prior to cardioversion. An advantage of a TEE compared to a standard echocardiogram is that it is more detailed. This procedure requires informed consent, the client to be NPO, and moderate sedation. NCSBN Client need: Topic: Reduction of Risk Potential; Subtopic: Diagnostic Tests

The nurse assists the code team with an unresponsive and pulseless client. Which intervention does the nurse prepare for based on the electrocardiogram (ECG) tracing? See the image below. A. Prepare an infusion of sodium bicarbonate [1%] B. Administer epinephrine [59%] C. Defibrillation [32%] D. Cardioversion [8%]

Explanation Choice B is correct. Epinephrine is necessary as this arrhythmia reflects asystole. Asystole (also known as ventricular standstill) requires an aggressive treatment consisting of high-quality cardiopulmonary resuscitation (CPR) and intravenous (IV) epinephrine. Epinephrine is necessary as this medication assists with restoring vascular tone. Choices A, C, and D are incorrect. A sodium bicarbonate infusion is not the essential treatment for asystole. While severe acidosis may contribute to life-threatening dysrhythmias, this is not an essential treatment. Defibrillation is the priority treatment in dysrhythmias such as ventricular fibrillation but is not helpful in asystole, considering no underlying rhythm is evident to shock. Cardioversion is an effective treatment for dysrhythmias such as atrial fibrillation and ventricular tachycardia (with a pulse). Additional Info A client with ventricular asystole has no pulse, respirations, or blood pressure. In some cases, the sinoatrial (SA) node may continue to fire and depolarize the atria, with only P waves seen on the ECG. However, the sinus impulses do not conduct to the ventricles, and QRS complexes remain absent. In most cases, the entire conduction system is electrically silent, with no P waves seen on the ECG. Essential treatment for ventricular asystole is high-quality CPR and intravenous (IV) push epinephrine.

The oncoming nurse is receiving a report on a pregnant patient with HELLP syndrome. This nurse knows that HELLP syndrome, a severe progression of preeclampsia stands for: A. Half Eclipsed Lipase Levels and Preeclampsia [10%] B. Hemolysis, elevated liver enzymes, and lowered platelets [83%] C. Hematocrit elevation, low lipase, and pancreatitis [2%] D. Hemoglobin, elevated lipids, and low plasma [5%]

Explanation Choice B is correct. HELLP syndrome stands for Hemolysis, elevated liver enzymes, and low platelets. HELLP syndrome is a condition in which hemolysis of the red blood cells occurs creating elevated liver enzymes and low platelets. Generally, complications are prevented by delivering the fetus as soon as symptoms develop. Choices A, C, and D are incorrect. These are not associated with HELLP syndrome. NCSBN client need Topic: Physiological Adaptations, alterations in body function

The nurse is caring for a client with narcolepsy. Which of the following medications would the nurse anticipate the primary healthcare provider (PHCP) prescribe? A. Aripiprazole [12%] B. Modafinil [47%] C. Ropinirole [13%] D. Quetiapine [28%]

Explanation Choice B is correct. Modafinil is a psychostimulant that is effective in treating narcolepsy. This medication promotes wakefulness and is dosed either once or twice a day. Choices A, C, and D are incorrect. Aripiprazole and quetiapine are atypical antipsychotics and not indicated in the management of narcolepsy. Quetiapine is highly sedating and would be counterproductive in the management of narcolepsy. Ropinirole is a dopaminergic and is indicated in treating Parkinson's disease and restless leg syndrome. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Expected actions/outcomes Question type: Knowledge/comprehension Additional Info Narcolepsy is a syndrome in which a client has significant daytime sleepiness that often lessens after a nap. Stimulants such as modafinil and armodafinil are indicated in the management of narcolepsy as they promote wakefulness. Common side effects of modafinil include headache, nervousness, anorexia, and weight loss.

While working on the pediatric floor, you are assigned a patient with impetigo. Which of the following actions do you take to prevent the spread of this disease? A. Initiate standard precautions [20%] B. Initiate contact precautions [74%] C. Initiate droplet precautions [5%] D. Initiate airborne precautions [1%]

Explanation Choice B is correct. Patients with impetigo need to be placed on contact precautions to prevent the spread of this highly contagious disease. According to the CDC, these precautions are "for patients who may be infected or colonized with specific infectious agents for which additional precautions are needed to prevent infection transmission. Contact precautions will be used for any disease in which direct contact with the infectious organism can cause illness. This includes impetigo and other conditions such as viral gastroenteritis, MRSA, and scabies. Contact precautions will require a gown and gloves before entering the room. Choice A is incorrect. According to the CDC, standard precautions are used for all patient care. They're based on a risk assessment and make use of common-sense practices and personal protective equipment (PPE) use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. Standard precautions include performing hand hygiene, using PPE when there is possible exposure to infectious material, properly cleaning equipment and instruments, and following safe injection practices. For impetigo, standard precautions are not enough. This is a highly contagious disease that will require more precautions. Choice C is incorrect. Droplet precautions are not the appropriate type of precautions for a patient with impetigo. Droplet precautions should be initiated for any patient that has an illness that may be spread through droplet particles. This includes influenza, pertussis, rubella, and many others. Impetigo is transmitted through direct contact with the bacteria on the skin, not through droplet particles. In droplet precautions, a face mask and gloves must be worn to prevent transmission. Choice D is incorrect. Airborne precautions are not the appropriate type of precautions for a patient with impetigo. Airborne precautions should be initiated for any patient that has an illness that may be spread through particles that survive in the air. This type of transmission occurs with diseases such as TB, varicella, and measles. Particular kinds of respirators must be used to prevent transfers, such as an N95 or a PAPR. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological adaptation, Pediatrics - Integumentary

The nurse has received a prescription for tenofovir and emtricitabine. The nurse understands that this medication is used to treat A. multiple sclerosis. [5%] B. human immunodeficiency virus (HIV). [83%] C. Parkinson's disease. [3%] D. Guillain-Barré syndrome.

Explanation Choice B is correct. Tenofovir and emtricitabine are antiretrovirals indicated in the prevention and treatment of HIV infection. This combination of medication aims to decrease the viral load (VL) and increase the CD4/CD8 count. Choices A, C, and D are incorrect. Multiple sclerosis treatment consists of muscle relaxers and interferons. Parkinson's disease is a condition requiring the treatment of dopamine agonists and muscle relaxers. Finally, Guillain-Barré syndrome may respond to treatment options such as plasmapheresis or immunoglobulin. Additional Info Combination antiretroviral therapy (cART) is a robust set of medications intended to lower the viral load (VL) and increase the CD4 and CD8 count in an individual with HIV or AIDS. A primary healthcare provider (PHCP) will likely prescribe a combination regimen to increase the likelihood of response and improve adherence with one pill versus multiple. While a client is taking these medications, creatinine, liver function tests, VL, and CD4/CD8 counts are monitored closely.

Which type of intravenous therapy complication is most likely to occur when the intravenous catheter is too large for the vein that is being used for intravenous therapy? A. Hematoma [20%] B. Mechanical phlebitis [63%] C. Fluid overload [13%] D. Bacterial phlebitis [4%]

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

The nurse caring for a client who has received third-degree burns to his arm notes that he is scheduled for an escharotomy. The nurse plans to keep a close eye out for which of the following anticipated outcomes of this procedure? A. Frank bleeding from the site [32%] B. Reduced edema [6%] C. Return of pulses distal to the site [28%] D. The formation of granular tissue [34%]

Explanation Choice C is correct. Escharotomies are completed to remove eschar, slough, or dead tissue from the skin and to relieve compartment syndrome, which sometimes occurs after severe burns. Health care providers consider these procedures successful when pulses distal to the site return. Choice A is incorrect. While some bleeding is expected after this procedure, frank bleeding is too much bleeding and may indicate a problem or adverse response to the therapy. Choice B is incorrect. This procedure generally does not impact the formation of swelling. Choice D is incorrect. The creation of granular tissue is not the intention of this procedure. NCSBN client need Topic: Physiologic Adaptation, Therapeutic procedures

The nurse in the medical ward just administered 6 units of regular insulin on a client subcutaneously. The nurse understands that after 3 hours, the nurse should monitor the client for which sign? A. Rapid, deep, labored breathing with cold sweats [13%] B. Confusion and lack of appetite [7%] C. Cold sweats and trembling [71%] D. Headache and increased urination [8%]

Explanation Choice C is correct. Regular insulin peaks at about 2 - 4 hours after administration. At this time, the nurse should be alert for signs and symptoms of hypoglycemia, the initial signs of which are cool, clammy skin, cold sweats, and trembling. Choice A is incorrect. Kussmaul respirations indicate hyperglycemia, not hypoglycemia. Choice B is incorrect. These symptoms are not associated with hypoglycemia. Choice D is incorrect. Headache and polyuria would not indicate hypoglycemia; although polyuria may indicate hyperglycemia.

Which focus is the nurse most likely to teach for a client with a flaccid bladder? A. Habit training: Attempt voiding at specific time periods. [13%] B. Bladder training: Delay voiding according to a pre-scheduled timetable. [9%] C. Credé's maneuver: Apply gentle manual pressure to the lower abdomen. [38%] D. Kegel exercises: Contract the pelvic muscles.

Explanation Choice C is correct. Since bladder muscles will not contract to increase intrabladder pressure and promote urination, the process is initiated manually. Overflow incontinence is continuous involuntary leakage or dribbling of urine that occurs with incomplete bladder emptying. It can be seen in men with an enlarged prostate and clients with a neurologic disorder (e.g. Parkinson's disease, spinal cord injury). An impaired neurologic function can interfere with the standard mechanisms of urine elimination, resulting in a neurogenic bladder. The client with a neurogenic bladder does not perceive bladder fullness and is unable to control the urinary sphincters. The bladder may become flaccid and distended or spastic, with frequent involuntary urination. Choices A, B, and D are incorrect. To promote continence, bladder contractions are required for habit training, bladder training, and increasing the tone of pelvic muscles. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Altered Urinary Elimination

The nurse is preparing a staff development conference on milieu therapy. Which of the following information should the nurse include? A. This type of environment is established in inpatient treatment facilities, emphasizing physical well-being. [17%] B. This therapy primarily focuses on helping clients develop emotional connections with individuals in the community. [14%] C. An emphasis of this therapy is the setting, the structure, and the emotional climate as important to the client's healing. [60%] D. The approach to milieu therapy is unstructured and allows clients to self-regulate what they feel should be allowed. [9%]

Explanation Choice C is correct. The cornerstone of milieu therapy is to provide an all-inclusive (staff and clients) structured environment that fosters routine, safety, and acceptance. This environment enables healing and promotes positive outcomes. Choices A, B, and D are incorrect. This type of therapy is not limited to inpatient facilities. This therapy may be established and maintained both inpatient and outpatient. Additionally, milieu therapy is holistic and does not focus just on physical well-being. This therapy aims to provide a safe, structured environment that promotes client healing - not establishing emotional connections with individuals in the community. The approach of the therapeutic milieu is to have structure and consistency that regulates the environment. This allows the client to feel productive, gain self-esteem, and problem solve. Learning Objective Understand that the milieu therapy is an all-inclusive (staff and clients) structured environment that fosters routine, safety, and acceptance. Additional Info Hildegard Peplau referred to the therapeutic milieu as an all-inclusive term that recognizes the people (clients and staff), the setting, the structure, and the emotional climate as essential to healing. Whether the setting involves treating children with psychotic disorders, adult clients in a psychiatric hospital, clients with substance use disorder in a residential treatment center, or clients in a day treatment program. The goal of milieu therapy is to offer clients a sense of security and promotes healing. The nurse can help maintain the therapeutic milieu by Minimizing disruptions in the unit through appropriate client placement Rendering culturally sensitive care Selecting appropriate activities that meet both the physical and mental needs Using the least restrictive environment

You are taking care of a 5-year-old girl on a pediatrics floor at the hospital. While engaging her in conversation, you note that she is using 4-5 words in complete sentences. She can tell you what color her stuffed animals are, and she tells you stories about what the stuffed animals have done today. Knowing the appropriate language development milestones, the nurse should do which of the following? A. Consult the speech language pathologist for evaluation. [7%] B. Notify the health care provider. [3%] C. Continue with your assessment. [68%] D. Engage the child's mother with questions about how the child communicates at home. [22%]

Explanation Choice C is correct. The nurse should continue with her assessment. The nurse has observed several milestones of language development that are normal for a 5-year-old. She should take note of this and continue to assess the child. Other language development milestones that she would expect include: a vocabulary of about 2,100 words, correctly naming objects and people, and knowing their own name and address. Choice A is incorrect. The nurse doesn't need to consult the speech-language pathologist for evaluation. The nurse has observed several milestones of language development that are normal for a 5-year-old. She notes that the child is speaking in complete sentences with a minimum of 4 to 5 words, is correctly naming colors, and is telling stories using fantasy. These are all developmental milestones the nurse would expect in a 5-year-old. Since she does not notice any delays or concerns, consulting the speech-language pathologist is not necessary. Choice B is incorrect. The nurse doesn't need to notify the health care provider. The nurse has observed several milestones of language development that are normal for a 5-year-old. She notes that the child is speaking in complete sentences with a minimum of 4 to 5 words, is correctly naming colors, and is telling stories using fantasy. These are all developmental milestones the nurse would expect in a 5-year-old. Since she does not notice any delays or concerns, it is not necessary to notify the health care provider. Choice D is incorrect. While engaging the child's mother is an essential part of therapeutic communication in the pediatric population, it is not necessary to engage the child's mother with questions about how the child communicates at home. The nurse has observed several milestones of language development that are normal for a 5-year-old and she does not have any concerns about the child's language development. NCSBN Client Need: Topic: Psychosocial Integrity, Subtopic: Pediatrics - Development

A 12-year-old child is scheduled for an appendectomy. The child's mother has already signed the consent form and the child is about to be wheeled by the nurse to the operating room when her father arrives. It is made known to the nurse that the child's parents are divorced and have joint legal custody. Which action by the nurse is most appropriate? A. Have the father sign a new consent form. [13%] B. Cancel the operation. [0%] C. Proceed with the child's operation. [62%] D. Notify the physician. [25%]

Explanation Choice C is correct. The signature of the child's mother is enough to provide consent. Choice A is incorrect. The signature of the child's mother is enough to provide consent. It is unnecessary to ask the father sign a new consent form. Choice B is incorrect. The signature of the child's mother is enough to provide consent. The surgery can proceed and there is no reason to cancel it. Choice D is incorrect. There is no need to contact the physician.

Your client has an order for one unit of packed red blood cells (PRBCs). One of the other nurses picked the blood up from the blood bank at 11 AM. You began the blood transfusion at noon after completing all of the safety, client identification, and preparation procedures. At what time should this unit of packed red blood cells be completely infused? A. 1 PM [11%] B. 2 PM [14%] C. 3 PM [41%] D. 4 PM [33%]

Explanation Choice C is correct. This unit of packed red blood cells must be infused entirely by 3 PM, which is 4 hours after this unit of packed red blood cells was picked up from the blood bank. This time limit prevents degradation and damage to the red blood cells. Choice A is incorrect. Although this unit of packed red blood cells must be infused entirely by a certain number of hours after this unit of packed red blood cells was picked up from the blood bank, this time is more than 2 hours. Choice B is incorrect. Although this unit of packed red blood cells must be infused entirely by a certain number of hours after this unit of packed red blood cells was picked up from the blood bank, this time is more than 3 hours. Choice D is incorrect. Although this unit of packed red blood cells must be infused entirely by a certain number of hours after this unit of packed red blood cells was picked up from the blood bank, this time is less than 5 hours.

The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question? A. Furosemide for a client with hyperparathyroidism [31%] B. Methimazole for a client with hyperthyroidism [12%] C. Hydrocortisone for a client with diabetes insipidus [44%] D. Prazosin for a client with pheochromocytoma

Explanation Choice C is correct. Treatment for diabetes insipidus includes medications such as desmopressin, thiazide diuretics, and anti-inflammatories. Hydrocortisone is a short-acting corticosteroid and is indicated in the treatment of adrenal insufficiency. This requires follow-up because DI is not treated with hydrocortisone. Choices A, B, and D are incorrect. Hyperparathyroidism causes hypercalcemia, and the treatment for hyperparathyroidism is a combination of 0.9% saline infusion followed by furosemide. Hyperthyroidism requires antithyroid medications such as methimazole or propylthiouracil. The classic manifestation of pheochromocytoma is hypertension, and treatment of this condition involves antihypertensive such as prazosin, an alpha-adrenergic blocker. Additional Info Diabetes insipidus may be central (problem with the pituitary gland secreting antidiuretic hormone) or nephrogenic (resistance at the ADH site of action in the collecting tubules). The major symptoms of central diabetes insipidus (DI) are polyuria, nocturia, and polydipsia due to the concentrating defect. In treating central DI, desmopressin is utilized and can be administered either intranasally or by tablet.

The nurse is caring for a married 31-year-old second-time pregnant female. Her first child is 4-years-old who was born vaginally and is considered to be a healthy preschooler. The patient explains that she's worried that her newborn child will be born with cystic fibrosis because her sister's daughter has it. What information about this genetic condition should the health care provider share? A. Her child is at an extremely high risk for passing cystic fibrosis to her child. [4%] B. Her child is not at risk for developing cystic fibrosis. [11%] C. While it is unlikely that this child will be born with cystic fibrosis, genetic testing may relieve some of the distress. [84%] D. She needs to adjust her diet in order to prevent passing on the medical condition. [1%]

Explanation Choice C is correct. While it is unlikely that this child will have cystic fibrosis, genetic testing can provide more information. Carrier testing may be recommended for people with a family history of this genetic disorder. Cystic fibrosis is an inherited autosomal recessive disorder that only appears in an infant whose parents have the mutated gene. Choice A is incorrect. There is not enough evidence to tell the patient that her child is at high risk for developing cystic fibrosis. Choice B is incorrect. There is not enough information to say that this child will not be born with cystic fibrosis. Choice D is incorrect. Her diet is irrelevant in regards to whether or not she will pass cystic fibrosis to her child.

The nurse is interviewing a client in the clinic looking to establish care. The nurse determines the client is demonstrating altruism by A. justifying illogical ideas, actions, or feelings by developing acceptable explanations. [30%] B. reverting to an earlier, more primitive, and childlike pattern of behavior. [12%] C. channeling anger from an unacceptable activity to one that is acceptable. [10%] D. a largely unconscious motivation to feel caring and concern for others. [48%]

Explanation Choice D is correct. Altruism is generally a positive defense mechanism that, when utilized appropriately, causes an individual to feel caring and concern for others and act for the well-being of others. Although this defense mechanism is generally regarded as a positive one, it may be maladaptive if a client threatens the health or safety of themselves or others (for example, a client adopts several stray animals, but it threatens the health of others in the household). Choices A, B, and C are incorrect. Justifying illogical ideas, actions, or feelings by developing acceptable explanations is the definition of rationalization. Reverting to an earlier, more primitive, and childlike pattern of behavior refers to regression. Finally, sublimation is channeling anger from an unacceptable activity to one that is acceptable. Additional Info Adaptive use of defense mechanisms helps people to lower their levels of anxiety and to achieve their goals in acceptable ways. Maladaptive use of defense mechanisms occurs when one or several are used to excess, particularly immature defenses. Most defense mechanisms can be used in both healthy and unhealthy ways. People generally use a variety of defense mechanisms but not always to the same degree.

The nurse is paired with an LPN in the pediatric unit. A four-month-old infant with a temporary colostomy is being discharged today. What is the most appropriate action of the nurse and the LPN? A. The LPN completes the discharge instructions to the mother. [1%] B. The LPN demonstrates to the mother how to irrigate the child's colostomy. [16%] C. The LPN gives the mother the child's medications, instructions on how to administer them, and explains the purpose of the medications. [5%] D. The LPN is tasked by the nurse to remove the child's IV catheter. [78%]

Explanation Choice D is correct. The LPN can remove the child's IV catheter and perform other routine tasks. Choice A is incorrect. The LPN cannot provide discharge instructions. It is not within their scope of practice. Choice B is incorrect. Demonstrating how to irrigate a colostomy to the mother constitutes discharge teaching. The LPN cannot provide discharge instructions and education. It is not within their scope of practice. Choice C is incorrect. Providing medication education and instruction to the mother constitutes discharge teaching. The LPN cannot provide discharge instructions and teaching. It is not within their scope of practice.

Which screening tool would you use to screen clients for their current nutritional status? A. The Klein-Bell Scale [19%] B. The Barthel Index [31%] C. The Wong-Baker Assessment tool [21%] D. The Patient Generated Subjective Global Assessment [29%]

Explanation Choice D is correct. The Patient-Generated Subjective Global Assessment is a screening tool you would use to screen clients for their current nutritional status. The Patient-Generated Subjective Global Assessment, referred to as the PG-SGA nutritional assessment, is an assessment tool that can be used to assess nutritional status, among others, such as the Nutritional Screening Initiative screening and assessment tool. Choice A is incorrect. The Klein-Bell Scale is used to perform a neurological and musculoskeletal assessment, not a nutritional screening or evaluation. Choice B is incorrect. The Barthel Index is used to perform a neurological and musculoskeletal assessment, not a nutritional screening or evaluation. Choice C is incorrect. The Wong-Baker assessment tool is a pain assessment tool, not a nutritional screening or assessment tool.

You are reinforcing counseling for two parents that are preparing for the birth of their first child. The mother has sickle cell anemia. So the father has decided to undergo genetic testing to determine if he is a carrier or not. He finds out that he is not a carrier. You tell them that their baby has what chance of having sickle cell anemia? A. 25% [36%] B. 50% [35%] C. 75% [3%] D. 0% [26%]

Explanation Choice D is correct. The baby has no chance, a 0% chance of having sickle cell anemia. Instead, the baby will be a carrier. Since the baby's mother has the disease, she is ss, and because the father has tested that he is not a carrier nor does he have the disease, he is SS. This means that the only combination possible for the baby is Ss (carrier). Choice A is incorrect. The baby does not have a 25% chance of having sickle cell anemia. Choice B is incorrect. The baby does not have a 50% chance of having sickle cell anemia. Choice C is incorrect. The baby does not have a 75% chance of having sickle cell anemia. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Risk of the potential reduction; Pediatrics - Hematology

The nurse is caring for a post-stroke client when suddenly she notes that the client has a fixed and dilated pupil. What would be the most appropriate action by the nurse? A. Reduce environmental stimuli. [4%] B. Reassess after ten minutes. [1%] C. Check the client's blood pressure. [25%] D. Notify the physician.

Explanation Choice D is correct. The client is manifesting signs of increased intracranial pressure. This situation warrants immediate medical intervention to decrease the ICP. The nurse needs to notify the physician immediately. Choice A is incorrect. A fixed and dilated pupil signifies an increase in ICP. Reducing environmental stimuli is not an appropriate intervention at the time. Choice B is incorrect. There is no need to reassess after ten minutes as this warrants immediate attention from the healthcare team. Choice C is incorrect. Checking the client's blood pressure is unnecessary.

A patient presents to the emergency department with pinpoint pupils, poor attention, and slurred speech. Upon assessment of vitals, the patient is found to have a BP of 92/60 mmHg, HR 58, RR 14, and T 96.8 degrees F. Which substance is this patient's intoxication most likely related to? A. Alcohol [24%] B. Cannabis [7%] C. Cocaine [23%] D. Opiates [46%]

Explanation Choice D is correct. The patient is showing signs of opiate intoxication. Opiate intoxication is characterized by pinpoint pupils, slurred speech, inattention, lethargy, psychomotor retardation, and impaired memory, judgment, and social function. Changes to vitals include hypotension, decreased heart rate, reduced temperature, and lower respiratory rate. Choice A is incorrect. Alcohol intoxication is characterized by unsteady gait/balance, nystagmus, flushed face, sedation, impaired judgment, uninhibited behavior, talkativeness, slurred speech, impaired memory, and irritability. Choice B is incorrect. Cannabis intoxication is characterized by reddened eyes, increased heart rate, dry mouth, hunger, loss of coordination/balance, relaxed mood, increased perceptions, social withdrawal, and paranoia. Choice C is incorrect. Cocaine intoxication is characterized by pupil dilation, increased or decreased heart rate and blood pressure, chills, nausea/vomiting, sweating, pacing, psychomotor agitation, visual or tactile hallucinations, and hyper-vigilance. NCSBN Client Need Topic: Pharmacology, Subtopic: Chemical and other dependencies/substance use disorder, high-risk behaviors, lifestyle choices

The nurse is caring for a client newly admitted to the mental health unit with bulimia nervosa. Which client statement requires immediate follow-up? A. "These sores in my mouth hurt." [2%] B. "When can I weigh myself?" [1%] C. "I hate my life and wish it was over." [74%] D. "I feel really dizzy right now." [23%]

Explanation Choice D is correct. The physical needs of the client with a mental health disorder prioritize over psychosocial needs. The client experiencing dizziness is highly concerning because this could be suggestive of severe dehydration or other electrolyte imbalances. Choices A, B, and C are incorrect. Dental caries, sores in the oral mucosa, electrolyte disturbances, dehydration, irregular menses, and calluses on the fingers are all manifestations associated with bulimia nervosa. A client expressing self-negating statements requires follow-up but does not prioritize over the client endorsing dizziness. Additional Info Maslow's Hierarchy of Needs signifies that physical needs must be assessed and cared for first before psychological needs can be satisfied. Thus, the priority is to take care of the client's physical need of dizziness as this is a manifestation associated with significant dehydration.

The nurse working with geriatric clients understands that falls are likely to occur in elderly patients who are: A. Living on disability insurance [4%] B. In their 80s [22%] C. Living in their own home [45%] D. Hospitalized [29%]

Explanation Choice D is correct. Unfamiliar surroundings is a significant risk factor for falls, especially in the elderly. The hospitalized patient may become confused or bump into furniture, which could result in a fall. Age-related changes may affect the mobility and safety of older adults. For example, decreased muscle strength, reduced balance, and osteoporosis put older adults at risk for falls and fractures. For health promotion, the nurse assesses the musculoskeletal functioning of the older adult and identifies any risk factors that may contribute to falls or the ability of the older adult to perform ADLs. Health promotion interventions often include providing information about the risk factors for osteoporosis and the importance of adequate intake of calcium and vitamin D. Choice A is incorrect. An individual's source of income has no bearing on the risk of falls. Choice B is incorrect. While age-related changes may cause weakness and a slowed reflex response, age is not the most likely risk factor for falls among the available answer choices. Choice C is incorrect. An elderly client living in his own home will be less likely to fall than a client who is in unfamiliar surroundings. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control, Physiological Aging

Which of the following is true regarding therapeutic communication with infants (1 month to 12 months)? Select all that apply. A. They use crying as a means for communication and you should take their crying seriously. [36%] B. They are able to comprehend 5-10 words at this age. [5%] C. They respond to touch and therefore patting and rubbing are effective calming methods. [39%] D. They respond better to a low-pitched voice. [19%]

Explanation Choices A and C are correct. At this age, most communication is still nonverbal. Infants use crying as a means for discussion and therefore you should take their crying seriously (Choice A). Infants are very responsive to touch. Patting, rocking, stroking, cuddling, and rubbing them are effective ways to calm them down. Therapeutic communication with an infant will be less focused on the actual words you say and more focused on how you interact with them to create a therapeutic environment (Choice C). Choice B is incorrect. Infants are not yet able to comprehend words. They will be attentive to your voice and other sounds, but they are not, however, prepared to understand what anyone is saying. Therefore trying to explain or rationalize something with them will be ineffective. Instead, you are just speaking to gain their attention and create interaction. Choice D is incorrect. A nursing strategy for therapeutic communication with infants is to speak in a high-pitched voice, not a low-pitched voice. The theory is that infants respond better to high-pitched voices because they sound more like their mothers and are soothed by this. NCSBN Client Need Topic: Effective, safe care environment, Subtopic: Coordinated care; Pediatric Development

The nurse is teaching a parenting class on car seat safety. Which statements should the nurse include? Select all that apply. A. "Place the car seat rear-facing in the back seat and at 45 degrees." [40%] B. "Place the car seat rear-facing in the front seat with the airbag disabled." [2%] C. "Infants should ride in a rear-facing, in the back seat, until six months." [19%] D. "Rolled blankets may be needed between the crotch and legs to prevent slouching." [21%] E. "You may add padding underneath the infant to increase their comfort." [18%]

Explanation Choices A and D are correct. It is appropriate to advise the parents to keep the car seat rear-facing at a 45-degree angle to prevent slumping and airway obstruction. It is also appropriate for the nurse to recommend that Rolled blankets and towels may be needed between the crotch and legs to prevent slouching and can be placed along the sides to minimize lateral movements. Choices B, C, and E are incorrect. The car seat should be rear-facing in the back seat of the car. The infant or toddler should never be positioned in the passenger seat. Infants and toddlers should also utilize the car seat until two years old or until they reach the highest weight or height recommended by the car seat manufacturer. Padding should not be added to the car seat as slack in the harness, leading to the possibility of the child's ejection from the seat in the event of a crash. Additional Info When counseling a client about car seat safety, the nurse should provide the following information - Parents should not place an infant in the front seat of a car with a passenger-side airbag. Infants and toddlers should ride in a rear-facing child safety seat in the car's back seat until age two years or until they reach the highest weight or height recommended by the car seat manufacturer. Rolled blankets and towels may be needed between the groin and legs to prevent slouching and can be placed along the sides to minimize lateral movements. Placing the infant in a safety seat at a 45-degree angle will prevent slumping and airway obstruction. Padding is never placed underneath or behind the infant because it creates slack in the harness, leading to the possibility of the child's ejection from the seat in the event of a crash.

The nurse is caring for assigned clients. The nurse should recognize that the client at risk for hypoglycemia includes which of the following? Select all that apply. A. A client with diabetic ketoacidosis receiving continuous regular insulin intravenously. [27%] B. A client receiving methylprednisolone for an exacerbation of asthma. [5%] C. A client with pancreatitis and is receiving total parenteral nutrition (TPN). [7%] D. A client who is nothing by mouth (NPO) status following a coronary artery bypass graft (CABG). [27%] E. A client who received six units of lispro insulin one hour ago and has not eaten. [33%]

Explanation Choices A and E are correct. A client with diabetic ketoacidosis (DKA) receiving regular insulin intravenously is at significant risk for hypoglycemia because regular insulin (given intravenously) peaks within fifteen to thirty minutes. This is the reason for the client to have their glucose taken every hour. Lispro insulin is a rapid-acting insulin, and if the client has not eaten within ten to fifteen minutes of getting the insulin, they run the risk of hypoglycemia. Choices B, C, and D are incorrect. Methylprednisolone is a corticosteroid that causes hyperglycemia. This client would need more aggressive glucose control while they are receiving this medication. TPN may cause hyper- or hypoglycemia; however, the risk of hyperglycemia is much higher, especially if the client has pancreatitis. The client who has had a CABG will likely have hyperglycemia because of the stress associated with the surgery. It will be important for the client to have good post-operative glucose control as it is associated with better outcomes. Additional Info Hypoglycemia may be caused by - Inappropriate dosing of insulin or antidiabetic medications such as glipizide Insulin and mealtime mismanagement (example - rapid-acting insulin given when the client is NPO or given too early prior to a meal) Inappropriate dosing of insulin Exercise or the consumption of alcohol

The nursing instructor is supervising a nursing student feeding a client at risk for aspiration. Which action by the nursing student requires follow-up by the nursing instructor? Select all that apply. A. Instructs the client to tilt the head backward when drinking. [38%] B. Reminds the client to assume a chin-down position. [18%] C. Provides rest periods as needed during the meal. [7%] D. Positions the client upright for 30-60 minutes after a meal. [9%] E. Positions the head of the bed at a 45-degree angle during the meal. [29%]

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

You are caring for a young woman who is pregnant for the first time. Common possible complications you should inform her about include: Select all that apply. A. Anemia [31%] B. Mood changes [27%] C. Hypotension [10%] D. Nausea and vomiting [32%]

Explanation Choices A, B, and D are correct. Possible complications during pregnancy include anemia, mood changes, and nausea/vomiting. Anemia is typically caused by dilution of red blood cells as blood volume increases. Depression usually occurs after birth and is often called postpartum depression or "baby blues." However, as hormones change during pregnancy, the mother-to-be can experience mood changes. Nausea and vomiting usually occur during the first trimester as a result of increasing levels of human chorionic gonadotropin (HCG). This "morning sickness" is thought to be a sign of a healthy pregnancy during the first three months, but when the vomiting is persistent and prolonged, it can result in hyperemesis gravidarum. This condition may require intervention to prevent weight loss and dehydration. Choice C is incorrect. Pregnancy often leads to hypertension rather than hypotension. NCSBN Client Need Topic: Physiological Adaptation, Subtopic: Alterations in Body Systems, Antepartum

A nurse is reviewing prescriptions for assigned patients. Which prescriptions require follow-up with the primary healthcare provider? A client with Select all that apply. A. congestive heart failure prescribed diltiazem. [18%] B. hypertension prescribed clonidine. [9%] C. diabetes insipidus prescribed hydrocortisone. [25%] D. pulmonary emboli prescribed clopidogrel. [13%] E. atrial fibrillation prescribed amiodarone. [10%] F. bacterial cystitis prescribed valacyclovir. [25%]

Explanation Choices A, C, D, and F are correct. A client with congestive heart failure should not be prescribed calcium channel blockers because of their negative inotropic effects, which would worsen heart failure. Further, hydrocortisone would be indicated to treat adrenal insufficiency, whereas vasopressin would be used for diabetes insipidus. Additionally, clopidogrel is an antiplatelet medication used to prevent stroke, whereas a client with a pulmonary embolism requires anticoagulants or thrombolytics. Finally, antibiotics such as ceftriaxone are indicated for bacterial cystitis, not antivirals such as valacyclovir. Choices B and E are incorrect. Clonidine is an antihypertensive used to treat hypertension and psychiatric conditions such as attention deficit hyperactivity disorder. Finally, amiodarone is a drug that may be used for atrial fibrillation. Additional Info The mainstay of treatment for congestive heart failure is ACE inhibitors and diuretics. The client should avoid any agents that could worsen heart failure, such as NSAIDs and calcium channel blockers.

Which of the following signs and symptoms are indicative of cystic fibrosis? Select all that apply. A. Steatorrhea [30%] B. Hypernatremia [17%] C. Meconium ileus [21%] D. Salty sweat [32%]

Explanation Choices A, C, and D are correct. A is correct. Steatorrhea is a symptom of CF. Steatorrhea is fatty, frothy stools. This is due to the malabsorption of fat. In CF, the body produces thick, sticky mucus that clogs up the body. The body is unable to absorb many things, including fat. Due to this, fat passes through the digestive tract without being absorbed and is excreted in the form of steatorrhea. C is correct. Meconium ileus is a symptom of CF. It is often the first sign of CF in an infant. Meconium ileus is when a newborn is unable to pass their first stool (meconium). In CF, this is because the thick, sticky mucous has clogged up the body and made it difficult for the infant to pass their first stool. D is correct. Salty tasting sweat is a symptom of CF. These children lose a large amount of sodium in their sweat, making their sweat taste salty. It puts them at risk for hyponatremia and is one of the first things parents might notice about their infant born with CF. Choice B is incorrect. CF patients are at risk for hyponatremia, not hyper. This is due to sweating excessive amounts of sodium out of their body. They lose so much sodium in their sweat that they have low serum sodium levels (hyponatremia). NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatrics - Respiratory

A client with a stroke is prescribed alteplase. The prescription is for 0.9 mg/kg. The client weighs 257 pounds. What is the total dose in milligrams (mg) that the client will receive? Round your answer to the nearest whole number. Fill in the blank. 105 mg

Explanation The first step is to convert the client's weight from pounds (lbs) to kilograms (kg) 257 lbs → 116.81 kg Next, multiply the prescribed dosage by the client's weight 0.9 mg x 116.81 kg = 105.129 mg Finally, take the answer and round it to the nearest whole number 105.129 mg = 105 mg The maximum dosage of alteplase is 90 mg. Thus, the nurse would only deliver this prescribed amount. However, when calculating the problem, it is essential to ascertain the dose for mg/kg first. Additional Info Alteplase is a thrombolytic indicated in the treatment of an ischemic stroke. To administer alteplase, the nurse must ensure that all invasive procedures are completed before the infusion to avoid bleeding. Two peripheral vascular access devices are needed, along with close monitoring of the client's vital signs and neurological status.

The primary healthcare provider (PHCP) prescribes 500 mL of 0.45% saline to be administered over one hour. The drop factor is 10 gtts/mL. The nurse sets the flow rate at how many drops per minute? Round your answer to the nearest whole number. Fill in the blank. gtts/minute

Explanation To solve this problem, the nurse will use the formula of total volume x drop factor / time in minutes First, take the prescribed volume and multiply it by the drop factor 500 mL x 10 gtt = 5000 mL Next, divide the total volume by the minutes 5000 mL / 60 minutes = 83 gtts/min Finally, perform appropriate rounding (if needed) Additional Info 0.45% saline is a hypotonic solution and is utilized to treat intracellular dehydration.

The nurse has just finished assisting the physician in applying a fiberglass cast to a client with a severe ankle sprain. The client inquires about the length of time to wait to walk on the cast. How much time will the nurse instruct the client to wait until walking again? A. 8 hours [14%] B. Half an hour [34%] C. After 24 hours [33%] D. After 48 hours [19%]

Explanation Choice B is correct. A fiberglass cast fully dries within 30 minutes (half an hour) of application. The client can walk (bear weight) on it if allowed by the physician after 30 minutes. Choices A, C, and D are incorrect. The client may bear weight (if permitted by the physician) on the cast once it is fully dry. A synthetic (fiberglass) cast fully dries after 30 minutes. A plaster cast takes 2-3 days to completely dry.

A patient has been on bed rest for a week after a fractured left hip. Which of the following symptoms, if noted in the patient, would be considered signs of complications due to immobility? Select all that apply. A. An area of the patient's sacrum is unable to be blanched. [25%] B. The skin has a faint yellow tinge. [11%] C. Crackles in the bases of the patient's lungs. [28%] D. Pain, swelling, and tenderness in the left calf. [30%] E. Using the bedpan to void. [4%] F. The patient's blood sugar is 79. [2%]

Explanation Choices A, C, and D are correct. A patient who has been on bedrest will begin to experience complications such as atelectasis, bedsores, and DVTs unless attended to by nursing staff. Choices B and F are incorrect. Liver function and blood sugar are not affected by immobility. Choice E is incorrect. The patient using a bedpan to void, rather than experiencing incontinence, is not a complication of immobility. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential

When assessing a client who has been ordered skeletal traction, the findings reveal her foot is pale, cold, and her pulse is not palpable. What is the priority nursing intervention? A. Reassess the foot in twenty minutes [1%] B. Readjust the traction [5%] C. Administer the ordered PRN medication [0%] D. Notify the physician [94%]

Explanation Choice D is correct. The symptoms indicate circulatory impairment. The physician (or practitioner) must be notified immediately. Choice A is incorrect. Although reassessment is essential, any sign of impairment should be addressed immediately. Choice B is incorrect. While readjustment of traction may be necessary, the signs of circulatory impairment are of utmost importance. Choice C is incorrect. The administration of pain medication will not resolve the issue of circulatory impairment and it is not the first nursing action that should be taken. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation - Musculoskeletal Impairment

When caring for an infant during cardiac arrest. Which pulse must be palpated to determine cardiac function? A. Carotid [21%] B. Brachial [72%] C. Pedal [4%] D. Radial [3%]

Choice B is correct. The brachial pulse is the most accessible pulse on an infant and, therefore, it is the site of choice. Accurate assessment of heart rate, breathing, and color is an essential part of infant resuscitation, and the guidelines state that heart rate may be assessed using a stethoscope, or palpating the umbilical, brachial, or femoral pulses. Choice A is incorrect. The carotid pulse may be difficult to palpate due to the fatty tissue that typically, and often, surrounds an infant's neck. Choice C and D are incorrect. The radial and pedal pulses may not be reliable indicators of cardiac function. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation

The nurse is caring for a client who has a prescription for vancomycin 1.5 grams. The nurse is to give the medication over two hours. How many mL/hr should the nurse administer when mixed in 500 ml of normal saline? A. 200 ml/hr [3%] B. 250 ml/hr [78%] C. 0.75 ml/hr [10%] D. 333 ml/hr [9%]

Explanation Choice B is correct. To solve this problem, the nurse should divide the volume on hand (500 ml) by the number of hours that it should be infused (2). Choices A, C, and D are incorrect. The other choices do not reflect the answer if the formula of volume/time (in hours) is followed. Additional Info To solve IV fluid calculation problems for mL/hr, divide the volume by the number of hours it is to be infused. The dosage (mg) is not relevant to solving this problem. Volume Time (hours) = mL/hr

The nurse is reviewing prescriptions for assigned patients. Which medication should the nurse question being incorrectly prescribed? A. Albuterol via nebulizer for a patient with hypokalemia. [65%] B. Clozapine for a patient with severe schizophrenia. [3%] C. Lisinopril for a patient with congestive heart failure. [10%] D. Verapamil for a patient with migraine headaches. [22%]

Explanation Choice A is correct. Albuterol is a bronchodilator that is used for asthma exacerbations. Adversely, this medication may lower serum potassium levels. The nurse should question this order as this medication may decrease the potassium further. Choices B, C, and D are incorrect. Clozapine is an atypical antipsychotic used in the treatment of severe schizophrenia. Lisinopril is an ACE inhibitor indicated for heart failure and hypertension. Verapamil is commonly used as prophylaxis for migraine headaches; this medication may also be used for individuals with hypertension. Additional information: Albuterol is a short-acting bronchodilator. Common side-effects associated with albuterol include tremor, tachycardia, palpitations, and metabolic disturbances such as hypokalemia and hyperglycemia. This medication is emergently indicated for asthma exacerbations.

The mother of a 2-month-old infant brings her child to the outpatient clinic due to fever. The mother tells the nurse that her child had a DPT injection the week prior. She asks the nurse if the temperature is because of the DPT injection. What would be the nurse's most appropriate response? A. "The fever after a DPT injection usually occurs within the first 2 hours of immunization." [12%] B. "Fever is very rare in a child after a DPT immunization." [2%] C. "Fever after the DPT injection is usually low-grade and appears within the first 2 days." [80%] D. "The child's fever should be treated."

Explanation Choice C is correct. Fever after a DPT (Diptheria, tetanus toxoids, and pertussis) injection is low-grade and is expected within 24-48 hours. Choice A is incorrect. Fever after a DPT injection is low-grade and is expected within 24-48 hours. Choice B is incorrect. Fever after a DPT injection is low-grade and is expected within 24-48 hours. Choice D is incorrect. The fever should be reported to the physician so that an antipyretic is prescribed.

Which of the following findings would lead you to suspect non-accidental trauma in your 1-year-old burn victim patient? Select all that apply. A. Scalding on the anterior trunk [20%] B. Circumferential burns on the feet [31%] C. Same thickness of skin damage throughout the burn [24%] D. Burns to the soles of the feet [24%]

Explanation Choices B and C are correct. B is correct. Circumferential burns on the feet would lead you to suspect non-accidental trauma in a 1-year-old. As a mandatory reporter, you are required to report these suspicions. Circumferential burns are full-thickness burns affecting the entire circumference of an area. They are very dangerous and can cause serious complications. In this case, it is unlikely a one-year-old could inflict a circumferential burn of the feet to themselves accidentally. This burn pattern can be caused by holding the child's feet in scalding water. C is correct. A burn that has the same thickness of skin damage throughout the burn is suspicious for non-accidental trauma. In an accident where something such as boiling water was spilled, the water will cool as it moves and leaves different levels of tissue damage in different areas. Likewise, if the child splashes in a bathtub with water that is too hot, areas will be affected differently. If the burn has the same thickness of skin damage throughout, it is suspicious for being non-accidental. Choice A is incorrect. It is more likely for a 1-year old to spill something on their anterior trunk accidentally. If they pull down on anything, such as a pot on the stove, it can spill onto their torso and burn them. Burns on the posterior surface of a one-year-old would be suspicious for non-accidental trauma. Choice D is incorrect. Burns to the soles of the feet are not necessarily a concern for non-accidental trauma. The child could have stepped onto something hot causing the burns accidentally. Areas of suspicion should include the back, buttocks, inside of the thighs, and genitalia. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatrics - Integumentary

The nurse is assessing a patient who has come to the emergency department after a motor vehicle accident. The ECG shows the patient is in sinus tachycardia and the nurse assesses a blood pressure of 132/88 mmHg. The patient complains of chest pain which is not relieved by nitroglycerin. Which diagnosis would the nurse suspect? A. Blunt cardiac injury [44%] B. Open pneumothorax [9%] C. Cardiac tamponade [35%] D. Cor pulmonale [11%]

Explanation Choice A is correct. The most common cause of blunt cardiac injury include motor vehicle accidents, falls, and direct blows to the chest, due to the force of either the sternum or thoracic vertebrae. Chest pain that is not relieved by nitroglycerin suggests that the patient may have a sternal or other types of fractures. The symptoms of tachycardia and hypertension support a diagnosis of blunt cardiac trauma or injury. The highest priorities for the patient with suspected blunt cardiac trauma are continuous ECG monitoring, assessment of troponin levels, prevention or treatment of heart failure, as well as fluid and electrolyte monitoring. Choice B is incorrect. An open pneumothorax is typically the result of penetrating trauma, such as a stab wound. Signs of an open pneumothorax include dyspnea, hypotension, chest and shoulder pain, as well as tracheal deviation. Choice C is incorrect. Cardiac tamponade describes a progressive accumulation of blood in the pericardial sac that compresses the heart chambers. Signs of cardiac tamponade include neck vein distention, muffled heart sounds, and hypotension. Choice D is incorrect. Cor pulmonale describes enlargement of the right ventricle which can lead to heart failure. Signs of cor pulmonale include a chronic, wet cough, dyspnea, tachypnea, edema, weakness, and fatigue.

The RN performs palpation and percussion in a head-to-toe assessment. Over what organ would he/she expect to hear tympany when percussed? A. Stomach [58%] B. Liver [16%] C. Normal lung tissue [13%] D. Tympany is an abnormal finding [13%]

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

Risk factors for nose, sinus, mouth, and throat problems include: A. Smoking, allergies, and high blood cholesterol [23%] B. The use of topical decongestants, smoking, and allergies [70%] C. High blood cholesterol, topical decongestant use, and allergies [2%] D. High blood cholesterol, topical decongestant use, and smoking

Explanation Choice B is correct. Risk factors specific to this area include topical decongestant use, smoking, inhaling substances and chemicals, allergies, and dust exposure. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Nose, Sinuses, Mouth, and Throat

The nurse is caring for a client receiving a continuous infusion of heparin and warfarin. Based on the client's laboratory data, the nurse should take which action? See the image below. A. Document the findings [22%] B. Stop the heparin infusion [63%] C. Hold future doses of the warfarin [6%] D. Obtain a prescription of Vitamin K [8%]

Explanation Choice B is incorrect. The heparin infusion should be stopped because the aPTT is too prolonged. The goal for a client receiving a continuous infusion of heparin is to prolong the control (baseline) aPTT 1.5 to 2.5 times. The normal aPTT is 30-40 seconds. Heparin has a short half-life, so even if the heparin infusion were paused for thirty minutes, this would lower the aPTT. The nurse should refer to the PHCP's order to determine the next course of action after the infusion is paused/stopped. Choices A, C, and D are incorrect. The INR is therapeutic and requires no action on the nurses' part. The aPTT is not within normal limits and requires the nurse to act and not document the findings. Additional Info Intravenous heparin is typically administered as a bolus dose first, then as a continuous infusion to achieve therapeutic aPTT. A baseline aPTT should be collected 6 hours after the first dose and 6 hours following any dose adjustments. The goal is to prolong the aPTT from 1.5 to 2.5 times the control value. The normal aPTT value is 30-40.

The nurse is caring for a client with a diagnosis of stroke. The client has stage I dysphagia. Which food should the nurse feed the client? A. Peeled, ripe peaches [8%] B. Peas, squash, and cooked carrots [21%] C. Puréed meat and egg yolks [66%] D. Pies, cakes and ice cream [4%]

Explanation Choice C is correct. A client with stage I dysphagia has severe difficulty in swallowing. They must be fed with puréed foods. These include puréed fruits and vegetables, purréed meats with gravy, egg yolks, and baby food. Choice A is incorrect. A client with stage I dysphagia has severe difficulty in swallowing. Peaches require the client to control food in their mouths and cannot be given to this client. Choice B is incorrect. Peas, squash, and cooked carrots are foods that can be given to a client with stage III dysphagia, where the client is now beginning to control diet in their mouths and can tolerate various food textures. Choice D is incorrect. Pies, cakes, sherbet, and ice cream are foods that can be given to a client with stage III dysphagia, where the client is now beginning to control diet in their mouths and can tolerate various food textures.

The husband of a client diagnosed with a brain tumor tells the nurse, "I don't know how I will make it if something happens to my wife. I love her so much." What is the most appropriate response from the nurse? A. "Let me call the chaplain to come and talk to you." [4%] B. "Do you have any family support to be with you?" [51%] C. "You don't know how you will make it if something happens?" [44%] D. "Do not worry, everything will be all right. You are a strong man." [1%]

Explanation Choice C is correct. This is an appropriate response and encourages the client's husband to ventilate his feelings. Choice A is incorrect. The nurse should not pass the responsibility to the chaplain. The nurse should address the comment. Choice B is incorrect. The nurse is not needed to problem-solve at the moment. The nurse just needs to address the comments of the husband. Choice D is incorrect. This is offering false reassurance. This is a non-therapeutic response.

A client was diagnosed with cystitis and was instructed to drink cranberry juice. Which assessment parameter would tell the nurse that this recommendation has been effective? A. Urine specific gravity [27%] B. Leukocyte count [27%] C. Urine pH [43%] D. Protein level [2%]

Explanation Choice C is correct. Cranberry juice is an acid-ash food/drink that lowers the urine pH. Monitoring urine pH would, therefore, be most useful in evaluating the effectiveness of this intervention. Choices A, B, and D are incorrect. Urine-specific gravity, leukocyte count, and protein level do not tell anything about the efficacy of acid-ash food/drink.

A patient admits that he thinks he has a problem with drinking too much alcohol. The nurse talks with the patient about substance abuse and the adverse effects of alcoholism. Which best describes how personal engagement with a patient is an active method of change? A. The patient will understand the information more than if it were presented electronically. [17%] B. The patient will be less likely to be litigious toward the healthcare facility. [6%] C. The patient will more likely desire change after connecting with another person. [67%] D. The patient will feel as if he has made a new friend.

Explanation Choice C is correct. Feeling connected to another person gives a sense of belonging and acceptance. The patient will be more likely to change after joining with another person. Change is necessary when a patient is exhibiting behaviors that are harmful to himself or others. Change can be implemented in many ways, but personal engagement, or talking, working with, and spending time with another person, can be useful in getting the message across about the high-risk behavior. With personal engagement, the patient is more likely to desire change because he feels a connection with another person. Choices A and B are incorrect. While these options may be right, they do not reflect the importance of personal engagement and how it affects change. Choice D is incorrect. When nurses facilitate personal engagement with a client, this is not a friendship, but rather a provider-client relationship. NCSBN Client Need Topic: Psychosocial Integrity, Subtopic: Therapeutic Communication

The client in a psychiatric clinic tells the nurse, "I want to kill my wife. The moment I see her, I am going to kill her." What should be the nurse's next action? A. Respect the client's right to privacy and confidentiality. [0%] B. Document the client's statements. [3%] C. Notify the client's psychiatrist of the comments. [45%] D. Explore the client's feelings about his wife. [52%]

Explanation Choice C is correct. Mental health staff must report suicidal/homicidal ideation (SI/HI) and alert identifiable third parties of threats made by a person, even if these threats were discussed in a private therapy session. Choice A is incorrect. Although the nurse should respect the confidentiality of the subject, the nurse should make arrangements so that the wife is informed of the threat to her safety. Choice B is incorrect. The nurse needs to document what the client said in the conversation; however, the nurse should implement measures to ensure the safety of the client's wife. Choice D is incorrect. Exploring the client's feelings regarding his wife would further increase the client's anger toward her. This is not an appropriate action for the nurse to take.

The nurse in the nursery is caring for a 24 hour-old infant. The nurse suspects the child of having pyloric stenosis. Which manifestation by the infant would confirm the nurse's suspicion? A. Melena [1%] B. Currant jelly stools [10%] C. Projectile vomiting [84%] D. Steatorrhea [5%]

Explanation Choice C is correct. Projectile vomiting is a manifestation of pyloric stenosis. This occurs due to the closure of the pyloric sphincter, which closes off the pathway of the food from the stomach. Choice A is incorrect. Melena would indicate upper GI bleeding. This is not a manifestation of pyloric stenosis. Choice B is incorrect. Currant jelly stools are characteristic manifestations of intussusception. Choice D is incorrect. Steatorrhea or feces with excessive fat is a normal stool for malabsorption disorders, not pyloric stenosis.

Which assessment data would the nurse recognize as a sign that a patient may have a duodenal ulcer? A. Gaseous pressure in the upper left abdomen [6%] B. Abdominal discomfort worsens 1-2 hours after eating [52%] C. 10 pound weight loss in the past 6 months [3%] D. Episodic stomach pain 2-4 hours after meals [39%]

Explanation Choice D is correct. Abdominal discomfort due to a duodenal ulcer is typically the worst 2-4 hours post meals and is periodic/episodic. Choice A is incorrect. Burning or gaseous pressure in the high left epigastrium, back, and upper abdomen describes common symptoms of a gastric ulcer. Choice B is incorrect. Abdominal pain worsens within 1-2 hours of meals for gastric ulcers. Choice C is incorrect. Nausea, vomiting, and weight loss are associated with gastric ulcers. NCSBN Client Need Topic: Adult health - Gastrointestinal, Subtopic: Elimination, nutrition and oral hydration, system-specific assessments, illness management, pathophysiology

The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first? A. Administer PRN analgesic. [6%] B. Obtain STAT EKG. [39%] C. Encourage ambulation. [16%] D. Discuss the pain with the patient. [39%]

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

At the initial prenatal visit, and often the subsequent visits, the health care provider will obtain a clean catch urine specimen to look for all of the following, except: A. Ketones [5%] B. Sexually transmitted infections [20%] C. Glucose [7%] D. Testosterone levels

Explanation Choice D is correct. Testosterone is not typically measured in prenatal clients. If a testosterone level needs to be measured, it will be estimated via a blood draw rather than a urinalysis. Choices A, B, and C are incorrect. These are all things tested at the initial and subsequent prenatal visits. Ketones and glucose labs are measured to identify the presence of diabetes. STI labs help health care providers find the best course of a treatment plan for the prenatal client. NCSBN client need Topic: Health Promotion and Maintenance, Ante / Intra / Postpartum Care

You are caring for an elderly client with chronic obstructive pulmonary disease (COPD) who is currently on the ventilator. You have just received the client's most recent arterial blood gas (ABG) results shown on the screen. How would you interpret this ABG result? Source : Archer Review A. Metabolic alkalosis [1%] B. Metabolic acidosis [5%] C. Respiratory alkalosis [5%] D. Respiratory acidosis [89%]

Explanation Choice D is correct. First, recall that a normal pH ranges from 7.35 to 7.45. Since this client's pH of 7.24 falls outside the normal range, we know the client has some type of acidosis. Next, recall that a normal CO2 level ranges from 35 to 45 mmHg. CO2 levels less than 35 mmHg are indicative of low levels of CO2, indicating a respiratory alkalosis. Conversely, CO2 levels greater than 45 mmHg are indicative of high levels of CO2, indicating respiratory acidosis. Based solely on this information, the arterial blood gas result indicates that this client is currently in respiratory acidosis. Additionally, the normal HCO3 correlates with the finding of respiratory acidosis. Therefore, Choice D is correct. Choice A is incorrect. Based solely on this client's pH of 7.24, the client would have some type of acidosis, not alkalosis. Therefore, Choice A can be immediately eliminated based on the client's pH alone and is incorrect. Choice B is incorrect. Although the client's pH of 7.24 indicates acidosis, however, in order for the client to have metabolic acidosis, the client's HCO3 would need to also be decreased. Here, the client's HCO3 is normal, therefore indicating the client is not in metabolic acidosis. Therefore, Choice B is incorrect. Choice C is incorrect. Similar to Choice A, based solely on the client's pH of 7.24, the client would have acidosis, not alkalosis. Therefore, Choice C can also be immediately eliminated based on the pH alone, thus making Choice C also incorrect. For a comprehensive and easy-to-understand video explaining arterial blood gas (ABG) interpretation, please see the "Additional Information" section below for a video entitled "Arterial Blood Gas (ABG) Interpretation -- All You Need for NCLEX" from Archer Review Learning Objective Interpret the client's arterial blood gas (ABG) results. Additional Info Acid-base balance is the maintenance of arterial blood pH between 7.35 and 7.45 through control of hydrogen ion production and elimination. Acidosis occurs when the arterial blood pH level falls below 7.35 while alkalosis occurs when the arterial blood pH level rises above 7.45. Bases bind free hydrogen ions in solution and lower the number of free hydrogen ions in solution. The most common base in human physiology is bicarbonate (HCO3 − ). Although it is a weak base, the many bicarbonate ions in the body are critical in preventing major changes in body fluid pH without harming body tissues.

A 3-year old presents to the emergency department with signs of respiratory distress. The child has epiglottitis associated with a high fever; he is apprehensive and drooling. The nurse must avoid which of the following? A. Listening to the child's lungs [2%] B. Assessing the child's vital signs [2%] C. Weighing the child [3%] D. Inspecting the child's mouth and throat with a tongue blade [94%]

Explanation Choice D is correct. When there are symptoms of epiglottitis, a tongue blade should not be used to assess the throat visually. The use of a tongue blade on the infected tissue might result in further swelling and inflammation, potentially closing off the child's airway completely. The symptoms of epiglottitis may resemble the signs of upper airway infection. These may include sudden onset of a severe sore throat, fever, loud voice, and a cough. Worsening symptoms may also involve drooling and leaning forward in a sitting position. Choices A, B, and C are incorrect. The nursing assessment should include listening to the lungs, assessing vital signs, and obtaining a weight. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Common Respiratory Disorders

When reviewing your client's labs in the morning, you note that his magnesium level is 3.4 mEq/L. On exam, his reflexes are decreased. Which of the following actions is appropriate? Select all that apply. A. Administer calcium gluconate. [36%] B. Repeat another level stat and continue monitoring. [15%] C. Notify the healthcare provider. [44%] D. Administer Sevelamer hydrochloride. [5%]

Explanation Choices A and C are correct. This magnesium level is critically high and must be addressed immediately. Calcium gluconate is administered as a treatment for hypermagnesemia and is appropriate to deliver as ordered. The healthcare provider should be notified right away. Decreased reflexes, headaches, confusion, and hypotension, may be seen with moderate hypermagnesemia. Choice B is incorrect. It is not appropriate to repeat another level and simply continue to monitor this patient. The patient is exhibiting symptoms; the magnesium level is critically high and must be addressed immediately. Choice D is incorrect. Sevelamer hydrochloride is not an appropriate medication in this situation. Sevelamer hydrochloride is a phosphate binder administered for hypocalcemia. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Pharmacological therapies

Which of the following obstetrical procedures can be used to assist the head of the fetus during vaginal delivery? Select all that apply. A. Amniotomy [4%] B. Forceps assisted delivery [44%] C. External version [8%] D. Vacuum assisted delivery [43%]

Explanation Choices B and D are correct. Forceps are tools used to help pull on the head of the baby to assist with the delivery. Vacuum-assisted delivery is a method where suction is applied to the head of the baby and pulled while the mother pushes. This helps to deliver the head of the infant. Choice A is incorrect. An amniotomy is the use of a hook or finger to break the amniotic sac. This helps to induce labor but does not assist in the delivery of the head of the fetus. Choice C is incorrect. The external version is a technique used when the baby is not in an appropriate position for vaginal delivery. The external cephalic version is used to turn a fetus from a breech position or side-lying (transverse) position into a more favorable head-down (vertex) position to help prepare the baby for a vaginal delivery. The external version is typically done before the labor begins, often around 37 weeks. Occasionally, it is done during labor but before the membranes have ruptured. If the amniotic sac has ruptured or if there is not enough amniotic fluid around the fetus (oligohydramnios), external version must not be done as it may end up injuring the fetus. External version does not directly assist in the delivery of the head of the fetus. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Risk potential reduction

Which of the following statements made by an elderly client indicate the achievement of ego integrity? Select all that apply. A. "I wish I could change some things in my past." [7%] B. "I'd like to volunteer at the youth center a few days a week." [32%] C. "I'm thinking of helping people learn to read and write." [33%] D. "I signed up for an art class at the senior center." [27%]

Explanation Choices B, C, and D are correct. Ego integrity signs are manifested by tasks or statements that help bring all previous phases of the life cycle together. Symptoms of successful ego integrity include continuing to learn, helping others, and volunteering. Choice A is incorrect. Ego Integrity vs. Despair is the final stage of Erikson's Psychosocial Development. Signs of self-disgust or despair are manifested when the older adult believes life has been too short or if he/she wants a chance to do things over in life. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Concepts of Growth and Development

The nurse is preparing to administer a regular insulin IV bolus to a client who has hyperglycemic-hyperosmolar state (HHS). The primary health care provider (PHCP) has prescribed an initial bolus dose of 0.1 unit/kg. The client weighs 277 lbs. How much regular insulin should the nurse administer to the client as an IV bolus? Fill in the blank. Round your answer to the nearest whole number. units

Explanation The first step is to convert the client's weight from pounds (lbs) to kilograms (kg) 277 lbs → 125.90 kg Next, multiply the prescribed dosage by the client's weight 0.1 units x 125.90 kg = 12.59 units Finally, take the answer and round it to the nearest whole number 12.59 units = 13 units Additional Info When a client is receiving a regular insulin intravenously, it is essential to monitor the client closely for adverse effects such as hypoglycemia and hypokalemia.

The nurse has received the following prescriptions for newly admitted clients. Which prescription should the nurse administer first? A. Aspirin to a patient experiencing an acute myocardial infarction [90%] B. Lisinopril to a patient with essential hypertension [4%] C. Risperidone to a patient with schizophrenia [2%] D. Levodopa-carbidopa to a patient with Parkinson's disease [3%]

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

The nurse is admitting a client diagnosed with hepatitis B. The nurse would be able to cohort the client in the same room with which of the following clients? A client with A. heart failure receiving diuretics [67%] B. bacterial meningitis receiving antibiotics [14%] C. prostate cancer receiving brachytherapy [4%] D. varicella prescribed antivirals

Explanation Choice A is correct. Although hepatitis B needs to be reported to the public health department, a client with hepatitis B does not need to be isolated. An appropriate client to room with would be an individual receiving intravenous diuretics for heart failure as this client does not have any transmissible pathogens. Choices B, C, and D are incorrect. A client with bacterial meningitis requires droplet precautions, a client receiving brachytherapy requires a private room, and airborne isolation must be initiated for an individual with varicella. Additional Info A nurse may cohort a client if the pathogen they have is the same. A patient requiring airborne isolation must have a private room with their door kept closed while maintaining negative pressure. Cohorting a client with an airborne pathogen is strongly discouraged.

The nurse is providing teaching to a student nurse about the immune system. Which of the following is the best example of natural adaptive immunity? A. Cell-mediated response [33%] B. Lymphocyte creation [13%] C. Inflammatory response [40%] D. The flu vaccine [14%]

Explanation Choice A is correct. Cell-mediated immunity is the best illustration of natural adaptive immunity. This immunity is spurred by cytokines and T-lymphocytes and doesn't include antibodies. Choices B and C are incorrect. These involve cytokines and antibodies, and so are often considered non-specific. Choice D is incorrect. Humoral responses to vaccines are referred to as artificially acquired adaptive immunity. NCSBN client need | Topic: Oncology

When evaluating the heart rate of a 2-year-old patient that is awake, the nurse documents which of the following heart rates as tachycardia? Select all that apply. A. 60 beats per minute [1%] B. 130 beats per minute [12%] C. 150 beats per minute [42%] D. 180 beats per minute [45%]

Explanation Choices C and D are correct. The average heart rate for a 2-year-old when awake is 100 to 140. So, the nurse would document heart rates of 150 (Choice C) and 180 (Choice D) as tachycardia. Tachycardia in an infant/ toddler may indicate fever, illness, pain, dehydration, anxiety, or stress. Since pediatric vitals differ from adult vitals, it is essential for the nurse to be aware of the normal vitals in children so the nurse can plan appropriate interventions should the vitals turn out abnormal. Choice A is incorrect. The average heart rate for a 2-year-old is 100 to 140. The nurse would document a heart rate of 60 as bradycardia, not tachycardia. Choice B is incorrect. The average heart rate for a 2-year-old is 100 to 140. The nurse would document a heart rate of 130 as usual, not tachycardia. NCSBN Client Need Topic: Effective, safe care environment, Subtopic: Coordinated care.

The primary healthcare provider (PHCP) prescribes azithromycin 500 mg, daily for a client with sepsis. The medication label reads 500 mg of azithromycin mixed in 250 mL of 0.9% saline. The drop factor is 15 gtts/mL and it is to be infused over 60 minutes. The nurse sets the flow rate at how many drops per minute? Round your answer to the nearest whole number. Fill in the blank. gtts/minute

Explanation To solve this problem, the nurse will use the formula of total volume x drop factor / time in minutes First, take the prescribed volume and multiply it by the drop factor 250 mL x 15 gtt = 3750 mL Next, divide the total volume by the minutes 3750 mL / 60 minutes = 62.5 gtts Finally, perform appropriate rounding (if needed) 62.5 gtts = 63 gtts Additional Info Azithromycin is a macrolide antibiotic effective in managing pulmonary infections (it has significant lung penetration) and can be utilized adjunctively in treating sepsis.

The nurse caring for a patient with Parkinson's disease is evaluating their medications. Which of the following medications should be discontinued? A. Phenelzine [57%] B. Levodopa [13%] C. Pramipexole [16%] D. Ropinirole [14%]

Explanation Choice A is correct. Phenelzine, also known as Nardil, are MAOI Inhibitors that are not safe for patients with Parkinson's Disease to take and may precipitate a hypertensive crisis. A hypertensive crisis is a sudden increase in blood pressure, which may be life-threatening. Choice B is incorrect. Levodopa is a typical medication used to treat Parkinson's disease. Choice C is incorrect. Pramipexole is a typical medication used to treat Parkinson's disease. Choice D is incorrect. Ropinirole is a typical medication used to treat Parkinson's disease. NCSBN client need Topic: Physiological Integrity, Pharmacological and Parenteral Therapy

The nurse is caring for an infant with a nasogastric tube. Their dosing weight is 4 kg. When the shift begins, the orders for the tube feeding are: Enfamil 20 kcal 150 ml/kg/day Continuous over 24 hours The infant has been tolerating the continuous feeding over 24 hours very well, and the provider decides to advance the feeding schedule to bolus feeds. The new orders tell the nurse to change to bolus feeds every 3 hours. The new order reads: Enfamil 20 kcal 150 ml/kg/day Bolus feeds q3 hours. What volume of formula does the nurse administer with each bolus feed under the new order? Fill in the blank; enter the numeric only. 150 mL

Explanation Correct answer: 75 mL. The first step to answering this question correctly is to multiply the number of mL of formula per kg needed per day by the dosing weight of the patient in kg. The patient gets 150 mL x 4 kg per day = 600 mL of formula per day. Next, calculate how much the formula will be in each bolus feed. The order reads bolus feeds q3 hours, so divide 24 hours daily by feeds every three hours to get eight total bolus feeds per day 24/3 = 8. Last, divide the 600 mL formula total by the eight bolus feeds for a total of 75 mL formula in each bolus feed. 600/8 = 75.